Journal Pre-proof

Heart Failure in Nursing Homes: A Scoping Review of Educational

Interventions for Optimising Care Provision

James McMahon , David R Thompson , Jan Cameron ,

Christine Brown Wilson , Loreena Hill , Paul Tierney , Doris Yu ,
Debra K Moser , Karen Spilsbury , Nittaya Srisuk ,
Jos M G A Schols , Mariëlle van der Velden , Gary Mitchell

PII: S2666-142X(24)00005-5
DOI: https://doi.org/10.1016/j.ijnsa.2024.100178
Reference: IJNSA 100178

To appear in: International Journal of Nursing Studies Advances

Received date: 11 August 2023

Revised date: 21 December 2023
Accepted date: 12 January 2024

Please cite this article as: James McMahon , David R Thompson , Jan Cameron ,
Christine Brown Wilson , Loreena Hill , Paul Tierney , Doris Yu , Debra K Moser ,
Karen Spilsbury , Nittaya Srisuk , Jos M G A Schols , Mariëlle van der Velden , Gary Mitchell ,
Heart Failure in Nursing Homes: A Scoping Review of Educational Interventions for Op-
timising Care Provision, International Journal of Nursing Studies Advances (2024), doi:
https://doi.org/10.1016/j.ijnsa.2024.100178

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2024 Published by Elsevier Ltd.

This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
 V5

A scoping review

Heart Failure in Nursing Homes: A Scoping Review of Educational Interventions for Optimising
Care Provision

James McMahon1*, David R Thompson1, Jan Cameron2, Christine Brown Wilson1, Loreena Hill1, Paul
Tierney1, Doris Yu3, Debra K Moser4, Karen Spilsbury5, Nittaya Srisuk6, Jos M G A Schols7, Mariëlle van
der Velden7 and Gary Mitchell1

1
School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK

2
School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia

3
School of Nursing, University of Hong Kong, Hong Kong, China

4
College of Nursing, University of Kentucky, Lexington, Kentucky, USA

5
School of Healthcare, University of Leeds, Leeds, UK

6
Faculty of Nursing, Surat Thani Rajabhat University, Surat Thani, Thailand

7
Department of Health Services Research and Department of Family Medicine, Care and Public

Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands

*Correspondence: j.mcmahon@qub.ac.uk

1
 V5

Heart Failure in Nursing Homes: A Scoping Review of Educational Interventions for Optimising
Care Provision

Abstract
Background: Heart failure has an estimated global prevalence of 64.3 million cases, with an average
age of a person living with heart failure at 75.2 years. Approximately 20% of residents living in
nursing homes (a long-term residential care environment for some individuals) report living with
heart failure. Residents living with heart failure in nursing home environments are often frail, have
reduced quality of life, higher rates of rehospitalisation and mortality, and greater complications in
heart failure management. Further, nursing home staff often lack the knowledge and skills required
to provide the necessary care for those living with heart failure. Interventions for improving heart
failure management in nursing homes have proven effective, yet there is a lack of understanding
regarding interventions for optimising care provision. The aim of this review was to synthesise the
current evidence on educational interventions to optimise care provided to people with heart failure
in nursing homes.

Methods: A scoping review with four databases searched: Medline, CINAHL, Web of Science, and
EMBASE. Relevant reference lists were searched manually for additional records. Studies of nursing
home staff or resident outcomes associated with changes in care provision (i.e., resident quality of
life, staff knowledge of heart failure) were included. Results from the charting data process were
collated into themes: intervention outcomes, changes to practice, and implementation and process
evaluation.

Results: Seven papers were deemed eligible for inclusion. Most studies (n=6) were comprised of
nursing home staff only, with one comprised only of residents. Study aims were to improve heart
failure knowledge, interprofessional communication, heart failure assessment and management.
Positive changes in staff outcomes were observed, with improvements in knowledge, self-efficacy,
and confidence in providing care reported. No difference was reported concerning nursing home
resident outcomes. Interprofessional communication and staff ability to conduct heart failure

2
 V5

assessments improved post-intervention. Changes to practice were mixed, with issues around
sustainability reported. Nursing home staff highlighted their appreciation towards receiving
education, recommending that videos, images, and humour could improve the intervention content.

Conclusions: There is a paucity of evidence around educational interventions to support residents

living with heart failure in nursing homes. However, available evidence suggests that educational
interventions in nursing homes may improve care through improving staff self-efficacy and
confidence in providing care, heart failure knowledge and interprofessional communication. The
complexity of implementing educational interventions in the nursing home setting must be
considered during the development process to improve implementation, effectiveness, and
sustainability.

Keywords: Heart Failure, Education, Interventions, Nursing homes, Older People, Scoping review

What is already known?

 There is a high prevalence of heart failure among residents living in nursing homes.
 Nursing home staff reportedly often lack the necessary knowledge and skills to provide
appropriate care for residents with heart failure.
 Educational interventions in nursing homes have proven effective for improving the
management of heart failure.

What this paper adds?

 There are few educational interventions associated with optimising care provision to nursing
home residents with heart failure.
 Existing interventions suggest that they can improve staff knowledge on heart failure, as well as
self-efficacy and confidence in providing care. However, there is limited evidence to support
interventions for improving resident outcomes.
 By concentrating explicitly on residents in permanent nursing home placements, the paper
provides novel insights into heart failure care within a distinct population with specific
characteristics and care needs.

3
 V5

Background
Heart failure, defined as a clinical syndrome characterised by structural and/or functional changes to
the heart (Bozkurt et al., 2021), has an estimated prevalence of 64.3 million cases worldwide
(Savarese et al., 2022). People living with heart failure often present with three or more
comorbidities, such as hypertension, diabetes mellitus and chronic kidney disease, which increases
the severity of heart failure symptoms and negatively impacts quality of life and prognosis
(Groenewegen et al., 2020). The presence of multi-comorbidities increases the complexity to
effectively manage patients with heart failure (Conrad et al., 2018). Consequently, difficulties in
management have resulted in higher rates of rehospitalisation (Groenewegen et al., 2020, Komajda,
2015, Wachter and Rommel, 2022), placing a significant demand on hospital facilities and personnel,
and incurring substantial healthcare costs (Cleland et al., 2019, Conrad et al., 2018, Lesyuk et al.,
2018, Urbich et al., 2020).

Due to an ageing population, improvements in diagnostic testing, and greater survival rates
following a cardiovascular event, the incidence of heart failure is expected to continue to rise (Lippi
and Sanchis-Gomar, 2020, Savarese et al., 2022). The prevalence of heart failure increases with age,
from 1% for those <55 years to 10% for those aged >70 years (McDonagh et al., 2021). In the USA
between 2001 and 2014, of the 14.6 million individuals hospitalised due to heart failure, 75.3% were
classified as older people (>65 years) (Akintoye et al., 2017). The mean age of this population is 75.2
years (Norhammar et al., 2023).

Nursing homes provide long-term residential care and support for older people in everyday
activities of living. The reported prevalence of heart failure in nursing homes varies greatly, with
data suggesting rates between 10—45% (Barents et al., 2008, Daamen et al., 2015, Daamen et al.,
2010, Heckman et al., 2014, Kantoch et al., 2018, Valle et al., 2005). Findings from an observational
study of 15,549 heart failure patients reported that those discharged to nursing homes from hospital
were frailer than those discharged home (Allen et al., 2011). Frailty in older people with heart failure

4
 V5

is associated with worsened health-related quality of life, greater levels of hospitalisation and
mortality, and complications in heart failure management (Heckman et al., 2014). Complications
include the presence of non-specific signs and symptoms associated with geriatric syndromes, such
as fatigue and delirium, confounding the diagnosis of heart failure exacerbations, and resulting in
worsened clinical outcomes (Daamen et al., 2015, Glenny et al., 2012, Heckman et al., 2014, Jarrett,
1995). Thus, it is imperative that nursing home residents with heart failure receive the appropriate
care and support to stabilise the condition, improve their quality of life, minimise the need for
hospitalisation, and reduce the risk of mortality.

Due to the complexity in providing care to older people with heart failure, nursing home staff
must be equipped with the necessary knowledge and skills to provide appropriate care (Spilsbury et
al., 2015). Recent qualitative findings suggest that nursing home staff lack the knowledge and
competency to appropriately care for residents with heart failure, are unaware of relevant signs and
symptoms, do not know how to identify exacerbations, and do not understand the purpose for daily
weighing (Morrow et al., 2020). Researchers have also reported that the level of staff training is
directly associated with the quality of care being provided to nursing home residents with heart
failure (Close et al., 2013). A recent workforce intelligence summary in the United Kingdom (Skills
for Care 2022) of UK care nursing homes has indicated that staff turnover is high (39.4% per year),
and this has been increasing since 2013. In addition, since 2012, there has been a 31% decrease in
the number of registered nurses working within care home settings (with an associated increase in
senior care assistant roles). Therefore, addressing the identified gaps in knowledge and skills among
nursing home staff is crucial to ensuring optimal care for older individuals with heart failure. The
reported deficiencies in recognising symptoms, identifying exacerbations, and understanding
essential care practices underscore the need for targeted training interventions for heart failure and
other long-term care conditions (Craig et al. 2023; Mitchell et al. 2016). The direct correlation
between staff training levels and the quality of care also emphasises the urgency of investing in
continuous education and skill development for nursing home personnel (Mitchell et al. 2017).
Moreover, the concerning trends in high staff turnover and the decrease in registered nurses
highlight the necessity for strategic workforce management and initiatives to enhance the
competency of the nursing home workforce (Cousins et al. 2016).

A scoping review of interventions to support heart failure management in skilled nursing

facilities and nursing homes settings was previously carried out in July 2017 (Heckman et al., 2018).
This scoping review reported on interventions for improving heart failure management in both
skilled nursing facilities and nursing homes settings. Importantly, this previous review had a broad
focus and most of the interventions included in this review were employed exclusively in skilled

5
 V5

nursing facilities which are a distinctly different setting to nursing homes. Skilled nursing facilities
traditionally provide intermediate or rehabilitative care to patients who are unable to be discharged
to their homes. Registered nurses, physicians, physical therapists, occupational therapists and
speech and language therapists comprise the professional team that work onsite within skilled
nursing facilities (National Library of Medicine, 2021; Heiks and Sabine, 2022). Inpatients that reside
within skilled nursing facilities will often do so temporarily until their rehabilitation is concluded.

On the contrary, residents living in nursing homes often have different care goals. This is
because older people living in nursing homes represent a frail population with impaired physical
function (Luo et al. 2015). Furthermore, registered nurses are usually the sole healthcare
professional that work onsite at a nursing home with multidisciplinary colleagues holding a
community role and serving a large geographical region (for example, general practitioner or
community physical therapist). While skilled nursing facilities focus on rehabilitative care and
discharge planning, nursing home settings often focus on comfort care and symptom management
(Zhang et al. 2019). In addition to this, it is estimated that the overall survival after nursing home
admission has been projected at 25.8 months (Reilev et al. 2020).

Given these distinctions and the specific needs of residents in nursing homes, there is a
compelling need for a targeted and comprehensive review of evidence-based interventions
specifically tailored for heart failure in nursing homes. Considering the contrasting care goals in
skilled nursing facilities (SNFs) and nursing homes for heart failure patients, where SNFs often
prioritise rehabilitation and discharge, while nursing homes emphasise comfort care and symptom
management, it is imperative to tailor interventions accordingly. This scoping review will therefore
specifically target evidence relevant to heart failure in nursing home settings.

The aim of this study was therefore to conduct a scoping review to synthesise the current evidence
on educational interventions for optimising care of residents with heart failure in nursing homes.
This was achieved through three key objectives:

i) What educational interventions have been implemented to optimise the provision of care
for residents living with heart failure in nursing homes?

ii) Have educational interventions implemented in nursing homes proven effective in

improving outcomes associated with optimising heart failure resident care?

iii) What are the reported experiences of providing educational interventions for optimising
care of heart failure residents in nursing homes by nursing home staff, including challenges,
facilitators, and barriers?

6
 V5

Beyond this review, the findings will be used by the authors to inform the design of a digital
educational intervention to optimise the quality of life of nursing home residents with heart failure
(McMahon et al., 2023).

Methods
This study was guided by Arksey and O'Malley (2005) recommendations for conducting scoping
reviews, Levac et al.’s (2010) paper on scoping review methodologies and reported in accordance
with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping
Reviews (PRISMA-ScR) checklist (Tricco et al., 2018). A protocol for this review was registered
prospectively on Open Science Framework (registration DOI:
https://doi.org/10.17605/OSF.IO/QVXRP).

Eligibility criteria
Eligibility criteria were developed using the Population, Concept, and Context (PCC) framework
recommended by the Joanna Briggs Institute (Peters et al., 2020).

Population

Nursing home residents with heart failure, and nursing home staff involved in providing care for
these residents, including care workers/care assistants, nurse/registered nurse, healthcare
professionals were included. Nursing home residents with other conditions, such as dementia, were
included if a diagnosis of heart failure was present. No restrictions were placed on how long the
residents must have resided in a nursing home facility.

Concept

Articles reporting on the implementation of an intervention to improve the provision of care for
individuals living with heart failure were considered for inclusion. Interventions could be delivered
through any method (e.g., telemedicine or educational interventions), and were included if they
reported on outcomes such as quality of life of residents, care staff knowledge, and self-efficacy of
staff in providing care. Articles were included when the intervention had a clear element associated
with heart failure but this may not have been the primary intention of the intervention. For example,
an intervention to improve the cardiovascular health of nursing home residents, but included
content and information specifically associated with heart failure. Non-interventional studies, those
not clearly related to heart failure, and those reporting on outcomes associated only with
management (e.g., medications), were excluded.

Context

7
 V5

Educational interventions implemented in a nursing home setting and other non-hospital long-term
care settings were included. Those that take place in hospital, acute or non-nursing home settings
were excluded.

Types of evidence sources

All empirical studies reporting on the implementation of an educational intervention for improving
care provision for nursing home residents with heart failure were considered for inclusion.
Commentary pieces, editorials, and summaries were excluded.

Search strategy
Search terms were developed through a review of those used previously in systematic and scoping
reviews about heart failure or nursing home settings, and in consultation with a subject librarian.
The search terms employed by JM during the search of Medline, as an example, can be found below
(Table 1). Search terms were adapted appropriately to search CINAHL, Web of Science, and EMBASE
in November 2022. No geographical or date restrictions were placed on the search. A search of the
WHO International Clinical Trials Registry Platform, UK Clinical Trials Gateway and ClinicalTrials.gov.
was also conducted. In addition, European cardiovascular disease and heart failure
websites/organisations/charities were searched e.g., Heart Failure Association of the ESC, British
Heart Foundation, and Northern Ireland Chest, Heart & Stroke. Lastly, a snowballing technique was
employed to search reference lists of relevant systematic and scoping reviews for articles not
identified through the database search.

Table 1. Example search terms applied in Medline

Concept/Search terms
Nursing home staff Heart failure Nursing homes
MeSH headings MeSH headings MeSH headings
1. Nurses/ OR 1. Heart failure/ OR 1. Nursing home/ OR
2. Nurse practitioner/ OR 2. Residential care/ OR
3. Nursing assistant/ OR 3. Residential home/ OR
4. Practical nurse/ OR 4. Home for the aged/ OR
5. Registered nurse/ OR 5. Long term care/ OR
6. Assisted living facility/ OR

Keywords Keywords Keywords

1. Nursing home personnel OR 1. Cardiac failure OR 1. Residential facilities OR
2. care worker* OR 2. Myocardial failure OR 2. Care home* OR
3. healthcare professional* OR 3. Heart decompensation AND 3. Long term care setting OR
4. care assistant* OR 4. Long term care facility* OR
5. healthcare assistant* OR 5. Old* people* home OR
6. HCA* OR 6. Old* age home OR
7. support worker* OR 7. Retirement home OR
8. certified nursing assistant* 8. Residential care institution*

8
 V5

OR OR
9. CNA* AND 9. Elderly care home* OR
10. Palliative care home*

Study selection and charting the data

All studies identified through the search strategy were imported into Covidence
(https://www.covidence.org/), a screening and data extraction tool for streamlining the production
of reviews. Following the removal of duplicates, JM and GM each independently carried out full
screening of the title and abstracts, with the same procedure used for full text screening. Any
disagreements throughout the screening process were resolved following a discussion between JM
and GM. Charting the data was carried out in Covidence, guided by the ‘JBI template source of
evidence details, characteristics and results extraction instrument’ (JBI, 2022). Study characteristics
extracted included the location, design, population, intervention, methods, outcomes, and results.

Summary and reporting of results

Results from the charting data process were collated into themes which, as recommended by Levac
et al. (2010), are discussed in the context of the aim of the study. In this case, to inform the design of
a digital intervention to optimise quality of life of nursing home residents with heart failure. Themes
include intervention outcomes, changes to practice, and implementation and process evaluation. As
the aim of this scoping review was to provide an overview of the available evidence rather than a
synthesised answer to a specific question, a critical appraisal of the included studies was not
conducted (Munn et al., 2018).

Results
The search strategy yielded 4212 results, with two additional records identified through other
sources. Following the removal of duplicates, title and abstract screening was applied to 3,722
records. Following full-text screening of the remaining records (n=18), seven were deemed eligible
for inclusion in this review. A PRISMA flow diagram has been provided to summarise the study
identification process (Figure 1).

Characteristics of included studies

Of the seven studies included in this review (Table 2), three were conducted in the USA (Kim et al.,
2016, Lekan et al., 2010, Sullivan, 2017), three in Canada (Boscart et al., 2017, Heckman et al., 2018,
Huson et al., 2015), and one in the UK (Hancock et al., 2012). Five were pilot studies (Boscart et al.,
2017, Hancock et al., 2012, Heckman et al., 2018, Huson et al., 2015, Kim et al., 2016), one a
feasibility study (Lekan et al., 2010), and one non-randomised controlled trial (Sullivan, 2017). Five

9
 V5

studies were peer-reviewed journal articles (Boscart et al., 2017, Hancock et al., 2012, Heckman et
al., 2018, Kim et al., 2016, Lekan et al., 2010), one a conference abstract (Huson et al., 2015), and
one a thesis as part of a Doctor of Nursing Practice degree (Sullivan, 2017). The composition of
participants varied: five were comprised of only nursing home staff professionals (Boscart et al.,
2017, Heckman et al., 2018, Huson et al., 2015, Kim et al., 2016, Lekan et al., 2010), and one of only
residents with heart failure (Hancock et al., 2012). One study strived to include both (Sullivan, 2017),
but were unable to recruit any residents. Of those studies that reported on sample size, a total of
215 participants were recruited. Of the four studies that reported the gender of participants (Boscart
et al., 2017, Hancock et al., 2012, Heckman et al., 2018, Kim et al., 2016), 122 of the 151 participants
were female (81%).

Figure 1. PRISMA flow diagram

10
 V5

Intervention characteristics
The aims of the interventions included in this review can largely be grouped into three categories –
improving interprofessional communication (Boscart et al., 2017, Heckman et al., 2018, Huson et al.,
2015, Lekan et al., 2010), improving heart failure knowledge (Boscart et al., 2017, Heckman et al.,
2018, Huson et al., 2015, Kim et al., 2016, Lekan et al., 2010, Sullivan, 2017), and improving onsite
assessment and management of heart failure symptoms (Hancock et al., 2012). A variety of
techniques were employed across the interventions to achieve these aims. Heart failure education
was central to all but one intervention (Hancock et al., 2012). The study by Hancock et al. 2012 did
however meet the inclusion criteria because bi-weekly visits by heart failure specialist nurses
included an educational component in the form of advice to residents and nurses. Three of the
studies (Boscart et al., 2017, Heckman et al., 2018, Huson et al., 2015) report on the ‘Enhancing
Knowledge and Interprofessional care for HF (EKWIP-HF)’ intervention which combines education
with the development of new communication processes. One intervention centred on the creation
of a heart failure team to assess residents and deliver an individualised heart failure management
plan (Hancock et al., 2012). The duration of the studies ranged from 1-12 months.

Outcomes
Outcomes assessed in the studies varied, with outcomes for both nursing home staff and residents
reported.

Nursing home staff

Staff knowledge of heart failure was reported in five studies (Boscart et al., 2017, Heckman et al.,
2018, Huson et al., 2015, Kim et al., 2016, Lekan et al., 2010). All studies reported improvements
post-intervention, one of which was statistically significant (Kim et al., 2016). Three studies assessed
nursing home staff self-efficacy in providing care to residents with heart failure (Heckman et al.,
2018, Huson et al., 2015, Sullivan, 2017). Improvements were reported in all, two of which were
significant (Heckman et al., 2018, Sullivan, 2017). One study (Boscart et al., 2017) reported
improvements in staff confidence, improving their ability to provide appropriate care to heart failure
residents and better assess residents not previously diagnosed with heart failure for the presence of
signs and symptoms. The final outcome assessed was anxiety related to providing care (Sullivan,
2017), with statistically significant improvements reported.

11
 V5

Nursing home residents with heart failure

Only one study reported on nursing home resident outcomes (Hancock et al., 2012). Assessing
change to functional capacity and quality of life (EQ-VAS and EQ5D questionnaires), no
improvements were observed in the intervention group.

12
 V5

Table 2. Study and intervention characteristics

Author, year, Study design Participants, sample Study aim Intervention Methods Outcomes of interest
country size, age
Lekan et al., 2010 Feasibility study Nursing home staff To develop, The Connected Twenty-six education Staff knowledge of
implement, and Learning Model – sessions over 7 heart failure,
USA Participant sample feasibility test ‘The aim to improve months. Time-points completion of heart
size and age not Connected Learning communication and and methods of data failure worksheets
described. Model’ learning capacity. collection not (audits and nursing
Educational program described. rounds), quality of
facilitated by a interactions and
Geriatric Advanced relationships
Practice Nurse. between nurses and
Classroom medical providers
(presentations/discu (verbal feedback).
ssions/handouts),
unit-based (role
play/presentations/d
iscussions) and
beside (practical
application).
Practical materials
(FACES card and
clinical work sheets)
to aid recall and
application in
practice.
Heckman et al., 2018 Pilot study Nursing home staff To evaluate the Enhancing Mixed-methods Primary: Heart
acceptability and Knowledge and repeated-measures failure knowledge

13
 V5

Canada Sample size = 27 feasibility of an Interprofessional design. Data (Dutch heart failure
intervention to care for HF (EKWIP- collection: baseline, knowledge scale and
Gender = 88.2% improve heart failure HF). Five phases: 6-months. Nurses Knowledge of
female care in long-term Heart Failure
care facilities 1) ‘Address Education
Age ranges = <35-65 knowledge gaps’. Principles), self-
(44.4% between 35- Interactive case- efficacy in heart
44 years). based education failure care (The
sessions. Provided Bridge Project
pocket cards. surveys),
interprofessional
2) ‘Develop communication
communication (Individualized Care
processes for HF’. Communication
Identify barriers in Subscale and
communication Interprofessional
processes. Socialization and
Develop/adapt Valuing Scale).
communication
processes. Secondary:
Feasibility,
3) ‘Implement acceptability,
communication preliminary impact.
processes and
consolidate
knowledge’. Identify
changes and resolve
knowledge and
communication

14
 V5

problems.

4) ‘Address
knowledge gaps’.
Interactive education
to improve clinical
and procedural skills.

5) ‘Full
interprofessional
integration’. Bi-
weekly bedside
sessions, case
conferences,
individualised care
management plans.
Huson et al., 2015 Pilot study Nursing home staff To report on the Employed the Mixed methods Heart failure
quantitative findings ‘Enhancing repeated measures knowledge (Dutch
Canada Sample size = 29 of a study assessing Knowledge and design. Data heart failure
the acceptability, Interprofessional collection: baseline, knowledge scale),
Age and gender not feasibility, and care for HF’ (EKWIP- 3 months. self-efficacy in
described. preliminary impact HF) intervention. See providing care
of an intervention to Heckman et al., 2018 (survey not
improve nursing above. described).
home staff
knowledge of heart
failure, develop
efficient
interprofessional

15
 V5

communication
processes, and
integrate improved
knowledge and
communication
processes.
Boscart et al., 2017 Pilot study Nursing home staff To report on the Employed the Mixed methods Staff knowledge of
qualitative findings ‘Enhancing repeated measures heart failure,
USA Sample size = 30 of a study to Knowledge and design. Data communication and
assessing the Interprofessional collection: baseline, information
Gender = 83% acceptability, care for HF’ (EKWIP- weekly for 6 months. exchange (field
female feasibility, and HF) intervention. See notes, monthly
preliminary impact Heckman et al., 2018 workshops, semi-
Age = Mean 40.7 of an intervention to above. structured
years improve nursing interviews).
home staff
knowledge of heart
failure, develop
efficient
interprofessional
communication
processes, and
integrate improved
knowledge and
communication
processes.
Hancock et al., 2012 Pilot randomised Nursing home To evaluate the Assessment visit by Intervention Changes in
controlled trial residents with heart implementation of a consultant duration: 12-months, functional capacity
UK failure heart failure team cardiologist to Data collection: and quality of life

16
 V5

delivering onsite initiate plan of baseline, 6, 12 (EQ-5D and EQ-VAS)

Sample size = 28 assessment and treatment at months Acceptability of
management admission. One to bi- heart failure service
Gender = 57% compared to routine weekly visits by
female general practitioner heart failure
care. specialist nurses to
Mean age = 83.6 enact plan, including
years blood tests,
assessment of
symptoms and signs,
educational advice,
and medication
titration.
Sullivan, 2017 Non-randomised Nursing home To evaluate the Nursing staff Intervention Anxiety related to
controlled trial residents with heart effectiveness of provided education duration: 1 month, heart failure
USA failure and nursing customizable heart on heart failure. data collection: (Generalized Anxiety
home staff failure clinical Clinical guidelines baseline, 1 month. Disorder 7 Item
guidelines to sheet to promote Scale)
Sample size = 35 enhance self- critical thinking and
(100% nurses). No efficacy, and reduce provide education Nursing home staff
residents recruited. anxiety among on signs and self-efficacy in
patients, family, and symptoms. providing care to
Age and gender of nursing home staff. heart failure
participants not Nursing home residents (Heart
described. residents provided failure self-efficacy
with a clinical scale).
guideline sheet,
educated on self-
identification and

17
 V5

how to report
exacerbations.
Kim et al., 2016 Pilot quality Certified nursing To improve certified Heart failure Mixed-methods Heart failure
improvement study assistants in a long- nursing assistants education program study. Data knowledge (adapted
USA term care facility knowledge of heart facilitated by a nurse collection varied for version of the
failure management practitioner, three outcomes, occurring Atlanta Heart Failure
Sample size = 66 strategies, reporting 20-minute sessions, at baseline, 1, 2, 3, 4, Knowledge Test),
of acute changes in once per week. 8, 12 weeks. Verbal communication of
Gender = 86.9% status of heart Materials adapted feedback gathered heart failure
female failure residents, from HFSA 2010 continuously. symptoms to nursing
reduce Comprehensive staff (audit of ‘Stop
Age ranges = 21->60. rehospitalization Heart Failure and Watch’ tool,
34.4% between 30- rates. Practice Guidelines, program feedback
39. and developed on (verbal feedback on
measures outlined in understanding of
the Heart Failure heart failure signs
Assessment and symptoms,
Guidelines for Long ability to identify and
Term Care. report
Content includes exacerbations, and
pathophysiology, communication
nutrition, barriers).
management
strategies, signs and
symptoms, FACES
pocket card.

Training on 'Stop and

Watch' tool.

18
 V5

Change to practice
For the purpose of this review, changes to practice relate to any change in the operational processes
or practices within the nursing home. Reported changes to practice occurred both directly as an aim
of the educational interventions, and indirectly following a review of current processes post-
implementation. First, changes to interprofessional communication were reported in five studies
through qualitative data and observations (Boscart et al., 2017, Heckman et al., 2018, Huson et al.,
2015, Kim et al., 2016, Lekan et al., 2010), all of which reported improvements. Of note, one study
also reported improvements in interprofessional communication towards overall resident care,
indicating a spill-over effect as a result of the intervention (Lekan et al., 2010). The study by
Heckman et al. (2018) employed a mixed method design, with a quantitative survey supporting the
qualitative findings, though these improvements were non-significant.

Of interest, the study by Boscart et al. (2017) reported that the implementation of the
intervention prompted a review and refinement of existing communication processes to incorporate
new practices for managing critical care episodes in residents with heart failure. The final study
reporting on interprofessional communication (Kim et al., 2016) did so through the ‘Stop and Watch’
communication tool. The ‘Stop and Watch’ tool, developed to identify non-specific changes in health
conditions , was utilised to improve the identification, evaluation, and communication of changes in
heart failure status of nursing home residents. However, six audits were conducted during the study
period, with the tool found to have not been completed by participants at any time point.

Four studies reported changes related to the assessment of heart failure by nursing home staff.
Nursing home staff in the studies that employed the EKWIP-HF intervention (Boscart et al., 2017,
Heckman et al., 2018, Huson et al., 2015) reported a perceived ability to better conduct heart failure
assessments and identify associated signs and symptoms. The final study reporting on assessment
(Lekan et al., 2010) utilised ‘heart failure worksheets’ to aid recall, guide assessment, and provide a
clear process for documenting/reporting changes to symptoms. Audits indicated that nursing home
staff were completing the worksheets and ensuring timely reporting of new heart failure related
signs and symptoms, yet there was a drop-off in completion of worksheets observed towards the
end of study (7 months). Prior to the intervention, there were no processes in place for assessing
heart failure, indicating that the implementation of such worksheets for conducting assessments
may be accepted by nursing home staff.

Implementation and process evaluation

Two studies (Boscart et al., 2017, Heckman et al., 2018) reported qualitative feedback from nursing
home staff related to education as an intervention component. Both studies reported positive

19
 V5

results, with nursing home staff highlighting that education enhanced their knowledge of heart
failure, ability to identify signs and symptoms, improve diagnoses, and make better decisions on
appropriate care. Of significance was the perceived ability to better distinguish signs and symptoms
associated with heart failure with other conditions or syndromes (e.g., delirium). Participants in both
studies also highlighted their appreciation for the ‘ANEWLEAF pocket card’ (to assist clinical
assessments and for developing appropriate care planning for heart failure residents. The
ANEWLEAF mnemonic lists the main symptoms of heart failure and is designed for use specifically in
nursing home settings (Harrington, 2008). Further, participants in the study by Heckman et al. (2018)
noted the value of clinical guidance sheets available in residents’ rooms. The guidance sheets not
only assisted heart failure assessments, but reportedly facilitated greater self-management by both
residents and their family. However, the methods in which self-management was improved was not
reported by the authors.

Participant feedback highlighted the benefits of ‘bedside sessions’, providing an opportunity for
staff to conduct assessments as a team. Not only did the perceived ability to conduct assessments
improve, but conducting these as a team was perceived to also improve interprofessional
communication. Improvements were observed due to staff feeling more valued and that their voice
was being heard, reportedly improving the quality of care as a result (Heckman et al., 2018). Only
one study reported feedback related to intervention content (Heckman et al., 2018). Employing the
EKWIP-HF intervention, participants indicated that the intervention materials could be improved
through incorporating video, images, and humour.

Intervention fidelity was discussed in one study (Heckman et al., 2018), reporting mixed findings
on the implementation of new communication and documentation processes. Participants
highlighted that several processes were easier to implement than others, although no further detail
was provided by the authors. However, due to such difficulties, refresher workshops were necessary
four months into the six-month intervention. In addition, nursing home staff were encouraged to
conduct daily weight monitoring which, although deemed feasible, proved burdensome to the
residents. Nursing home staff perceived daily weight monitoring as unnecessary as the intervention
was ensuring that appropriate care was being provided.

A further two studies (Hancock et al., 2012, Kim et al., 2016) reported contextual findings
related to each respective intervention. Participants in both studies endorsed the interventions, with
those in the study by Kim et al. (2016) emphasizing their appreciation towards receiving education.
However, the sessions were conducted face-to-face, which proved time intensive for the facilitator
due to being delivered over several shift patterns. Further, attendance at the face-to-face sessions

20
 V5

were poor, with only 50% (n= 33) of participants attending all three, and 30.3% (n= 20) attending
two sessions. Participants in this study also indicated that the lack of using the ‘Stop and Watch’ tool
was due to a poor understanding of how to find and complete the tool, and the perception that it
was time consuming.

Discussion
This scoping review aimed to synthesise the current evidence of educational interventions designed
to optimise care provision for nursing home residents with heart failure. As only seven studies were
included in this review, there is clearly a dearth of literature in the area. Nonetheless, findings from
this review suggest that educational interventions employed in nursing homes may optimise care
provision for heart failure residents. This is achieved through improving staff self-efficacy and
confidence in providing care, improving heart failure knowledge and interprofessional
communication, and reducing care-related anxiety. However, evidence for such interventions
improving resident outcomes is not as clear.

Our findings are comparable with a previous scoping review of the literature that focused on
heart failure management within skilled nursing facilities and nursing home settings (Heckman et al.,
2018), with similar improvements in staff heart failure knowledge reported. Similarly, a prior
systematic review of educational interventions for another common chronic progressive condition in
nursing home settings, dementia (Zhao et al., 2021), reported improvements in staff knowledge of
dementia and self-efficacy in providing care, whilst also reporting inconsistent statistically significant
results. However, in contrast to the findings in this current review, reviews of interventions for
improving dementia care in nursing homes have reported a lack of improvements associated with
interprofessional communication (Rapaport et al., 2017, Zhao et al., 2021). Interprofessional
communication is of significance, promoting teamwork and shared decision making among
healthcare professionals, whilst improving patient care (Bok et al., 2020, Busari et al., 2017, Choi and
Chang, 2023), and has been found to be a significant barrier to heart failure care in nursing homes
(Heckman et al., 2016, Strachan et al., 2014).

Feedback associated with intervention components was limited. In all studies, a face-to-face
approach was utilised, and although education appears to be appreciated by participants, it remains
unclear whether this is their preferred mode of delivery. Poor attendance at the face-to-face
education sessions in the study by Kim et al. (2016), and the reported time burden placed on the
intervention facilitator, would suggest that another mode of delivery may be worth exploring.
Positively, education was reported to have improved nursing home staff ability to separate common
age-related symptoms from those associated with heart failure, an issue known to confound their

21
 V5

ability to identify heart failure exacerbations (Daamen et al., 2015, Glenny et al., 2012, Heckman et
al., 2014, Jarrett, 1995). Several techniques were utilised to reinforce the education provided and
assist with implementation in practice, with pocket cards and clinical guidance sheets welcomed by
nursing home staff (Boscart et al., 2017, Heckman et al., 2018). Secondly, bedside sessions to
conduct heart failure assessments as a team improved nursing home staff feelings of being valued,
reported to improve the effectiveness of interventions in nursing homes (Kadri et al., 2018,
Lawrence et al., 2016, Rapaport et al., 2017).

Resident outcomes were limited to one study only (Kim et al., 2016). Although the study by
Sullivan (2017) aimed to assess resident outcomes, they failed to recruit any participants. Barriers
towards recruiting nursing home residents include cognitive and physical impairment of residents,
and procedural challenges such as the need to build relationships with nursing home staff to act as
‘gatekeepers’ (Ellwood et al., 2018, Law and Ashworth, 2022, Ritchie et al., 2023). Thus, methods to
improve the recruitment of nursing home residents must be considered in research to better
understand the potential of interventions for optimising resident-related outcomes associated with
optimising the provision of care.

Mixed findings were reported for changes to practice, specifically regarding the completion of
the ‘Stop and Watch’ tool and heart failure worksheets. Both tools were utilised to provide a clear
process for documenting and reporting changes to heart failure status of residents. Although the
heart failure worksheets were completed regularly, a drop-off was observed, highlighting a potential
concern regarding sustainability of this tool (Lekan et al., 2010). In contrast, the ‘Stop and Watch’
tool (Kim et al., 2016) was not completed at any time point during the study, with participants citing
time constraints and a lack of understanding on how to use the tool as key barriers. Although staff
received training on how to access and complete the ‘Stop and Watch’, their understanding of how
to complete the process varied. In addition, nursing home supervisors communicated varied
expectations regarding the completion of the tool to staff, leading to confusion and
miscommunication. Therefore, for such processes to be successfully implemented, nursing home
staff must receive the appropriate education, and senior staff need to understand the importance of
these tools to ensure that they are completed consistently. This aligns with prior research which
asserts that changes to practice in nursing homes are complex but possible, and that barriers and
facilitators should be uncovered with nursing home staff during the conception of the research study
to improve the likelihood of success (Low et al., 2015).

Ensuring sustainability of interventions and quality improvement projects in the nursing home
setting have proved challenging (Devi et al., 2022, Rapaport et al., 2017, Zhao et al., 2021). One

22
 V5

reason for such challenges is the high rates of staff turnover (Castle, 2006, Castle and Engberg, 2005,
Gandhi et al., 2021, Thomas et al., 2013), associated with low levels of staff resilience and wellbeing
leading to burnout (Mallon et al., 2023). High rates of staff turnover can also directly impact the
implementation and sustainability of heart failure guidelines (Nazir et al., 2015), with three of the
studies included in this review citing staff turnover as a significant barrier (Heckman et al., 2018, Kim
et al., 2016, Sullivan, 2017). Most interventions included in this review had a duration of 1-6 months,
with only one reporting outcomes at 12-months post baseline (Hancock et al., 2012). However, the
outcomes in this study were associated only with heart failure management, for example medication
management, dietary modifications, fluid balance monitoring, and vital signs. Thus, it is unclear
whether interventions can achieve long-term positive effects related to enhancements in the
provision of care, such as reducing hospital admissions, enhancing quality of life, and optimising
symptom management. Co-production is an example of how improving sustainability of
interventions in nursing homes may be achieved, improving integration, acceptability, and success
(Peryer et al., 2022), yet research applying co-production in this setting is limited (Hallam-Bowles et
al., 2022). Partnerships between care and research are essential to support the design, delivery and
translation of research to promote evidence informed care in these environments (Spilsbury et al.,
2023).

To improve the potential sustainability and effectiveness of interventions within the nursing
home setting, researchers may consider digital health as a mode of intervention delivery. Increasing
in prominence, digital health interventions can support healthcare providers in decision making,
interprofessional communication, and provide necessary training to improve the provision of
healthcare (Fatehi et al., 2020, Stark et al., 2022, World Health Organisation, 2018). Digital health
interventions within the nursing home setting are in their infancy. However, they have shown
potential for improving staff knowledge and confidence related to dementia care (Tunnard et al.,
2022), and improving overall delivery of timely, high-quality care (Gillespie et al., 2019). Thus, digital
health interventions may prove an acceptable mode for delivering education to nursing home staff,
removing the burden placed on the facilitator and improving ease of access (Cousins et al., 2022).

Strengths and limitations

To our knowledge, this is the first scoping review to synthesise the available evidence on
interventions to optimise care provision for residents living with heart failure in nursing homes. The
findings of this review advance the literature, with the scoping review by Heckman et al. (2018)
focusing on the management of heart failure, and included interventions employed in skilled nursing
facilities. In contrast, the current review assessed outcomes associated with resident care, taking
place only in the nursing home setting. Including both quantitative and qualitative findings provide a

23
 V5

greater understanding of whether interventions have proven successful, and the reported barriers
and facilitators towards implementation. There are two key limitations of this review to note. First,
including only studies written in English may omit relevant studies in other languages, causing
important findings to be missed. Second, three studies were conducted by the same group and
reported on the same intervention (Boscart et al., 2017, Heckman et al., 2018, Huson et al., 2015),
thus potentially skewing the findings.

Conclusions
The findings from this review highlight the potential of interventions implemented in nursing homes
for improving care provision to residents with heart failure. However, outcomes reported across the
included studies were mostly focused on nursing home staff. Thus, future research is needed to
determine whether such interventions are effective in improving outcomes associated with nursing
home residents. Also, future research should aim to determine whether such interventions can
produce long-term effects and sustainability. Education was a common intervention component
employed across the studies, provided face-to-face to nursing home staff. Participant feedback,
although limited, indicated that education was well-received and beneficial, improving heart failure
knowledge of staff. However, this study reported poor participant attendance at the sessions, with
the intervention facilitator indicating that this approach was burdensome. The delivery of a digital
intervention may provide greater success, reducing the burden on staff and the need for an
intervention facilitator. A digital approach also provides participants with the ability to access the
intervention at a time that suits them, potentially improving intervention acceptability, user
engagement, and likelihood of success.

Acknowledgements
Not applicable.

Conflict of interest
The authors declare that they have no conflicts of interest.

Funding sources
This research is co-funded by Northern Ireland Chest Heart & Stroke (NICHS) grant reference number
2021_H04, and the Health and Social Care Research & Development Division (HSC R&D Division) of
the Public Health Agency in Northern Ireland grant reference number COM/5714/22. The funding
bodies have played no role in the study design, decision to publish, or preparation of this
manuscript.

24
 V5

References
Akintoye, E., Briasoulis, A., Egbe, A., Dunlay, S.M., Kushwaha, S., Levine, D., Afonso, L., Mozaffarian,
D., Weinberger, J., 2017. National trends in admission and in‐hospital mortality of patients
with heart failure in the united states (2001–2014). Journal of the American Heart
Association 6, e006955.
Allen, L.A., Hernandez, A.F., Peterson, E.D., Curtis, L.H., Dai, D., Masoudi, F.A., Bhatt, D.L.,
Heidenreich, P.A., Fonarow, G.C., 2011. Discharge to a skilled nursing facility and subsequent
clinical outcomes among older patients hospitalized for heart failure. Circulation Heart
Failure 4 (3), 293-300.
Arksey, H., O'Malley, L., 2005. Scoping studies: Towards a methodological framework. International
Journal of Social Research Methodology 8 (1), 19-32.
Barents, M., Van Der Horst, I.C.C., Voors, A.A., Hillege, J.L., Muskiet, F.A.J., De Jongste, M.J.L., 2008.
Prevalence and misdiagnosis of chronic heart failure in nursing home residents: The role of
b-type natriuretic peptides. Netherlands Heart Journal 16 (4), 123-128.
Bok, C., Ng, C.H., Koh, J.W.H., Ong, Z.H., Ghazali, H.Z.B., Tan, L.H.E., Ong, Y.T., Cheong, C.W.S., Chin,
A.M.C., Mason, S., Krishna, L.K.R., 2020. Interprofessional communication (ipc) for medical
students: A scoping review. BMC Medical Education 20, 372.
Boscart, V.M., Heckman, G.A., Huson, K., Brohman, L., Harkness, K.I., Hirdes, J., McKelvie, R.S.,
Stolee, P., 2017. Implementation of an interprofessional communication and collaboration
intervention to improve care capacity for heart failure management in long-term care.
Journal of Interprofessional Care 31 (5), 583-592.
Bozkurt, B., et al., 2021. Universal definition and classification of heart failure. Journal of Cardiac
Failure 27 (4), 387-413.
Busari, J., Moll, F., Duits, A., 2017. Understanding the impact of interprofessional collaboration on
the quality of care: A case report from a small-scale resource limited health care
environment. Journal of Multidisciplinary Healthcare 10, 227-234.
Castle, N.G., 2006. Measuring staff turnover in nursing homes. Gerontologist 46 (2), 210-219.
Castle, N.G., Engberg, J., 2005. Staff turnover and quality of care in nursing homes. Medical Care 43
(6), 616-626.
Choi, Y.-R., Chang, S.O., 2023. Exploring interprofessional communication during nursing home
emergencies using the sbar framework. Journal of Interprofessional Care 37 (1), 83-90.
Cleland, J.G.F., Van Veldhuisen, D.J., Ponikowski, P., 2019. The year in cardiology 2018: Heart failure.
European Heart Journal 40 (8), 651-661.
Close, H., Hancock, H., Mason, J.M., Murphy, J.J., Fuat, A., De Belder, M., Hungin, A.P.S., 2013. “It’s
somebody else’s responsibility”- perceptions of general practitioners, heart failure nurses,
care home staff, and residents towards heart failure diagnosis and management for older
people in long-term care: A qualitative interview study. BMC Geriatrics 13, 69.
Conrad, N., Judge, A., Tran, J., Mohseni, H., Hedgecott, D., Crespillo, A.P., Allison, M., Hemingway, H.,
Cleland, J.G., McMurray, J.J.V., Rahimi, K., 2018. Temporal trends and patterns in heart
failure incidence: A population-based study of 4 million individuals. Lancet 391, 572-580.
Cousins, C., Burrows, R., Cousins, G., Dunlop, E., & Mitchell, G. (2016). An overview of the challenges
facing care homes in the UK. Nursing Older People, 28(9), 18-
21. https://doi.org/10.7748/nop.2016.e817
Cousins, E., Preston, N., Doherty, J., Varey, S., Harding, A., McCann, A., Harrison Dening, K., Finucane,
A., Carter, G., Mitchell, G., Brazil, K., 2022. Implementing and evaluating online advance care
planning training in uk nursing homes during covid-19: Findings from the necessary
discussions multi-site case study project. BMC Geriatrics 22, 419.
Craig, S., Cao, Y., McMahon, J., Anderson, T., Stark, P., Brown Wilson, C., Creighton, L., Gonella, S.,
Bavelaar, L., Vlckvoa, K., & Mitchell, G. (2023). Exploring the holistic needs of people living
with cancer in care homes: an integrative review. Healthcare, 11(24), Article
3166. https://www.mdpi.com/2227-9032/11/24/3166

25
 V5

Daamen, M.A.M.J., Hamers, J.P.H., Gorgels, A.P.M., Brunner-La Rocca, H.-P., Tan, F.E.S., Van Dieijen-
Visser, M.P., Schols, J.M.G.A., 2015. Heart failure in nursing home residents; a cross-
sectional study to determine the prevalence and clinical characteristics. BMC Geriatrics 15,
167.
Daamen, M.A.M.J., Schols, J.M.G.A., Jaarsma, T., Hamers, J.P.H., 2010. Prevalence of heart failure in
nursing homes: A systematic literature review. Scandinavian Journal of Caring Sciences 24
(1), 202-208.
Devi, R., Martin, G.P., Banerjee, J., Gladman, J.R., Dening, T., Barat, A., Gordon, A.L., 2022. Sustaining
interventions in care homes initiated by quality improvement projects: A qualitative study.
BMJ Quality & Safety, bmjqs-2021-0143.
Ellwood, A., Airlie, J., Cicero, R., Cundill, B., Ellard, D.R., Farrin, A., Godfrey, M., Graham, L., Green, J.,
McLellan, V., Siddiqi, N., Forster, A., 2018. Recruiting care homes to a randomised controlled
trial. Trials 19, 535.
Fatehi, F., Samadbeik, M., Kazemi, A., 2020. What is digital health? Review of definitions. Studies in
Health Technology and Informatics, 275, 67-71.
Gandhi, A., Yu, H., Grabowski, D.C., 2021. High nursing staff turnover in nursing homes offers
important quality information. Health Affairs 40 (3), 384-391.
Gillespie, S.M., Moser, A.L., Gokula, M., Edmondson, T., Rees, J., Nelson, D., Handler, S.M., 2019.
Standards for the use of telemedicine for evaluation and management of resident change of
condition in the nursing home. Journal of the American Medical Directors Association 20 (2),
115-122.
Glenny, C., Heckman, G., McKelvie, R., 2012. Heart failure in older persons: Considerations for the
primary care physician. Canadian Geriatrics Society Journal of CME 2 (1), 9-17.
Groenewegen, A., Rutten, F.H., Mosterd, A., Hoes, A.W., 2020. Epidemiology of heart failure.
European Journal of Heart Failure 22 (8), 1342-1356.
Hallam-Bowles, F.V., Logan, P.A., Timmons, S., Robinson, K.R., 2022. Approaches to co-production of
research in care homes: A scoping review. Research Involvement and Engagement 8 (1), 74.
Hancock, H.C., Close, H., Mason, J.M., Murphy, J.J., Fuat, A., de Belder, M., Hunt, T., Baker, A.,
Wilson, D., Hungin, A.P.S., 2012. Feasibility of evidence-based diagnosis and management of
heart failure in older people in care: A pilot randomised controlled trial. BMC Geriatrics 12
(1), 70.
Harrington, C.C., 2008. Assessing heart failure in long-term care facilities. Journal of Gerontological
Nursing 34 (2), 9-14.
Heckman, G.A., Boscart, V.M., D'Elia, T., Kaasalainen, S., McAiney, C., Kelley, M.L., Stolee, P.,
Strachan, P., McKelvie, R.S., 2016. The role of unregulated care providers in managing heart
failure patients in long-term care facilities. Journal of Clinical Nursing 26, 849-861.
Heckman, G.A., Boscart, V.M., Huson, K., Costa, A., Harkness, K., Hirdes, J.P., Stolee, P., McKelvie,
R.S., 2018. Enhancing knowledge and interprofessional care for heart failure (ekwip-hf) in
long-term care: A pilot study. Pilot and Feasibility Studies 4, 9.
Heckman, G.A., Boscart, V.M., McKelvie, R.S., 2014. Management considerations in the care of
elderly heart failure patients in long-term care facilities. Future Cardiology 10 (4), 563-577.
Heckman, G.A., Shamji, A.K., Ladha, R., Stapleton, J., Boscart, V., Boxer, R.S., Martin, L.B., Crutchlow,
L., McKelvie, R.S., 2018. Heart failure management in nursing homes: A scoping literature
review. Canadian Journal of Cardiology 34 (7), 871-880.
Heiks, C., & Sabine, N. (2022). Long-Term Care and Skilled Nursing Facilities. Delaware Journal of
Public Health, 8(5), 144–149. https://doi.org/10.32481/djph.2022.12.032
Huson, K., Boscart, V., McKelvie, R., Hirdes, J.P., Stolee, P., Heckman, G., 2015. Interprofessional care
processes to manage residents with heart failure in long-term care. Canadian Journal of
Cardiology 31, S128.
Jarrett, P.G., 1995. Illness presentation in elderly patients. Archives of Internal Medicine 155, 1060-
1064.

26
 V5

JBI, 2022. JBI template source of evidence details, characteristics and results extraction instrument.
Retrieved 21 November, 2022, from https://jbi-global-
wiki.refined.site/space/MANUAL/4687579/Appendix+11.1+JBI+template+source+of+evidenc
e+details%2C+characteristics+and+results+extraction+instrument
Kadri, A., Rapaport, P., Livingston, G., Cooper, C., Robertson, S., Higgs, P., 2018. Care workers, the
unacknowledged persons in person-centred care: A secondary qualitative analysis of uk care
home staff interviews. PloS One 13 (7), e0200031.
Kantoch, A., Gryglewska, B., Wojkowska-Mach, J., Heczko, P., Grodzicki, T., 2018. Treatment of
cardiovascular diseases among elderly residents of long-term care facilities. Journal of the
American Medical Directors Association 19 (5), 428-432.
Kim, J., Ea, E., Parish, A.L., Levin, R.F., 2016. A nurse practitioner-led heart failure education program
for certified nursing assistants in a long-term care facility. Annals of Long-Term Care 24 (5),
27-34.
Komajda, M., 2015. Current challenges in the management of heart failure. Circulation Journal 79
(5), 948-953.
Law, E., Ashworth, R., 2022. Facilitators and barriers to research participation in care homes:
Thematic analysis of interviews with researchers, staff, residents and residents’ families.
Journal of Long Term Care (2002), 49-60.
Lawrence, V., Fossey, J., Ballard, C., Ferreira, N., Murray, J., 2016. Helping staff to implement
psychosocial interventions in care homes: Augmenting existing practices and meeting needs
for support. International Journal of Geriatric Psychiatry 31 (3), 284-293.
Lekan, D., Hendrix, C.C., McConnell, E.S., White, H., 2010. The connected learning model for
disseminating evidence-based care practices in clinical settings. Nurse Education in Practice
10 (4), 243-248.
Lesyuk, W., Kriza, C., Kolominsky-Rabas, P., 2018. Cost-of-illness studies in heart failure: A systematic
review 2004–2016. BMC Cardiovascular Disorders 18, 74.
Levac, D., Colquhoun, H., O'Brien, K.K., 2010. Scoping studies: Advancing the methodology.
Implementation Science 5 (1), 69.
Lippi, G., Sanchis-Gomar, F., 2020. Global epidemiology and future trends of heart failure. AME
Medical Journal 5, 15-15.
Low, L.-F., Fletcher, J., Goodenough, B., Jeon, Y.-H., Etherton-Beer, C., Macandrew, M., Beattie, E.,
2015. A systematic review of interventions to change staff care practices in order to improve
resident outcomes in nursing homes. PloS One 10 (11), e0140711.
Luo, H., Lum, T.Y.S., Wong, G.H.Y., Kwan, J.S.K., Tang, J.Y.M., & Chi, I. (2015). Predicting adverse
health outcomes in nursing homes: a 9-year longitudinal study and development of the
FRAIL-minimum data set (MDS) quick screening tool. Journal of the American Medical
Directors Association, 16, 1042–1047.
Mallon, A., Mitchell, G., Carter, G., McLaughlin, D., Wilson, C.B., 2023. A rapid review of evaluated
interventions to inform the development of a resource to support the resilience of care
home nurses. BMC Geriatrics 23, 275.
McDonagh, T.A., et al., 2021. 2021 esc guidelines for the diagnosis and treatment of acute and
chronic heart failure. European Heart Journal 42 (36), 3599-3726.
McMahon, J., Brown Wilson, C., Hill, L., Tierney, P., Thompson, D.R., Cameron, J., Yu, D., Moser, D.K.,
Spilsbury, K., Srisuk, N., Schols, J.M.G.A., Van Der Velden, M., Mitchell, G., 2023. Optimising
quality of life for people living with heart failure in care homes: Protocol for the co-design
and feasibility testing of a digital intervention. Plos One 18 (7), e0288433.
Mitchell, G., McGreevy, J., Preshaw, D. HL., Agnelli, J., & Diamond, M. 2016. Care home managers’
knowledge of palliative care: a Northern Irish study. International Journal of Palliative
Nursing, 22(5), 230-235. https://doi.org/10.12968/ijpn.2016.22.5.230

27
 V5

Mitchell, G., Cousins, C., Burrows, R., & Cousins, G. 2017. A review of safe-staffing models and their
applicability to care homes. Journal of Nursing Management, 25(2), 157-162. Advance online
publication. https://doi.org/10.1111/jonm.12450
Morrow, C.D., Reeder, B.P., Perraillon, M.C., Ozkaynak, M., Wald, H.L., Eber, L.E., Trojanowski, J.I.,
Battaglia, C., Boxer, R.S., 2020. Information needs of skilled nursing facility staff to support
heart failure disease management. AMIA Annual Symposium Proceedings 2020, 878-885.
Munn, Z., Peters, M.D.J., Stern, C., Tufanaru, C., McArthur, A., Aromataris, E., 2018. Systematic
review or scoping review? Guidance for authors when choosing between a systematic or
scoping review approach. BMC Medical Research Methodology 18 (1).
National Library of Medicine. 2021. Skilled Nursing or Rehabilitation Facilities. U.S. Department of
Health and Human Services, National Institutes of Health.
https://medlineplus.gov/ency/patientinstructions/000435.htm
Nazir, A., Dennis, M.E., Unroe, K.T., 2015. Implementation of a heart failure quality initiative in a
skilled nursing facility: Lessons learned. Journal of Gerontological Nursing 41 (5), 26-33.
Norhammar, A., Bodegard, J., Vanderheyden, M., Tangri, N., Karasik, A., Maggioni, A.P., Sveen, K.A.,
Taveira-Gomes, T., Botana, M., Hunziker, L., Thuresson, M., Banerjee, A., Sundström, J.,
Bollmann, A., 2023. Prevalence, outcomes and costs of a contemporary, multinational
population with heart failure. Heart 109, 548-556.
Ouslander, J.G., Bonner, A., Herndon, L., Shutes, J., 2014. The interventions to reduce acute care
transfers (interact) quality improvement program: An overview for medical directors and
primary care clinicians in long term care. Journal of the American Medical Directors
Association 15 (3), 162-170.
Peryer, G., Kelly, S., Blake, J., Burton, J.K., Irvine, L., Cowan, A., Akdur, G., Killett, A., Brand, S.L.,
Musa, M.K., Meyer, J., Gordon, A.L., Goodman, C., 2022. Contextual factors influencing
complex intervention research processes in care homes: A systematic review and framework
synthesis. Age and Ageing 51, 1-16.
Peters, M.D.J., Marnie, C., Tricco, A.C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey,
C.M., Khalil, H., 2020. Updated methodological guidance for the conduct of scoping reviews.
JBI Evidence Synthesis 18 (10), 2119-2126.
Rapaport, P., Livingston, G., Murray, J., Mulla, A., Cooper, C., 2017. Systematic review of the
effective components of psychosocial interventions delivered by care home staff to people
with dementia. BMJ Open 7 (2), e014177.
Reilev, M., Lundby, C., Jensen, J., Post Larsen, S., Hoffmann, H., Pottegård, A. (2020). Morbidity and
mortality among older people admitted to nursing home. Age and Ageing, 49(1), 67–73.
https://doi.org/10.1093/ageing/afz136
Ritchie, L.A., Gordon, A.L., Penson, P.E., Lane, D.A., Akpan, A., 2023. Stop and go: Barriers and
facilitators to care home research. Journal of Frailty & Aging 12 (1), 63-66.
Savarese, G., Becher, P.M., Lund, L.H., Seferovic, P., Rosano, G.M.C., Coats, A.J.S., 2022. Global
burden of heart failure: A comprehensive and updated review of epidemiology.
Cardiovascular Research 118 (17), 3272-3287.
Skills for Care. 2022. Workforce Intelligence Summary: Care homes with nursing in the adult social
care sector. Retrieved 20 Dec 2023 from: https://www.skillsforcare.org.uk/Adult-Social-
Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-
sector/Summary-of-care-home-services-with-nursing-2022.pdf
Spilsbury, K., Hanratty, B., McCaughan, D., 2015. Supporting nursing in care homes. Retrieved 10
Oct, 2023, from https://rcnfoundation.rcn.org.uk/Funded-projects/Improving-Patient-
Care/Supporting-Nursing-in-Care-Homes
Spilsbury, K., Peryer, G., Devi, R., Haunch, K., Jordao, M., Thompson, C., Goodman, C., 2023. On your
marks, get set, pause: What care home teams should consider before partnering with a trial
research group. Nursing and Residential Care 25, 1-5.

28
 V5

Stark, P., McKenna, G., Wilson, C.B., Tsakos, G., Brocklehurst, P., Lappin, C., Quinn, B., Mitchell, G.,
2022. Interventions supporting community nurses in the provision of oral healthcare to
people living at home: A scoping review. BMC Nursing 21, 269.
Strachan, P.H., Kaasalainen, S., Horton, A., Jarman, H., D’Elia, T., Van Der Horst, M.-L., Newhouse, I.,
Kelley, M.L., McAiney, C., McKelvie, R., Heckman, G.A., 2014. Managing heart failure in the
long-term care setting: Nurses’ experiences in ontario, canada. Nursing Research 63 (5), 357-
365.
Sullivan, T.J. 2017. Taking a closer look at how to manage heart failure patients in long term nursing
care facilities. Doctor of Nursing Practice, University of North Carolina at Charlotte.
Thomas, K.S., Mor, V., Tyler, D.A., Hyer, K., 2013. The relationships among licensed nurse turnover,
retention, and rehospitalization of nursing home residents. Gerontologist 53 (2), 211-221.
Tricco, A.C., et al., 2018. Prisma extension for scoping reviews (prisma-scr): Checklist and
explanation. Annals of Internal Medicine 169 (7), 467-473.
Tunnard, I., Gillam, J., Harvey, C., Davies, N., Vickerstaff, V., Ellis-Smith, C., