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Running head: CHF AND THE IMPACT OF CULTURE BROKERAGE
Congestive Heart Failure and the Impact of Culture Brokerage
LaToya Thomas
Nova Southeastern University
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CHF AND THE IMPACT OF CULTURE BROKERAGE
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Congestive Heart Failure and the Impact of Culture Brokerage
Congestive heart failure (CHF) is a major health condition that is associated with
decreased quality of life, high hospital readmission rates, and increased healthcare costs (Hines,
Yu, & Randall, 2010). CHF affects approximately five million people in the United States and
550,000 new patients are diagnosed with the disease annually (Hines et al., 2010). This
disabling disorder is the single most common cause of hospitalization of people over the age of
65 (Tansey, 2010). The potential of developing CHF increases with age and due to advances in
technology, patients with high risks factors and chronic illnesses are now living longer. CHF has
cost Medicare $17.4 billion due to high annual readmission rates (Hines et al., 2010). This
health care dilemma has prompted many hospitals to focus on improving the healthcare
outcomes of this patient population (Hines et al., 2010).
Background
Congestive heart failure occurs when the pumping action of the heart is impaired, and
excess fluid backs up into the lungs and other body tissues (Bart, 2009). The majority of patients
with heart failure experience symptoms of peripheral or pulmonary congestion, which include
fatigue, dyspnea, cough, ankle swelling and angina (Bart, 2009). The three major treatment
goals for patients with CHF are relief of symptoms, prevention of disease progression, and the
reduction in mortality risk (Green & Harris, 2008).
Heart failure is a chronic condition that requires an immense amount of self-care (Riegel,
Lee, & Dickson, 2011). In order to maintain a healthy lifestyle, patients are urged to adhere to a
daily routine consisting of medication compliance, diet restrictions, and daily weights. There is
no cure for CHF and this routine is vital in preventing the progression of CHF symptoms (Britz
& Dunn, 2010). Poor self-care remains common amongst this patient population. Fewer than
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half of CHF patients weigh themselves routinely to monitor fluid retention and most do not
comply with the recommended sodium restricted diet (Riegel et al., 2011). According to
Rushton, Satchithananda, and Kadam (2011), many CHF patients view self-management of the
CHF as challenging. Patients often report feeling overwhelmed due to the lack of
communication with the healthcare provider, limited understanding and the complexity of the
information given to them upon being discharged after hospitalization (Rushton et al., 2011).
These frustrations lead to noncompliance and eventual reoccurrence of CHF related symptoms
(Rushton et al., 2011).
Problem Statement
Congestive heart failure patients who have poor post-discharge support and lack
motivation to self-manage the disease are at a greater risk for hospital readmission. According to
Bart (2009), 2% to 22% of patients die during the acute hospitalization, 44% are readmitted
within six months and 33% are deceased within one year. Researchers have explicitly shown
through mixed method studies, the relationship between heart failure patients and the quality of
life of this population (Hines et al., 2010). Patients that lack the desire to manage the disease
themselves develop worsened cognition, more sleepiness, and greater depression (Riegel et al.,
2011). Studies also found that patients who develop an improved sense of confidence in their
ability to cope with CHF, avoid the acute onset of symptoms (Britz & Dunn, 2010). Early
recognition of symptoms allows the patient to seek medical assistance at the primary stages of
exacerbation and decreases the potential readmission by addressing the symptoms before they
become uncontrollable (Britz & Dunn, 2010).
Patient education regarding the management of congestive heart failure is an essential
preventative measure that can aid in positive health outcomes and decreased readmissions
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(Rushton et al., 2011). Nurses play an integral role in the promotion of optimal outcomes in
cases of CHF through implementing education of the disease process, diet and nursing support
for psychosocial issues (Smeulders et al., 2010). Nursing support is usually initiated while the
patient is hospitalized, but the efforts need to be continued after discharge through programs like
telephonic follow-up calls (Smeulders et al., 2010). These calls ease the transition of the patient
being treated in the hospital and returning to care for themselves at home. Several studies report
significant improvements in patient outcomes with use of telephone follow-up calls that evaluate
medication use and other measures of CHF symptom management (Smeulders et al., 2010).
Slater, Phillips, and Woodard (2008), implemented a telephonic program that served as a
resource for post-discharged CHF patients. Nurses contacted patients every week, telephonically
over a three-month time frame. These calls consisted of evaluation that assessed the patients
understanding of CHF, signs and symptoms, importance of daily weights, medication review,
diet and controllable risk factors. This program empowered CHF patients to take an active role in
the managing the disease with constant reinforcement and education. Based upon these
assessments, nurses developed plans of care to address deficits that may have hindered selfmanagement of the disease (Slater et al., 2008). The telephonic follow-up calls resulted in a
dramatic reduction in readmission rates, emergency room visits and motivated patients to take
control of their illness (Slater et al., 2008).
