CICARE communication model and hierarchical responsibility nursing coordination in the application research of elderly patients with chronic heart failure

Abstract

The aim of this study was to evaluate the efficacy of implementing the CICARE communication model and hierarchical responsibility nursing coordination in managing chronic heart failure among elderly patients. From June 2021 to June 2023, 120 elderly patients diagnosed with chronic heart failure were admitted to our hospital. They were divided into 2 groups according to different treatment methods: the regular group and the observation group. Both groups of patients received nursing interventions for 3 months. Before and after the intervention, we assessed the levels of cardiac function indicators (left ventricular end-diastolic diameter, left ventricular ejection fraction, and B-type natriuretic peptide levels) and exercise tolerance (6-minute walk test) in both groups of patients. The time to clinical symptom relief, self-efficacy, and quality of life scores were compared between the 2 groups of patients. Before the intervention, there were no significant differences in cardiac function indicators between the 2 groups (P > .05). However, after the intervention, both groups exhibited improvements in left ventricular end-diastolic diameter and B-type natriuretic peptide levels, with the observation group demonstrating greater reductions compared to the control group. Furthermore, both groups showed increased left ventricular ejection fraction levels, with the observation group experiencing a significantly higher improvement. Although exercise tolerance did not differ significantly between the groups before the intervention, post-intervention analysis revealed a greater increase in 6-minute walk test distance in the observation group compared to the control group (P < .05). The time to relief of breathlessness and edema did not significantly differ between the groups (P > .05). Similarly, there were no significant differences in self-efficacy and quality of life scores between the groups before the intervention (P > .05); however, post-intervention analysis showed higher self-efficacy scores in the observation group. Application of the CICARE communication model and hierarchical responsibility nursing coordination in elderly patients with chronic heart failure can effectively improve the patients’ cardiac function levels and significantly enhance their exercise tolerance, self-efficacy, and quality of life.

1. Introduction

Chronic heart failure (CHF) presents a substantial medical challenge globally, particularly among the elderly population. Its clinical features include diminished physical endurance, compromised cardiac pumping capacity, and a spectrum of physiological and psychological ramifications. With the ongoing rise in the global aging demographic, enhancing the quality of life and clinical outcomes for elderly individuals with CHF has emerged as a pivotal focus in both medical research and clinical application. Implementing systematic and evidence-based nursing strategies is increasingly recognized as essential for addressing the multifaceted needs of elderly CHF patients, thereby advancing medical care and patient outcomes.^[1,2] In this regard, continuous optimization and innovation of nursing models are crucial. The CICARE communication model stands as a well-established and patient-centric nursing communication framework. It underscores the importance of thorough, respectful, transparent, timely, and precise information exchange throughout the nursing process. The model promotes the cultivation of a positive rapport between nurses and patients, aiming to bolster patient satisfaction and facilitate improved self-management and treatment adherence.^[3,4] Hierarchical responsibility nursing entails categorizing patients’ disease severity according to their condition and methodically allocating nursing resources and staff in a rational manner. This approach delineates the roles and responsibilities of nursing personnel across different tiers, thereby facilitating the precise implementation of nursing protocols, ensuring the delivery of high-quality care, and promoting patient safety.^[5,6,7] While the above-mentioned nursing models have individually shown favorable clinical outcomes in the field of elderly-related chronic diseases, their specific effects when used in combination for CHF patients are not yet known. Considering this, the aim of this study is to analyze the value of applying the combination of the CICARE communication model and hierarchical responsibility nursing in elderly patients with CHF. This analysis aims to provide theoretical and practical references for the subsequent nursing care of elderly heart failure patients.

2. Materials and methods

2.1. General data

The study was approved by the Ethics Committee of Xi’an Ninth Hospital. From June 2021 to June 2023, a total of 120 elderly patients with CHF admitted to our hospital were selected. They were divided into 2 groups: the regular group (received standard care, n = 60) and the observation group (received a combination of the CICARE communication model and hierarchical responsibility nursing, n = 60). The general characteristics of both groups are shown in Table 1 (P > .05).

Table 1.

Comparison of general information between the 2 groups [n (%), ($\overline{\chi }\pm s$)].

