King's Theory-Based Multicomponent Interventions in Heart Failure Patient Rehabilitation

Heart failure is a progressive, chronic clinical syndrome characterized by the heart's inability to pump blood at a level sufficient to meet the metabolic demands of the body's tissues. Affecting more than 64 million people globally, heart failure is associated with high morbidity and mortality, frequent hospital readmissions, a diminished quality of life, and increased healthcare system costs. Consequently, current guidelines from the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) emphasize that the management of heart failure should encompass not only pharmacological treatment but also patient education, self-care, lifestyle modifications, regular monitoring, and rehabilitation.

Cardiac rehabilitation is a multi-component care approach aimed at improving the physical capacity, symptom control, functional status, and quality of life of individuals with heart disease. Recent Cochrane reviews have demonstrated that exercise-based cardiac rehabilitation can enhance health-related quality of life and reduce the risk of hospital readmission in individuals with heart failure. A 2024 Cochrane update reported that exercise-based rehabilitation may not result in a significant difference in mortality, but it may offer benefits by reducing hospitalizations due to heart failure and all-cause hospital admissions.

Cardiac rehabilitation programs are multidisciplinary approaches effective in increasing exercise capacity, managing symptoms, and reducing hospital readmissions in patients with heart failure. Despite the efficacy of cardiac rehabilitation, access to these programs remains limited for many patients, and long-term adherence can be challenging. Factors such as difficulties in traveling to rehabilitation centers, loss of motivation, symptom burden, comorbidities, a lack of social support, and insufficient monitoring outside of the clinical setting negatively impact the sustainability of rehabilitation. The 2021 guidelines on cardiovascular disease prevention, published by the European Society of Cardiology (ESC), suggest that home-based cardiac rehabilitation, telehealth, and mobile health applications may be considered to enhance patient engagement and long-term adherence to healthy behaviors.

Recent studies indicate that telerehabilitation and remote monitoring have positive effects on the quality of life, exercise capacity, and adherence to rehabilitation among patients with heart failure. The TELEREH-HF randomized controlled trial demonstrated that patients undergoing hybrid telerehabilitation showed improved treatment adherence and a significant enhancement in their quality of life. Similarly, the CardioBBEAT study reported that remote telemonitoring practices improve quality of life and support patient monitoring in individuals with chronic heart failure. These findings highlight the necessity of supplementing hospital-based rehabilitation with education, monitoring, and support mechanisms provided in the home environment.

Patient education is a core component of heart failure management, as it fosters self-care behaviors. In recent years, alongside traditional face-to-face education, video-based, digital, and mobile-supported educational approaches have gained prominence. Video-based education allows patients to review information, facilitates learning through visual aids-which is particularly beneficial for those with lower literacy levels-and enables the inclusion of spouses in the educational process. It has been reported that discharge education supported by videos and booklets can enhance both quality of life and self-management behaviors in patients with heart failure. Systematic reviews evaluating educational approaches that incorporate the "teach-back" method underscore the importance of structured, repeatable, and patient-centered techniques for ensuring that patients understand information and translate it into behavioral change.

In the management of heart failure, social support is a significant determinant of a patient's adherence to treatment and their ability to sustain self-care behaviors. Support from a spouse or partner, in particular, can have a direct impact on a patient's ability to remember to take medications, engage in physical activity, adhere to salt and fluid restrictions, recognize symptoms early, and maintain motivation. However, the level of evidence derived from "dyadic" (pair-based/couple-focused) intervention studies-which address the patient-spouse dyad together in the context of heart failure-remains low. Furthermore, it has been noted that such studies should be supported by diverse sample groups, programs for sustainable behavioral change, and models that can be translated into clinical practice. Therefore, addressing peer support not merely as a form of natural support, but as a structured component of an intervention, helps fill a significant gap in the literature.

Tele-monitoring and remote tracking systems enable the monitoring of heart failure patients in their home environment, which can facilitate the early detection of symptom deterioration, promote adherence to treatment, and maintain communication between the patient and their healthcare team. Recent systematic reviews indicate that mobile health and telehealth-based interventions can have positive effects on self-care, hospital admissions, and patient-centered outcomes among individuals with heart failure. Moreover, it has been reported that interventions based on tele-monitoring practices have the potential to reduce heart failure-related readmissions, hospital expenses, and overall healthcare costs. A recent systematic review and meta-analysis found that telehealth and remote monitoring strategies are effective in reducing hospital readmissions and mortality in patients with heart failure. Nevertheless, it is suggested that in the management of heart failure, tele-monitoring practices-rather than being limited solely to symptom tracking-may prove more effective for sustaining self-care behaviors when integrated with components such as patient education, individual goal setting, and social support.

The theoretical foundation for this study is Imogene King's Theory of Goal Attainment. King's theory focuses on the process of interaction, communication, mutual perception, joint goal setting, and goal attainment between the nurse and the patient. In the context of chronic illnesses requiring long-term self-care-such as heart failure-this theory provides a robust framework that shifts the patient from being a passive recipient of care to an active participant in the decision-making process. In this thesis, Imogene King's Theory of Goal Attainment will be applied to support the adaptation of patients with heart failure to the cardiac rehabilitation process. This approach will be structured around the interaction between the patient, their spouse, and the nurse, utilizing goal setting, goal monitoring, and feedback-focused on self-care behaviors, physical activity, and symptom management-as the core mechanisms of the intervention.

Theory-based interventions ensure that nursing practices are developed in a structured, explicable, measurable, and replicable manner, rather than as ad hoc or incidental actions. While the existing literature addresses interventions for heart failure patients-such as education, telemonitoring, social support, and exercise-there is a limited number of holistic models that integrate these components with spousal support, guided by King's Theory of Goal Attainment and supplemented by video-based education and telemonitoring via WhatsApp or telephone. While current European (ESC) and American (AHA/ACC/HFSA) guidelines emphasize the importance of patient education, rehabilitation, self-care, and monitoring, there remains a need for practical models on how these components can be sustained in the home environment with the involvement of a spouse or partner.

This thesis was developed to address specific needs among patients with heart failure, including challenges in maintaining self-care behaviors during the cardiac rehabilitation process, insufficient levels of physical activity, a lack of continuous monitoring at home, and the limited availability of theory-based, comprehensive, nurse-led interventions.

The study will implement a multidimensional, theory-based nursing intervention for patients with heart failure undergoing cardiac rehabilitation. This intervention incorporates partner support, education, and tele-monitoring to improve self-care behaviors and physical activity levels. Video-based educational modules will enhance patients' knowledge and awareness regarding disease management, symptom recognition, medication adherence, fluid and salt restriction, and physical activity; meanwhile, partner support will facilitate the maintenance of self-management behaviors in daily life and the home environment. Furthermore, tele-monitoring will enable the regular assessment of symptoms, weight tracking, the early detection of clinical deterioration, and timely clinical guidance. In this regard, the study aims to establish a sustainable, nurse-led model of care that bridges hospital-based rehabilitation with home-based self-care.