Purpose of the Study
The aim of this paper is to examine the effects of post-discharge nursing support and the
adherence of self-care routines on the readmission rates of congestive heart failure patients. The
focus is on the factors that contribute to the success in achieving self care amongst patients with
CHF and the outcomes of post-discharge nursing intervention.
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Hypothesis
If readmission rates are adversely related to post-discharge nursing support and the
patient’s adherence to self-management routines, then increased nursing intervention and
proactive self-care will decrease the readmission rates of congestive heart failure patients.
Theoretical Framework
Theory Description
Purpose of the theory. The purpose of this theory is to bridge, link, or mediate between
persons of differing cultural backgrounds for the purpose of reducing conflict or producing
change (Jezewski, 1995, p. 20).
Scope. This is a middle range theory.
Origins of the theory. The term “culture brokering” was first coined in the colonial era
when anthropologist observed when individuals in communities acting as middlemen between
the government and the peasant societies that were ruled by the colonial powers (Jezewski,
1995). These middlemen brokered to resolve conflicts between the local people and the
government. In the 1960s, health care researchers began to explore the idea of brokering in
relation to the health care delivery system and how health care professionals could act as brokers
between patients and the health service system (Jezewski, 1995).
Major concepts. The major concepts of the theory include culture, cultural brokerage,
and conflict.
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Major theoretical propositions :
1. Promotes patient advocacy to ensure the delivery of effective care, recognizing
the values that guide attitudes and behaviors. (Jezewski, 1995).
2. Establishes greater congruence between the patient’s perception of illness and the
practitioner’s perception of the patient’s diagnosis (Chalanda, 1995).
3. Increases the compatibility between the patients’s understanding of desired
treatments and the scientific therapeutic regimen. (Chalanda, 1995)
4. Promotes healthcare through problem resolution by intervening in conflict
situations when tensions arise (Jezewski, 1995).
Major assumptions:
1. Culture was viewed as a system of learned and shared standards for perceiving,
interpreting and behaving in interactions with others and the environment
(Jezewki, 2005, p.16).
2. The health care system was viewed as a cultural and social system consisting of
external factors (social, political and economic) to internal processes
(psychophysiological, behavioral and communicative (p.16).
3. Professional nurses are valued component in clients interactions within the health
care system (p.16).
4. People have the right to health care that ideally they were able to manage in
cooperation with the health care provider (p.17).
Context for use. Culture Brokering was used in the context of caring for groups of
clients who were politically and economically hopeless and individuals who were facing a life
threatening condition and required to make informed decisions under stressful conditions
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(Jezewski, 1995). The literature states, “the domain of focus is at the level of system, the
community, or the individual/family”, this implies that it may be used in multiple settings and
situations (Alexander, Uz, Hinton, & Jones, 2008, p.467).
Theory Analysis
Theoretical definitions of major concepts:

Culture- Integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values and institutions of
race, ethnic, religious, or social groups (Jezewki, 2005, p.17).

Cultural Brokerage- The act of bridging, linking, or mediating between groups or
persons of differing cultural backgrounds for the purpose of reducing conflict or
producing change (p.20).

Conflict- Asymmetry of power between the person seeking care and the
individual providing care (p.19).
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Theoretical Model
Figure 1
( Source: Michie, M. (2003). The role culture brokers in intercultural science education: A research proposal. Retrieved from
http://aaablogs.uoregon.edu/beijingfieldschool/files/2011/07/The-Role-of-Culture-Brokers-in-Intercultural-Science-Education.pdf)
Theory Evaluation
Congruence with nursing standards. The Theory of Culture Brokerage does appear
congruent with today’s standards of nursing care. Culture Brokerage encompasses the cultural
self-awareness of the nurse, value for broad cultural meanings of health and illness, and
proactive efforts to mediate between the healthcare system and cultural patterns that influence
daily health behaviors (Jeffreys, 2005). A number of articles were identified in recent nursing
literature describing cultural brokering as it applies to cultural uniqueness of individuals in which
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patterns of learned behavior were turned into a plan of thoughts and actions (Alexander et al.,
2008).
Congruence with nursing interventions. Literature-based descriptions utilized cultural
brokerage strategies in diabetic education (Alexander et al., 2008). Glegg (2010) adapted the
model to assist clinicians in compiling useful resources to assist team members in incorporating
evidence into practice by way of knowledge brokering and the investigation of the role of
Australian Nurse Practitioners as brokers of care was examined in the elderly residential
population (Arbon et al., 2009).
Previous testing of the theory. The theory was derived from empirical studies, data
from health care situations and statement synthesis (Jezewski, 1995). The theory is supported by
multiple research studies and reviews of literature.
Social and cultural relevance. The theory is relevant to individuals, families, and groups
regardless of age or socioeconomic status. The theory has also been applied in a diverse sample
of cultural groups as stated in the referenced literature.
Appropriateness of the Theory to the Problem
People of various backgrounds have an array of beliefs, issues and perspectives when
dealing with chronic illnesses like congestive heart failure (Chalanda, 1995). Individual
perspectives govern the way that a patient may interpret the management of an illness. The
Theory of Culture Brokerage is an intervention that can be applied by nurses in practice to
overcome barriers that may impede self-care in patients with CHF. The primary goal of Culture
Brokerage is to resolve conflict (Jezewski, 1995). Nurses can become the catalyst in resolving
conflict that frequently occurs when physicians assume that patients are more knowledgeable
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about managing an illness than they are and that patients have the economic means to follow
through with treatment (Jezewski, 1995).
Nurses can act as liaisons by bridging gaps that may exist between the provider and the
patient. Interventions of this nature empower patients with the resources needed to manage the
disease process and supports self-management that promotes self-confidence. When patients
have knowledge regarding their conditions and the changes that their bodies may be
experiencing, this alleviates the stress that chronic illness may cause (Britz & Dunn, 2008).
Summary
Congestive heart failure has led to frequent readmissions due to the complex management
of this progressive disease (Hines et al., 2010). Heart failure readmissions are due to multiple
factors such as the lack of patient compliance, inadequate discharge preparation, poor
communication and limited economic resources (Hines et al., 2010). High readmission rates
have resulted in a significant financial burden on the nation’s health care industry (Hines et al.,
2010). Continued reinforcement by healthcare providers ensures that CHF patients understand
the importance of self-care routines (Rushton et al., 2011). Evidence based studies have proven
that patients who adhere to their prescribed heart failure regimen have fewer symptoms and an
increased functional capacity, which lead to decreased hospitalization (Britz & Dunn, 2010).
Compliance is essential in improving patient outcomes and overall wellbeing. Utilizing nurses
as Cultural Brokers to improve patient’s quality of life, will not only reduce the readmission rate,
but also improve the patient’s quality of life by addressing the patient’s physical, emotional,
cultural and social needs.
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References
Alexander, G., Uz, S., Hinton, I., & Jones, R. (2008). Culture brokerage strategies in diabetes
education. Public Health Nursing, 25(5), 461-470. doi: 10.1111/j.15251446.2008.00730.x
Arbon, P., Bail, K., Eggert, M., Gardner, A., Hogan, S., Phillips, C.,...Waddington, G. (2009).
Reporting a research project on the potential of aged care nurse practitioners in the
Australian capital territory. Journal of Clinical Nursing, 18(2), 255-262. doi:
10.1111/j.1365-2702.2008.02452.x
Bart, B. A. (2009). Treatment of congestion in congestive heart failure: Ultrafiltration is the only
rational initial treatment of volume overload in decompensated heart failure. Journal of
the American Heart Association, 2, 499-504. doi:
10.1161/CIRCHEARTFAILURE.109.863381
Britz, J., & Dunn, K. (2010). Self-care and quality of life among patients with heart failure.
Journal of the American Academy of Nurse Practitioners, 22, 480-487. doi:
10.1111/j.1745-7599.2010.00538.x
Chalanda, M. (1995). Brokerage in multicultural nursing. International Nursing Review, 41(1),
19-22.
Glegg, S. (2010). Knowledge brokering as an intervention in pediatric rehabilitation practice.
International journal of Therapy & Rehabilitation, 17(4), 203-211.
Green, R., & Harris, N. (2008). Pathology and therapeutics for pharmacists (3rd ed.). London,
UK: Pharmaceutical.
Hines, P., Yu, K., & Randall, M. (2010). Preventing heart failure readmissions: Is your
organization prepared? Nursing Economic$, 28(2), 74-85.
CHF AND THE IMPACT OF CULTURE BROKERAGE
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Jezewski, M. A. (1995). Evolution of grounded theory: Conflict resolution through culture
brokering. Advances in Nursing Science, 17(3), 14-30.
Riegel, B., Lee, C., & Dickson, V. (2011). Self Care in Patients With Chronic Heart Failure.
Nature Reviews Cardiology, 8(1), 1-11.
Rushton, C., Satchithananda, D., & Kadam, U. (2011). Comorbidity in modern nursing: a closer
look at heart failure. British Journal of Nursing, 20(5), 280-285.
Slater, M. R., Phillips, D., & Woodard, E. (2008). Cost-effective care a phone call away: A
nurse-managed telephonic program for patients with chronic heart failure. Nursing
Economic$, 26(1), 41-44.
Smeulders, E., Van Haastregt, J., Ambergen, T., Uszko-Lencer, N., Janssen-Boyne, J., Gorgels,
A.,...Kempen, C. (2010). Nurse-led self-management group program for patients with
congestive heart failure: randomized controlled trial. Journal of Advanced Nursing,
66(7), 1487–1499. doi: 10.1111/j.1365-2648.2010.05318.x
Tansey, P. (2010). Counting the cost of heart failure to the patient, the nurse and the NHS.
British Journal of Nursing, 19(22), 1396-1401.