AN INDEPENDENT VOICE FOR NURSING
Optimum Function in Patients With Heart Failure Austin G. Goodman, MS, AGPCNP-BC, RN, Karen S. Yehle, PhD, MS, RN, FAHA, Karen J. Foli, PhD, RN, and Rosanne R. Griggs, RN, PhD, FNP-BC Austin G. Goodman, MS, AGPCNP-BC, RN, is Nurse Practitioner, Pike Medical Consultants, Zionsville, IN; Karen S. Yehle, PhD, MS, RN, FAHA, is Associate Professor of Nursing, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN; Karen J. Foli, PhD, RN, is Assistant Professor of Nursing, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN; and Rosanne R. Griggs, RN, PhD, FNP-BC, is Clinical Associate Professor, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN. Keywords Advanced practice nurse, heart failure, optimum function Correspondence Karen S. Yehle, PhD, MS, RN, FAHA, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN E-mail: [email protected]
Goodman
Yehle
Foli
Griggs
PURPOSE. The aim of this article is to use Walker and Avant’s methodological approach to provide clarity and a definition of optimum function as it relates to patients with heart failure (HF). BACKGROUND. Understanding optimum function in patients with HF can help advanced practice nurses (APNs) identify clinical signs of deterioration. Interpreting patient descriptions of signs and symptoms may be the first cues prior to diagnosis. DATA SOURCE. Literature searches included electronic scientific databases and a manual search. Literature from 2005 to 2013 was reviewed. Themes were searched for function. The text was limited to English language peer-reviewed articles, resulting in 43 articles and 3 books in the analysis. CONCLUSION. A definition of optimum function was developed from a synthesis of the literature’s common themes. The four defining attributes include: multidimensional aspect (physical, cognitive, psychosocial, physiological, and spiritual), achieving a desired goal, dynamic and relative change (compared with previous functioning), and most favorable level of functioning. Defining optimum function in patients with HF provides clarity of patient communication to and between APNs. The concept promotes patient-centered care, enabling goal adjustment by the patient and APN. The concept analysis facilitates a deeper understanding of communication during the patient encounter.
Introduction Optimum function among patients with heart failure (HF) is an important concept because patients
often have symptoms that are described by a change in function. In 2012, the financial impact of HF was $30.7 billion and is expected to increase to $69.7 billion by 2030 (Heidenreich et al., 2013). HF impacts 49
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Optimum Function in Patients With Heart Failure 5.1 million Americans and is associated with one of every nine deaths in the United States (Heidenreich et al., 2013). Optimum function is a dynamic, relative, and important concept that is defined by the individual. Advanced practice nurses (APNs) need an understanding of comparisons in change of function in patients with HF. Knowledge of the concept optimum function will facilitate early and ideal interventions for patients living with HF. Function is important for comparing what one is ideally capable of doing and what one can actually do. The results of assessment of function influence the actions of the APN. For example, patients that expressed greater difficulty with walking also had a decline in performing activities of daily living (ADL); similarly, changes in optimum functions may convey changes in cardiac function (Julius, Brach, Wert, & VanSwearingen, 2012). Patients with HF often compare previous and current functional ability to convey cardiac status. Given the importance of identifying changes in optimum function in this population, it is critical to have a common understanding of what the concept “optimum function” means. The purpose of this paper is to provide evidence to support the concept, present how the concept is used, define attributes, identify antecedents and consequences, and offer empiric referents. A new definition of optimum function as it pertains to patients with HF will be provided. The method of this concept analysis incorporates Walker and Avant’s (2010) approach. Data Source This concept analysis of optimum function was based on an examination of the literature and derived from clinical presentations of patients with HF. The concept analysis of optimum function was generated by searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. The search term “function” provided over 72,000 articles. The search was narrowed by setting limits: year range 2005–2013, abstract, linked full text, and references, resulting in approximately 2,300 articles. Because the search of “function” was very broad and needed refinement, the combination of “functional status” and “heart failure” was also used, resulting in 21 articles. Six articles pertinent to functional status in HF were selected. Elton B. Stevens Company Host Business Source Premier, Medline, Military and Government Collection, and CINAHL were searched for the 50 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
A. G. Goodman et al. definition of function in the disciplines of business, mathematics, and engineering. The key words “definition of function” were used and resulted in 3,138 articles. These articles were further screened by including limits of English, year 2005–2013, full text, scholarly (peer reviewed) journals, and abstract available, resulting in 128 articles. All articles were viewed by title and abstract for the word “function.” Out of business, mathematics, and engineering, the discipline of engineering was most similar to the concept, and one article pertaining to engineering theory on technical function was selected as pertinent to this discussion. PubMed and PsycINFO were searched for optimum function in psychology. Uses of “optimum,” “function,” “optimal,” and “experience” were used interchangeably in search of a definition from psychology. Within the search, articles were screened by the years 2005–2013, title, abstract, full text available, peer review, references available, and English language. “Optimal experience” within PubMed and PsycINFO generated a total of 19 articles. The 19 articles were then reviewed by title and abstract for the words “function” or “experience.” One article was selected from the discipline of psychology as relating to the concept and pertinent to the discussion. Uses of the Concept Definition Optimum function is not a widely used concept, and thus, it is important to begin with a basic meaning of the term to facilitate understanding. Merriam-Webster Online Dictionary (Optimum, 2014) has two meanings for optimum: “the amount or degree of something that is most favorable to some end; especially: the most favorable condition for the growth and reproduction of an organism” and “greatest degree attained or attainable under implied or specified conditions.” “Function” is a broad and widely used term. According to Merriam-Webster Online Dictionary (Function, 2014), the word function has several different meanings, and there are two that apply to this concept analysis: “the action for which a person or thing is specially fitted or used or for which a thing exists: purpose” and “any of a group of related actions contributing to a larger action; especially: the normal and specific contribution of a bodily part to the economy of a living organism.”
A. G. Goodman et al. Disciplines’ Use of Optimum Function The discipline of engineering describes optimum function as minimizing or maximizing a function to achieve the desired result (Belegundu & Chandrupatla, 2011). Engineers use the term optimization as it applies to a function or process. A technical function is putting together technical artifacts to make a central processing unit that enables components to work together as whole to accomplish an end (Kroes, 2010). For example, the developers of a television set consider the technology and how the components function together to produce a functional end— picture and sound (Kroes, 2010). The discipline of psychology does not specifically address the concept of optimum function. However, there is reference in the literature to “optimal experience” (Fave & Massimini, 2005). Optimal experience is the focus and practice of cognition that promotes development and change and affects the outcomes of human behavior (Fave & Massimini, 2005). Optimal experience is a state of mind, perceived well-being, a thought that conditions and factors are at their best (Fave & Massimini, 2005). An example of influences that can affect an optimal experience are an external factor such as the birth of a baby, or internal factors such as the ability to complete a marathon, inability to complete a task, or a disease process that is worsening (Hamilton-Smith, 1992; LeDoux, 2003). The discipline of nursing does not specifically use the term optimum function. The nursing profession does use functional status, which pertains to an individual’s physical, psychosocial, cognitive, spiritual, and physiological state (Leibowitz et al., 2011; Leidy, 1994; Pihl, Fridlund, & Martensson, 2011; Ski, Thompson, Hare, Stewart, & Watson, 2012). The discipline of nursing utilizes the term functional status to encompass and measure performance of an individual’s ability to meet his/her needs, complete expected tasks, and sustain healthy living and comfort (Leidy, 1994; Wang, 2004). Although the discipline of nursing uses the concept of functional status, the clarity of dynamic and relative change that is needed for describing a patient with HF optimum function is lacking. Defining Attributes Four attributes of optimum function were extracted from the literature that relates to patients with HF: multidimensional aspect (physical, cognitive, psychosocial, physiological, and spiritual), achieving a desired
Optimum Function in Patients With Heart Failure goal, dynamic, and relative change (compared with previous functioning), and most favorable condition. The attributes provide clarity to deriving the definition of optimum function. Multidimensional is the attribute that conveys the diverseness of optimum function. Multidimensional includes the components of physical, cognitive, psychosocial, physiological, and spiritual functions working together in an individual to provide optimum function (Fave & Massimini, 2005; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963; Lawton & Brody, 1969; Leibowitz et al., 2011; Leidy, 1994; Nasreddine et al., 2005). Physical function surrounds activities such as mobility, dexterity, and ADL (e.g., toileting and eating). Cognitive function is the ability to process the environment in a meaningful way, including general orientation to time, place, and person. Psychosocial function is the patient’s ability to engage and interact with others, including those who are intimate with them and acquaintances. Physiological function relates to the body’s internal processes, including organs, tissues, and cells. Spiritual function is the patient’s fifth element, a belief in another power that is apart from the corporeal world. The multidimensional components manifest differently in each individual, but are interconnected so that optimum function is achieved. Achieving a desired goal is embedded in obtaining optimum function, which means arriving at a perceived end point: the attainment of optimum function (Julius et al., 2012). An example of achieving a desired goal might be accomplishing various ADL: bathing, dressing, toileting, transferring, and feeding (Leibowitz et al., 2011). More complex activities required to be able to live at home are: grocery shopping, doing laundry, cooking, using transportation, and managing money (Bowling et al., 2012). Most favorable condition is another attribute of optimum function. An individual seeks to maintain the quality of life, the ability to meet basic needs, independence and function within his/her constituted norms, thereby obtaining the most favorable condition (Kutzleb & Reiner, 2006; Leidy, 1994). Dynamic and relative changes are the last attributes of optimum function. The cognitive and physical functions of an individual changes with aging and health conditions, and affects the individual’s abilities to continue operating at the expected level (Leibowitz et al., 2011). Dynamic and relative changes relate to an individual’s adjustment in cognition, physical, psychosocial, physiological, and spiritual processes. The changes require the individual to modify his/her way 51
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Optimum Function in Patients With Heart Failure of doing things and/or seek other ways to continue to function at a consistent level (Pihl et al., 2011). Derived Definition Given the review of literature related to optimum function and the above attributes that were derived, the following definition was developed as it related to patients with HF: Optimum function in patients with HF is multidimensional, pertaining to the dynamic and relative changes of role, task, or duty. The definition also requires the individual to satisfy his/her most favorable level of functioning and be able to achieve his/her goal(s). Antecedent and Consequences Antecedents are needed for a concept to exist; consequences occur after the presence of a concept (Walker & Avant, 2010). The antecedents that occur before the concept of optimum function in patients with HF are: ● Intact cognitive process: the ability of the patient to understand the disease process and adapt to the changes, self-evaluation, and subjective interpretation of changes of function ● Psychologically sound: absence or controlled state of mental illness ● Physical and physiological aptitude: ability to perform physical activities; heart’s ability to perfuse the body and adequately oxygenate ● Adherence to treatment regimen: medications, exercise, and physical therapy to manage HF Consequences of optimum function in patients with HF include: reaching goal(s), meeting daily need(s), being cognitively intact, and physically and physiologically able. The individual is able to reach his/her most favorable condition, a satisfied state of being. Empirical Referents Empirical referents enable the APN to identify and validate the presence of the concept (Walker & Avant, 2010). Optimum function can best be determined by the existence or absence of certain phenomena (Walker & Avant, 2010). The phenomena that pertain to optimum function in patients with HF relate to the attributes of multidimensional aspects, dynamic and 52 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
A. G. Goodman et al. relative change, achieving a desired goal, and the most favorable condition. Although there is no single empirical referent for optimum function, there are several tools and assessment questions that can act as proxies for this concept. Relative change in patients with HF is important for APNs to assess and it can be completed through physical assessment. A question the APN can ask is, “Have you noticed any swelling or weight gain over the last month?” The question validates the presence or lack of fluid overload and enables the patient to selfmonitor. Assessing physical activity clarifies changes in optimum function and evaluates the patients’ ability to achieve desired goals. The Index of Activities of Daily Living and Instrumental Activities of Daily Living are predictors of late and early HF symptoms (Bowling et al., 2012). Questions such as, “What may be some challenges in the home?” or “Are you having any difficulties managing life in the home, and can you describe your difficulties?” may indicate the decline of ADL. Monitored changes facilitate early intervention. Achieving desired goals and reaching the most favorable condition may be measured by quality of life assessments in patients with HF. Questions that the APN can ask are: “Are you satisfied with how you are able to function?” or “Are there any other activities you would like to be able to do at this time?” Measurement of quality of life in patients with HF will enable the APN to assess the patient’s most favorable condition and dynamic and relative change. Two measurements that can be used to assess quality of life in patients with HF are the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (Green, Porter, Bresnahan, & Spertus, 2000; Riegel et al., 2002; Spertus et al., 2005). The multidimensional aspects of optimum function have no tool to measure it as a whole. The above referents are combined to synthesize the presence or absence of the multidimensional aspects of optimum function in patients with HF. Table 1 provides a visual flow of the antecedents to consequences with empirical referents. Discussion APNs need to consider the use of the above empirical referents and be aware of how patients describe personal optimal function to assist in diagnosis and
Optimum Function in Patients With Heart Failure
A. G. Goodman et al.
Table 1. Antecedents, Attributes, Consequences, and Empirical Referents Antecedents
Attributes
Consequences
Empirical referents
Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen
Multidimensional (working together)
Optimum function
Physical assessment, ADL, IADL, MLHFQ, KCCQ
Achieving a set goal
Completed goal
ADL, IADL
Most favorable conditions
Quality of life: meet basic needs, health maintenance, well-being
MLHFQ, KCCQ
Dynamic and relative change
Continued ability within functional norms with or without impairments, making adjustment as needed
Physical assessment, ADL, IADL
ADL, activities of daily living; IADL, instrumental activities of daily living; MLHFQ, Minnesota Living with Heart Failure Questionnaire; KCCQ, Kansas City Cardiomyopathy Questionnaire.
distinguish early onset or worsening of HF symptoms. APNs need to educate patients about HF, use a multidisciplinary team approach, and refer patients to HF clinics when appropriate to prevent further complications and slow deterioration (Grady et al., 2000). Patients with HF do not always describe changes in optimal function in the same manner. It is important to elicit the patient’s description of optimum function and also their current level of function in order to determine declining health. Optimum function is not limited to HF and is applicable to other disease states, such as chronic pulmonary disease, diabetes, renal failure, Alzheimer’s, Parkinson’s disease, and cancer. These chronic diseases have a decline in health that is described through changes in function. Thus, it is important for APNs to recognize optimum function in other chronic disease states. APNs provide initial assessments in clinics and primary care and can contribute to confirming a diagnosis by noting patient descriptions of optimal function. As APNs, it is important to understand how a patient with HF or other disease states may convey signs and symptoms. APNs can recognize quickly decompensation by asking questions about signs and
symptoms of changes in optimum functioning, and then order appropriate diagnostic testing. Conclusion Optimum function in patients with HF is multidimensional, pertaining to the dynamic and relative changes of role, task, or duty, and is characterized by attainable goals that satisfy an individual’s most favorable condition/being when reached. The definition of optimum function provides consistency of practice for patients presenting with HF, a dynamic condition. Past and present function is often compared with optimum function when assessing signs and symptoms associated with HF. Also, APNs should use multidisciplinary teams, education, diagnostic tools, and HF clinics to inform patients about signs and symptoms and treatment related to the disease process. A concept analysis on optimal function in patients with HF can assist APNs to have a clearer understanding of how optimum function relates to patients with HF. Optimum function applies to multiple diseases or changing health states and should be used to determine declining health status and facilitate early interventions by the APN. 53
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Optimum Function in Patients With Heart Failure References Belegundu, A. D., & Chandrupatla, T. R. (2011). Optimization concepts and applications in engineering. New York: Cambridge University Press. Bowling, C. B., Fonarow, G. C., Patel, K., Zhang, Y., Feller, M. A., Sui, X., & Ahmed, A. (2012). Impairment of activities of daily living and incident heart failure in community-dwelling older adults. European Journal of Heart Failure: Journal of the Working Group on Heart Failure of the European Society of Cardiology, 14(6), 581–587. doi: 10.1093/eurjhf/hfs034 Fave, A. D., & Massimini, F. (2005). The investigation of optimal experience and apathy: Developmental and psychosocial implications. European Psychologist, 10(4), 264– 274. doi:10.1027/1016-9040.10.4.264 Function. (2014). In Merriam-Webster online dictionary. Retrieved from http://www.merriam-webster.com/ dictionary/function Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., & Young, J. B. (2000). Team management of patients with heart failure: A statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association. Circulation, 102(19), 2443–2456. doi:10.1161/01.cir.102 .19.2443 Green, C. P., Porter, C. B., Bresnahan, D. R., & Spertus, J. A. (2000). Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: A new health status measure for heart failure. Journal of the American College of Cardiology, 35(5), 1245–1255. doi:10.1016/S07351097(00)00531-3 Hamilton-Smith, E. (1992). Work, leisure and optimal experience. Leisure Studies, 11(3), 243–256. doi:10.1080/ 02614369200390121 Heidenreich, P. A., Albert, N. M., Allen, L. A., Bluemke, D. A., Butler, J. M., Fonarow, G. C., & Trogdon, J. G. (2013). Forecasting the impact of heart failure in the United States: A policy statement from the American Heart Association. Circulation: Heart Failure, 6(3), 606–619. doi: 10.1161/HHF.0b013e318291329a Julius, L. M., Brach, J. S., Wert, D. M., & VanSwearingen, J. M. (2012). Perceived effort of walking: Relationship with gait, physical function and activity, fear of falling, and confidence in walking in older adults with mobility limitations. Physical Therapy, 92(10), 1268–1277. doi: 10.2522/ptj.20110326 Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914–919. Kroes, P. (2010). Theories of technical functions: Function ascriptions versus function assignments, part 1. Design Issues, 26(3), 62–69. doi:10.1162/Desi_a_00030
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A. G. Goodman et al. Kutzleb, J., & Reiner, D. (2006). The impact of nursedirected patient education on quality of life and functional capacity in people with heart failure. Journal of the American Academy of Nurse Practitioners, 18(3), 116–123. doi: 10.1111/j.1745-7599.2006.00107.x Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179–186. LeDoux, J. E. (2003). Synaptic self: How our brains become who we are. New York: Penguin Group. Leibowitz, D., Jacobs, J. M., Stessman-Lande, I., Cohen, A., Gilon, D., Ein-Mor, E., & Stessman, J. (2011). Cardiac structure and function and dependency in the oldest old. Journal of the American Geriatrics Society, 59(8), 1429–1434. doi:10.1111/j.1532-5415.2011.03534.x Leidy, N. K. (1994). Functional status and the forward progress of merry-go-rounds: Toward a coherent analytical framework. Nursing Research, 43(4), 196–202. Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. doi:10.1111/j.15325415.2005.53221.x Optimum. (2014). In Merriam-Webster online dictionary. Retrieved from http://www.merriam-webster.com/ medical/optimum Pihl, E., Fridlund, B., & Martensson, J. (2011). Patients’ experiences of physical limitations in daily life activities when suffering from chronic heart failure; A phenomenographic analysis. Scandinavian Journal of Caring Sciences, 25(1), 3–11. doi:10.1111/j.1471-6712 .2010.00780.x Riegel, B., Moser, D. K., Glaser, D., Carlson, B., Deaton, C., Armola, R., & Albert, N. G. (2002). The Minnesota Living with Heart Failure Questionnaire: Sensitivity to differences and responsiveness to intervention intensity in a clinical population. Nursing Research, 51(4), 209–218. Ski, C. F., Thompson, D. R., Hare, D. L., Stewart, A. G., & Watson, R. (2012). Cardiac Depression Scale: Mokken scaling in heart failure patients. Health Quality of Life Outcomes, 10, 141. doi:10.1186/1477-7525-10-141 Spertus, J. A., Peterson, E. D., Conard, M. W., Heidenreich, P. A., Krumholz, H. M., Jones, P., & Rumsfeld, J. S. (2005). Monitoring clinical changes in patients with heart failure: A comparison of methods. American Heart Journal, 150(4), 707–715. doi:10.1016/j.ahj.2004.12.010 Walker, L. O., & Avant, K. C. (2010). Strategies for theory construction in nursing. Upper Saddle River, NJ: Pearson Prentice Hall. Wang, T. J. (2004). Concept analysis of functional status. International Journal of Nursing Studies, 41(4), 457–462. doi:10.1016/j.ijnurstu.2003.09.004
Optimum Function in Patients With Heart Failure Austin G. Goodman, MS, AGPCNP-BC, RN, Karen S. Yehle, PhD, MS, RN, FAHA, Karen J. Foli, PhD, RN, and Rosanne R. Griggs, RN, PhD, FNP-BC Austin G. Goodman, MS, AGPCNP-BC, RN, is Nurse Practitioner, Pike Medical Consultants, Zionsville, IN; Karen S. Yehle, PhD, MS, RN, FAHA, is Associate Professor of Nursing, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN; Karen J. Foli, PhD, RN, is Assistant Professor of Nursing, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN; and Rosanne R. Griggs, RN, PhD, FNP-BC, is Clinical Associate Professor, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN. Keywords Advanced practice nurse, heart failure, optimum function Correspondence Karen S. Yehle, PhD, MS, RN, FAHA, College of Health and Human Sciences, Center on Aging and the Life Course, Purdue University, West Lafayette, IN E-mail: [email protected]
Goodman
Yehle
Foli
Griggs
PURPOSE. The aim of this article is to use Walker and Avant’s methodological approach to provide clarity and a definition of optimum function as it relates to patients with heart failure (HF). BACKGROUND. Understanding optimum function in patients with HF can help advanced practice nurses (APNs) identify clinical signs of deterioration. Interpreting patient descriptions of signs and symptoms may be the first cues prior to diagnosis. DATA SOURCE. Literature searches included electronic scientific databases and a manual search. Literature from 2005 to 2013 was reviewed. Themes were searched for function. The text was limited to English language peer-reviewed articles, resulting in 43 articles and 3 books in the analysis. CONCLUSION. A definition of optimum function was developed from a synthesis of the literature’s common themes. The four defining attributes include: multidimensional aspect (physical, cognitive, psychosocial, physiological, and spiritual), achieving a desired goal, dynamic and relative change (compared with previous functioning), and most favorable level of functioning. Defining optimum function in patients with HF provides clarity of patient communication to and between APNs. The concept promotes patient-centered care, enabling goal adjustment by the patient and APN. The concept analysis facilitates a deeper understanding of communication during the patient encounter.
Introduction Optimum function among patients with heart failure (HF) is an important concept because patients
often have symptoms that are described by a change in function. In 2012, the financial impact of HF was $30.7 billion and is expected to increase to $69.7 billion by 2030 (Heidenreich et al., 2013). HF impacts 49
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Optimum Function in Patients With Heart Failure 5.1 million Americans and is associated with one of every nine deaths in the United States (Heidenreich et al., 2013). Optimum function is a dynamic, relative, and important concept that is defined by the individual. Advanced practice nurses (APNs) need an understanding of comparisons in change of function in patients with HF. Knowledge of the concept optimum function will facilitate early and ideal interventions for patients living with HF. Function is important for comparing what one is ideally capable of doing and what one can actually do. The results of assessment of function influence the actions of the APN. For example, patients that expressed greater difficulty with walking also had a decline in performing activities of daily living (ADL); similarly, changes in optimum functions may convey changes in cardiac function (Julius, Brach, Wert, & VanSwearingen, 2012). Patients with HF often compare previous and current functional ability to convey cardiac status. Given the importance of identifying changes in optimum function in this population, it is critical to have a common understanding of what the concept “optimum function” means. The purpose of this paper is to provide evidence to support the concept, present how the concept is used, define attributes, identify antecedents and consequences, and offer empiric referents. A new definition of optimum function as it pertains to patients with HF will be provided. The method of this concept analysis incorporates Walker and Avant’s (2010) approach. Data Source This concept analysis of optimum function was based on an examination of the literature and derived from clinical presentations of patients with HF. The concept analysis of optimum function was generated by searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. The search term “function” provided over 72,000 articles. The search was narrowed by setting limits: year range 2005–2013, abstract, linked full text, and references, resulting in approximately 2,300 articles. Because the search of “function” was very broad and needed refinement, the combination of “functional status” and “heart failure” was also used, resulting in 21 articles. Six articles pertinent to functional status in HF were selected. Elton B. Stevens Company Host Business Source Premier, Medline, Military and Government Collection, and CINAHL were searched for the 50 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
A. G. Goodman et al. definition of function in the disciplines of business, mathematics, and engineering. The key words “definition of function” were used and resulted in 3,138 articles. These articles were further screened by including limits of English, year 2005–2013, full text, scholarly (peer reviewed) journals, and abstract available, resulting in 128 articles. All articles were viewed by title and abstract for the word “function.” Out of business, mathematics, and engineering, the discipline of engineering was most similar to the concept, and one article pertaining to engineering theory on technical function was selected as pertinent to this discussion. PubMed and PsycINFO were searched for optimum function in psychology. Uses of “optimum,” “function,” “optimal,” and “experience” were used interchangeably in search of a definition from psychology. Within the search, articles were screened by the years 2005–2013, title, abstract, full text available, peer review, references available, and English language. “Optimal experience” within PubMed and PsycINFO generated a total of 19 articles. The 19 articles were then reviewed by title and abstract for the words “function” or “experience.” One article was selected from the discipline of psychology as relating to the concept and pertinent to the discussion. Uses of the Concept Definition Optimum function is not a widely used concept, and thus, it is important to begin with a basic meaning of the term to facilitate understanding. Merriam-Webster Online Dictionary (Optimum, 2014) has two meanings for optimum: “the amount or degree of something that is most favorable to some end; especially: the most favorable condition for the growth and reproduction of an organism” and “greatest degree attained or attainable under implied or specified conditions.” “Function” is a broad and widely used term. According to Merriam-Webster Online Dictionary (Function, 2014), the word function has several different meanings, and there are two that apply to this concept analysis: “the action for which a person or thing is specially fitted or used or for which a thing exists: purpose” and “any of a group of related actions contributing to a larger action; especially: the normal and specific contribution of a bodily part to the economy of a living organism.”
A. G. Goodman et al. Disciplines’ Use of Optimum Function The discipline of engineering describes optimum function as minimizing or maximizing a function to achieve the desired result (Belegundu & Chandrupatla, 2011). Engineers use the term optimization as it applies to a function or process. A technical function is putting together technical artifacts to make a central processing unit that enables components to work together as whole to accomplish an end (Kroes, 2010). For example, the developers of a television set consider the technology and how the components function together to produce a functional end— picture and sound (Kroes, 2010). The discipline of psychology does not specifically address the concept of optimum function. However, there is reference in the literature to “optimal experience” (Fave & Massimini, 2005). Optimal experience is the focus and practice of cognition that promotes development and change and affects the outcomes of human behavior (Fave & Massimini, 2005). Optimal experience is a state of mind, perceived well-being, a thought that conditions and factors are at their best (Fave & Massimini, 2005). An example of influences that can affect an optimal experience are an external factor such as the birth of a baby, or internal factors such as the ability to complete a marathon, inability to complete a task, or a disease process that is worsening (Hamilton-Smith, 1992; LeDoux, 2003). The discipline of nursing does not specifically use the term optimum function. The nursing profession does use functional status, which pertains to an individual’s physical, psychosocial, cognitive, spiritual, and physiological state (Leibowitz et al., 2011; Leidy, 1994; Pihl, Fridlund, & Martensson, 2011; Ski, Thompson, Hare, Stewart, & Watson, 2012). The discipline of nursing utilizes the term functional status to encompass and measure performance of an individual’s ability to meet his/her needs, complete expected tasks, and sustain healthy living and comfort (Leidy, 1994; Wang, 2004). Although the discipline of nursing uses the concept of functional status, the clarity of dynamic and relative change that is needed for describing a patient with HF optimum function is lacking. Defining Attributes Four attributes of optimum function were extracted from the literature that relates to patients with HF: multidimensional aspect (physical, cognitive, psychosocial, physiological, and spiritual), achieving a desired
Optimum Function in Patients With Heart Failure goal, dynamic, and relative change (compared with previous functioning), and most favorable condition. The attributes provide clarity to deriving the definition of optimum function. Multidimensional is the attribute that conveys the diverseness of optimum function. Multidimensional includes the components of physical, cognitive, psychosocial, physiological, and spiritual functions working together in an individual to provide optimum function (Fave & Massimini, 2005; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963; Lawton & Brody, 1969; Leibowitz et al., 2011; Leidy, 1994; Nasreddine et al., 2005). Physical function surrounds activities such as mobility, dexterity, and ADL (e.g., toileting and eating). Cognitive function is the ability to process the environment in a meaningful way, including general orientation to time, place, and person. Psychosocial function is the patient’s ability to engage and interact with others, including those who are intimate with them and acquaintances. Physiological function relates to the body’s internal processes, including organs, tissues, and cells. Spiritual function is the patient’s fifth element, a belief in another power that is apart from the corporeal world. The multidimensional components manifest differently in each individual, but are interconnected so that optimum function is achieved. Achieving a desired goal is embedded in obtaining optimum function, which means arriving at a perceived end point: the attainment of optimum function (Julius et al., 2012). An example of achieving a desired goal might be accomplishing various ADL: bathing, dressing, toileting, transferring, and feeding (Leibowitz et al., 2011). More complex activities required to be able to live at home are: grocery shopping, doing laundry, cooking, using transportation, and managing money (Bowling et al., 2012). Most favorable condition is another attribute of optimum function. An individual seeks to maintain the quality of life, the ability to meet basic needs, independence and function within his/her constituted norms, thereby obtaining the most favorable condition (Kutzleb & Reiner, 2006; Leidy, 1994). Dynamic and relative changes are the last attributes of optimum function. The cognitive and physical functions of an individual changes with aging and health conditions, and affects the individual’s abilities to continue operating at the expected level (Leibowitz et al., 2011). Dynamic and relative changes relate to an individual’s adjustment in cognition, physical, psychosocial, physiological, and spiritual processes. The changes require the individual to modify his/her way 51
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Optimum Function in Patients With Heart Failure of doing things and/or seek other ways to continue to function at a consistent level (Pihl et al., 2011). Derived Definition Given the review of literature related to optimum function and the above attributes that were derived, the following definition was developed as it related to patients with HF: Optimum function in patients with HF is multidimensional, pertaining to the dynamic and relative changes of role, task, or duty. The definition also requires the individual to satisfy his/her most favorable level of functioning and be able to achieve his/her goal(s). Antecedent and Consequences Antecedents are needed for a concept to exist; consequences occur after the presence of a concept (Walker & Avant, 2010). The antecedents that occur before the concept of optimum function in patients with HF are: ● Intact cognitive process: the ability of the patient to understand the disease process and adapt to the changes, self-evaluation, and subjective interpretation of changes of function ● Psychologically sound: absence or controlled state of mental illness ● Physical and physiological aptitude: ability to perform physical activities; heart’s ability to perfuse the body and adequately oxygenate ● Adherence to treatment regimen: medications, exercise, and physical therapy to manage HF Consequences of optimum function in patients with HF include: reaching goal(s), meeting daily need(s), being cognitively intact, and physically and physiologically able. The individual is able to reach his/her most favorable condition, a satisfied state of being. Empirical Referents Empirical referents enable the APN to identify and validate the presence of the concept (Walker & Avant, 2010). Optimum function can best be determined by the existence or absence of certain phenomena (Walker & Avant, 2010). The phenomena that pertain to optimum function in patients with HF relate to the attributes of multidimensional aspects, dynamic and 52 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
A. G. Goodman et al. relative change, achieving a desired goal, and the most favorable condition. Although there is no single empirical referent for optimum function, there are several tools and assessment questions that can act as proxies for this concept. Relative change in patients with HF is important for APNs to assess and it can be completed through physical assessment. A question the APN can ask is, “Have you noticed any swelling or weight gain over the last month?” The question validates the presence or lack of fluid overload and enables the patient to selfmonitor. Assessing physical activity clarifies changes in optimum function and evaluates the patients’ ability to achieve desired goals. The Index of Activities of Daily Living and Instrumental Activities of Daily Living are predictors of late and early HF symptoms (Bowling et al., 2012). Questions such as, “What may be some challenges in the home?” or “Are you having any difficulties managing life in the home, and can you describe your difficulties?” may indicate the decline of ADL. Monitored changes facilitate early intervention. Achieving desired goals and reaching the most favorable condition may be measured by quality of life assessments in patients with HF. Questions that the APN can ask are: “Are you satisfied with how you are able to function?” or “Are there any other activities you would like to be able to do at this time?” Measurement of quality of life in patients with HF will enable the APN to assess the patient’s most favorable condition and dynamic and relative change. Two measurements that can be used to assess quality of life in patients with HF are the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (Green, Porter, Bresnahan, & Spertus, 2000; Riegel et al., 2002; Spertus et al., 2005). The multidimensional aspects of optimum function have no tool to measure it as a whole. The above referents are combined to synthesize the presence or absence of the multidimensional aspects of optimum function in patients with HF. Table 1 provides a visual flow of the antecedents to consequences with empirical referents. Discussion APNs need to consider the use of the above empirical referents and be aware of how patients describe personal optimal function to assist in diagnosis and
Optimum Function in Patients With Heart Failure
A. G. Goodman et al.
Table 1. Antecedents, Attributes, Consequences, and Empirical Referents Antecedents
Attributes
Consequences
Empirical referents
Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen Cognitively intact, physical and physiological aptitude, psychologically sound, and adherence to medication regimen
Multidimensional (working together)
Optimum function
Physical assessment, ADL, IADL, MLHFQ, KCCQ
Achieving a set goal
Completed goal
ADL, IADL
Most favorable conditions
Quality of life: meet basic needs, health maintenance, well-being
MLHFQ, KCCQ
Dynamic and relative change
Continued ability within functional norms with or without impairments, making adjustment as needed
Physical assessment, ADL, IADL
ADL, activities of daily living; IADL, instrumental activities of daily living; MLHFQ, Minnesota Living with Heart Failure Questionnaire; KCCQ, Kansas City Cardiomyopathy Questionnaire.
distinguish early onset or worsening of HF symptoms. APNs need to educate patients about HF, use a multidisciplinary team approach, and refer patients to HF clinics when appropriate to prevent further complications and slow deterioration (Grady et al., 2000). Patients with HF do not always describe changes in optimal function in the same manner. It is important to elicit the patient’s description of optimum function and also their current level of function in order to determine declining health. Optimum function is not limited to HF and is applicable to other disease states, such as chronic pulmonary disease, diabetes, renal failure, Alzheimer’s, Parkinson’s disease, and cancer. These chronic diseases have a decline in health that is described through changes in function. Thus, it is important for APNs to recognize optimum function in other chronic disease states. APNs provide initial assessments in clinics and primary care and can contribute to confirming a diagnosis by noting patient descriptions of optimal function. As APNs, it is important to understand how a patient with HF or other disease states may convey signs and symptoms. APNs can recognize quickly decompensation by asking questions about signs and
symptoms of changes in optimum functioning, and then order appropriate diagnostic testing. Conclusion Optimum function in patients with HF is multidimensional, pertaining to the dynamic and relative changes of role, task, or duty, and is characterized by attainable goals that satisfy an individual’s most favorable condition/being when reached. The definition of optimum function provides consistency of practice for patients presenting with HF, a dynamic condition. Past and present function is often compared with optimum function when assessing signs and symptoms associated with HF. Also, APNs should use multidisciplinary teams, education, diagnostic tools, and HF clinics to inform patients about signs and symptoms and treatment related to the disease process. A concept analysis on optimal function in patients with HF can assist APNs to have a clearer understanding of how optimum function relates to patients with HF. Optimum function applies to multiple diseases or changing health states and should be used to determine declining health status and facilitate early interventions by the APN. 53
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Optimum Function in Patients With Heart Failure References Belegundu, A. D., & Chandrupatla, T. R. (2011). Optimization concepts and applications in engineering. New York: Cambridge University Press. Bowling, C. B., Fonarow, G. C., Patel, K., Zhang, Y., Feller, M. A., Sui, X., & Ahmed, A. (2012). Impairment of activities of daily living and incident heart failure in community-dwelling older adults. European Journal of Heart Failure: Journal of the Working Group on Heart Failure of the European Society of Cardiology, 14(6), 581–587. doi: 10.1093/eurjhf/hfs034 Fave, A. D., & Massimini, F. (2005). The investigation of optimal experience and apathy: Developmental and psychosocial implications. European Psychologist, 10(4), 264– 274. doi:10.1027/1016-9040.10.4.264 Function. (2014). In Merriam-Webster online dictionary. Retrieved from http://www.merriam-webster.com/ dictionary/function Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., & Young, J. B. (2000). Team management of patients with heart failure: A statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association. Circulation, 102(19), 2443–2456. doi:10.1161/01.cir.102 .19.2443 Green, C. P., Porter, C. B., Bresnahan, D. R., & Spertus, J. A. (2000). Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: A new health status measure for heart failure. Journal of the American College of Cardiology, 35(5), 1245–1255. doi:10.1016/S07351097(00)00531-3 Hamilton-Smith, E. (1992). Work, leisure and optimal experience. Leisure Studies, 11(3), 243–256. doi:10.1080/ 02614369200390121 Heidenreich, P. A., Albert, N. M., Allen, L. A., Bluemke, D. A., Butler, J. M., Fonarow, G. C., & Trogdon, J. G. (2013). Forecasting the impact of heart failure in the United States: A policy statement from the American Heart Association. Circulation: Heart Failure, 6(3), 606–619. doi: 10.1161/HHF.0b013e318291329a Julius, L. M., Brach, J. S., Wert, D. M., & VanSwearingen, J. M. (2012). Perceived effort of walking: Relationship with gait, physical function and activity, fear of falling, and confidence in walking in older adults with mobility limitations. Physical Therapy, 92(10), 1268–1277. doi: 10.2522/ptj.20110326 Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914–919. Kroes, P. (2010). Theories of technical functions: Function ascriptions versus function assignments, part 1. Design Issues, 26(3), 62–69. doi:10.1162/Desi_a_00030
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