General information	Regular group (n = 60)	Observation group (n = 60)	t/χ2	P
Gender
male	38 (63.33)	40 (66.67)	0.147	.702
female	22 (36.67)	20 (33.33)
Age/year	72.52 ± 9.23	73.18 ± 8.79	−0.401	.689
BMI	23.22 ± 2.21	23.49 ± 2.72	−0.638	.554
Cardiac function classification
Grade II	15 (25.00)	11 (18.33)	0.786	.675
Grade III	33 (55.00)	36 (60.00)
Grade IV	12 (20.00)	13 (21.67)
Course of disease
< 1 year	12 (20.00)	10 (16.67)	0.670	.716
1–5 year	17 (28.33)	21 (35.00)
> 5 years	31 (51.67)	29 (48.33)
Hyperlipemia	26 (43.3%)	33 (55.0%)	2.564	.109
Hypertension	17 (28.3)	19 (31.7%)	0.274	.601
Diabetes	6 (10.0)%	6 (10.0%)	0.001	1.000

Inclusion criteria: (1) in line with the diagnostic criteria of chronic heart failure in the “Chinese heart failure diagnosis and treatment guidelines 2018.”^[8] (2) Cardiac function classification: grade II–IV. (3) Age ≥60 years old. (4) No serious cognitive dysfunction or mental retardation, can effectively participate in the intervention. (5) Patients had signed the informed consent, approved by the hospital medical ethics committee.

Exclusion criteria: (1) patients with severe cardiac or noncardiac complications. (2) Patients with severe mental illness; patients with malignant tumors or infectious diseases. (4) Patients with severe physical disorders and unable to carry out daily life activities independently.

2.2. Methods

The regular group received standard care, which included routine admission orientation and discharge instructions. Throughout their hospitalization, they received dietary guidance and underwent close monitoring of vital signs. Both groups received standard therapies, including routine oxygen inhalation and medications such as cardiotonic agents, diuretics, hypotensives, and vasodilators. Specifically, digoxin was administered orally at a dose of 0.125 mg once daily, spironolactone was given orally at a dose of 20 mg once daily for diuresis, nifedipine sustained-release tablets were administered orally at a dose of 10 mg twice daily, and isosorbide nitrate tablets were given orally at a dose of 5 mg twice daily for coronary dilation. Any deviations from normal parameters were promptly identified and managed with appropriate interventions.

The observation group received a combination of the CICARE communication model and hierarchical responsibility nursing coordination:

• (1) A responsibility nursing team was assembled, comprising personnel including the department nursing director, head nurse, staff nurses, and specialized nurses. Upon patients’ admission, this team undertook a comprehensive assessment of elderly CHF patients. This assessment encompassed evaluating cardiac function indicators, reviewing radiological findings, and collecting data on symptoms and lifestyle. Subsequently, leveraging the NYHA classification scoring tool and the assessment outcomes, the team delineated individualized care plans tailored to each patient’s specific needs,^[9] the severity of CHF was determined and categorized as mild, moderate, or severe CHF. Mild CHF (NYHA Class I): the focus was on implementing lifestyle modifications and devising personalized exercise and dietary plans. Emphasis was placed on ensuring patient comprehension and adherence to the prescribed medication regimen. Additionally, patients were educated on self-monitoring techniques for weight, symptoms, and recognizing when to seek medical assistance. Moderate CHF (NYHA Classes II–III): a heightened level of scrutiny was applied, involving more frequent examinations and monitoring of relevant indicators to track disease progression. Regular assessments of the patient’s condition were conducted, allowing for timely adjustments to the medication regimen as necessary. Severe CHF (NYHA Class IV): Intensified monitoring, including cardiac ultrasound, electrocardiogram, blood tests, and monitoring of fluid intake and output. Established a disease monitoring plan, including the monitoring of early symptoms for timely treatment adjustments. Developed emergency plans to address sudden situations.

• (2) During the implementation of nursing measures, the CICARE communication model was employed: (1) Connect: when interacting with patients, it is essential to maintain a respectful and friendly tone throughout. Begin by greeting the patient using their name and, if appropriate, using titles like Mr. or Mrs. This demonstrates acknowledgments and respect for the individual. Throughout the conversation, ensure that words and tone convey respect, empathy, and understanding, creating a positive and supportive atmosphere for the patient. (2) Introduction: before treatment begins, introduce the members of the healthcare team to the patient and their family, including the attending physician and nurses. Explain the nursing process and treatment plan in detail to ensure that the patient understands what will happen next, alleviating any anxiety. Provide detailed information about treatments and tests, including why they are needed and potential risks or discomfort. (3) Communication: establish effective 2-way communication with the patient. Encourage the patient to share their symptoms, concerns, and questions, and actively listen to their feedback. Use clear and simple language to communicate, avoiding medical jargon or technical terms to ensure the patient can understand. When explaining information about chronic heart failure and related diseases in the elderly, provide diagrams or illustrations to help the patient better understand the diagnosis and treatment. (4) Ask: actively inquire about the patient’s feelings, needs, concerns, or questions. Use open-ended questions such as “How are you feeling?” to encourage the patient to describe their feelings and experiences in detail. Ensure the patient understands they can ask questions or provide feedback at any time and express a willingness to address their concerns. (5) Response: provide clear and detailed responses to address the patient’s questions and concerns. If you do not know the answer, commit to finding it and responding promptly. (6) Exit: at the conclusion of the nursing process, express gratitude for the patient’s cooperation and trust. For example, say, “Thank you for your time and cooperation, Mr./Mrs. xx. If you have any questions or need further assistance, please don’t hesitate to reach out to us.”

2.3. Observed indexes

• (1) Cardiac function indicators: before and after the intervention, the left ventricular end-diastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF) of the patients were measured using the ACUSON SC2000 ultrasound machine produced by Siemens Healthineers. Before performing the examination, the ultrasound doctor should hold the probe with his left hand, take the patient in the left lying position, place the probe near the sternum, and inspect the heart apex. After that, the probe was placed in the suprasternal fossa and the shoulder was raised to maintain the supine position to further improve the accuracy of the examination. The left ventricle near the sternum can be scanned with long-axial plane to examine the position of the apex of the heart. After that, the probe was placed in the suprasternal fossa and the shoulder was raised to maintain the supine position to further improve the accuracy of the examination. The left ventricle adjacent to the sternum can be scanned with long-axial plane, and the left sternoclavicular joint and its alignment position can be carefully observed. In the examination of the great artery beside the sternum, the short-axis section examination should be taken, and the probe should be placed between the ribs of the left margin of the sternum 2–3, and the plane and left ventricular long-axis scanning should be performed. When scanning the sections of the major and minor axis of the aortic arch, the probe should be placed in the suprasternal fossa facing the heart, and the transverse aortic arch scan should be performed after rotation of 90°. The size and organizational structure of the heart were investigated in more detail, so as to accurately grasp the state of the heart, and the structure and level of activity of the heart were observed in combination with ultrasound diagnosis.

At the same time, 5 mL of fasting venous blood was collected from the patients before and after the intervention. After centrifugation, serum was separated, and B-type natriuretic peptide (BNP) levels were measured using enzyme-linked immunosorbent assay. The ELISA kit was sourced from Shanghai Enzyme-linked Immunobioscience Co., Ltd.

• (2) Exercise tolerance: exercise tolerance of the patients before and after the intervention was assessed using the 6-minute walk test (6MWT).^[10] In the 6MWT, the individuals being tested are required to walk as far as possible in a flat indoor or outdoor corridor for a duration of 6 minutes, and the distance they cover is recorded.

• (3) Time to relief of clinical symptoms: during the nursing intervention, the time to relief of shortness of breath and edema was recorded for both groups of patients.

• (4) Self-efficacy score^[11]: before and after the intervention, the patients’ self-efficacy was assessed using a general self-efficacy scale, with scores ranging from 10 to 40 points. Patient self-efficacy increases with higher scores.

• (5) Quality of life score^[12]: before and after the intervention, the Minnesota Living with Heart Failure Questionnaire was used to assess the patients’ quality of life, with scores ranging from 0 to 20 points. Higher scores indicate a poorer quality of life.

2.4. Statistical processing

SPSS26.0 was used for statistical analysis. The measurement data were described by ($\overline{\chi }\pm s$), and t test was used. Enumeration data were described by n (%), using χ² test.

3. Results

3.1. Comparison of cardiac function indexes between the 2 groups

As indicated in Table 2, before the intervention, baseline levels of cardiac function indicators did not significantly differ between the 2 groups of patients (P > .05). However, following the intervention, both groups exhibited a reduction in LVEDD and BNP levels, with the observation group demonstrating lower levels of LVEDD and BNP compared to the regular group. Moreover, both groups experienced an increase in LVEF levels, with the observation group displaying higher LVEF levels than the regular group (P < .05).

Table 2.

Comparison of cardiac function indexes between the 2 groups ($\overline{\mathit{\chi }}\mathbf{\pm }\mathit{s}$).

Group	LVEDD (mm)		LVEF (%)		BNP (pg/mL)
	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention
Regular group (n = 60)	60.12 ± 5.77	55.39 ± 5.21*	36.02 ± 3.17	46.28 ± 3.98*	689.52 ± 194.78	574.22 ± 166.54*
Observation group (n = 60)	59.85 ± 5.64	51.24 ± 4.98*	36.21 ± 3.34	52.37 ± 4.60*	699.08 ± 186.12	496.08 ± 152.37*
t	0.259	4.460	−0.320	−7.755	−0.275	2.681

^* Compared with the group before intervention, P < .05.

3.2. Comparison of exercise tolerance between the 2 groups

As depicted in Table 3, prior to the intervention, there were no significant differences in exercise tolerance between the 2 groups of patients (P > .05). However, following the intervention, both groups demonstrated a notable increase in the distance covered during the 6MWT compared to baseline measurements. Furthermore, the observation group exhibited a significantly greater improvement in 6MWT distance compared to the regular group (P < .05).

Table 3.

Comparison of exercise tolerance between the 2 groups ($\overline{\chi }\pm s$).

Group	6MWT distance (m)
	Pre-intervention	Post-intervention
Regular group (n = 60)	235.69 ± 25.58	276.34 ± 23.08*
Observation group (n = 60)	238.75 ± 23.22	414.21 ± 32.96*
t	−0.686	−26.54
P	.494	.000

^* Compared with the group before intervention, P < .05.

3.3. Comparison of clinical symptom relief time between the 2 groups

As illustrated in Table 4, following the intervention, there were no significant differences observed in the time to relief of shortness of breath and edema between the 2 groups of patients (P > .05). This indicates that CICARE communication model and hierarchical responsibility nursing coordination cannot significantly improve patients’ long-term symptoms.

Table 4.

Comparison of clinical symptom relief time between the 2 groups ($\overline{\chi }\pm s$).

Group	Dyspnea relief time (d)	Edema remission time (d)
Regular group (n = 60)	7.06 ± 1.96	7.53 ± 2.34
Observation group (n = 60)	6.85 ± 2.08	7.38 ± 2.27
t	0.569	0.356
P	.570	.722

3.4. Comparison of self-efficacy and quality of life scores between the 2 groups

As depicted in Table 5, before the intervention, there were no significant differences observed in self-efficacy and quality of life scores between the 2 groups of patients (P > .05). However, after the intervention, both groups exhibited an improvement in self-efficacy scores. Particularly, the observation group demonstrated significantly higher self-efficacy scores compared to the regular group (P < .05). Additionally, both groups experienced a decrease in quality of life scores post-intervention, with the observation group displaying lower quality of life scores compared to the regular group (P < .05).

Table 5.

Comparison of self-efficacy and quality of life scores between the 2 groups ($\overline{\chi }\pm s$).

Group	Self-energy efficiency score (score)		Quality of life rating (score)
	Pre-intervention	Post-intervention	Pre-intervention	Post-intervention
Regular group (n = 60)	17.58 ± 3.14	23.65 ± 5.23*	15.38 ± 3.31	12.02 ± 2.46*
Observation group (n = 60)	17.46 ± 3.08	34.13 ± 5.97*	15.46 ± 3.22	7.96 ± 1.85*
t	0.211	−10.228	−0.134	10.217
P	.833	.000	.893	.000

^* Compared with the group before intervention, P < .05.

4. Discussion

CHF is a prevalent and grave cardiovascular condition often accompanied by a myriad of clinical symptoms including breathlessness, edema, fatigue, and others. These symptoms significantly diminish patients’ quality of life, imposing substantial challenges on their daily functioning and well-being.^[13,14] In elderly patients with CHF, the degeneration of physiological functions and the presence of multiple comorbidities pose heightened complexity and challenges in nursing care. Unfortunately, conventional nursing models often prioritize physiological and biochemical disease management, inadvertently overlooking the crucial psychological, social, and communication needs of these patients.^[15,16] In recent years, the CICARE communication model has emerged as an innovative strategy in nursing communication. This model prioritizes patient-centered communication and nursing practices, aiming to optimize the quality of care by fostering enhanced communication between patients and healthcare professionals.^[17,18] This model involves systematic communication in 6 phases, which include addressing the patient, introducing oneself, effective communication, asking questions, providing answers, and concluding the interaction. It advocates for a nursing culture that prioritizes the patient’s experience, respects their values, and meets their needs.^[19,20] The tiered responsibility nursing coordination strategy places emphasis on the rational allocation and optimal utilization of nursing resources to achieve refined and personalized nursing services.^[21,22] Although these 2 strategies have shown certain advantages in other medical fields, their application and effectiveness in elderly CHF patients have not been thoroughly researched and validated.

The results of this study demonstrated that the observation group had significantly lower levels of LVEDD and BNP, and higher LVEF levels after the intervention compared to the conventional group. This suggests that the observation group, which utilized the CICARE communication model and tiered responsibility nursing coordination strategy, showed greater improvement in cardiac function. The reason for this was that the observation group conducted comprehensive assessments and implemented tiered nursing, providing specific attention and care strategies tailored to the severity of the patients’ condition. For instance, patients with mild CHF may have reduced the burden on their hearts through lifestyle changes, while those with moderate and severe CHF received more precise and frequent monitoring, leading to more timely intervention and treatment.^[23,24] Additionally, combining the CICARE communication model allowed for better patient education and guidance regarding CHF, enhancing patients’ self-management abilities and autonomy. This helped them control and manage their symptoms and lifestyle more effectively in their daily lives.^[25] Furthermore, the observation group’s education on medication plans and self-monitoring techniques can also assist patients in adhering more accurately to their treatment regimens and promptly identifying potential issues.^[26,27]

The results of this study also revealed that while there was no statistically significant difference in the time to relief of clinical symptoms between the 2 groups after the intervention, there was an increase in the 6MWT distance for patients following the intervention in both groups. Furthermore, the observation group exhibited a significantly greater improvement in 6MWT distance compared to the conventional group. This suggested that the utilization of the CICARE communication model and tiered responsibility nursing coordination strategy contributes to enhancing patients’ exercise tolerance. This was primarily because tiered responsibility nursing, tailored to different degrees of CHF, can more effectively preserve the functional status of patients, particularly in those with mild to moderate CHF. Lifestyle adjustments and education in this group can significantly slow down the progression of the disease.^[28,29] Secondly, the emphasis on personalized communication and care in the CICARE communication model provides robust psychological support for patients. This approach aids patients in coping more effectively with their illness and treatment process on a psychological level, consequently reducing anxiety and stress. This reduction in psychological distress can have a positive impact on their physiological health.^[30,31]

Further comparison of their self-efficacy and quality of life scores revealed that both groups of patients demonstrated higher self-efficacy scores after the intervention compared to before. However, the observation group exhibited a more significant improvement in self-efficacy scores, indicating that patients in this group, under the CICARE communication model and tiered responsibility nursing intervention, became more proactive and demonstrated enhanced self-management and decision-making abilities. Similarly, regarding quality of life, the observation group displayed higher scores after the intervention compared to the conventional group, suggesting that the implementation of the CICARE communication model contributed to enhancing the patients’ quality of life. The analysis highlights that the nursing approach utilizing the CICARE communication model prioritizes patient involvement and understanding. This emphasis aids patients in gaining a better comprehension of their medical condition and treatment plans, subsequently bolstering their self-management and decision-making skills.^[32,33] Through a finely-tailored tiered nursing strategy, CHF patients with varying degrees of severity can receive more personalized care plans. This not only allows for timely adjustments to treatment plans but also contributes to enhancing patient comfort and satisfaction, ultimately improving their quality of life.^[34] Additionally, the CICARE communication model fosters 2-way communication between the nursing team and patients. This approach facilitates increased emotional support and care for patients, which in turn helps to alleviate psychological stress and enhance their overall quality of life.^[35] The limitations of this study primarily stem from the small sample size, although this does not compromise the accuracy of the statistical data presented in the article. Additionally, we should increase the follow-up time to observe the long-term efficacy of CICARE’s care. This study is a single-center study, and the results of our study are biased to a certain extent. Despite these limitations, we believe that the CICARE communication model holds significant potential. In future research, we plan to conduct multi-center studies with extended follow-up periods to further explore the effectiveness of both the CICARE communication model and the hierarchical responsibility nursing coordination model. Our aim is to discover better care strategies for elderly patients with chronic heart failure.

In summary, the application of the CICARE communication model and hierarchical responsibility nursing coordination strategy in elderly patients with CHT can effectively improve patients’ cardiac function, enhance their exercise tolerance, self-efficacy, and overall quality of life. These findings indicate that this approach is worth considering for clinical implementation and promotion.

Author contributions

Conceptualization: Yuhuan Zhao, Mi Pang, Yuanle Xu.

Data curation: Yuhuan Zhao, Mi Pang, Yuanle Xu.

Investigation: Yuhuan Zhao, Mi Pang, Yuanle Xu.

Methodology: Mi Pang, Yuanle Xu.

Supervision: Yuhuan Zhao, Mi Pang, Yuanle Xu.

Visualization: Yuanle Xu.

Writing – original draft: Yuhuan Zhao, Mi Pang, Yuanle Xu.

Writing – review & editing: Yuhuan Zhao, Mi Pang, Yuanle Xu.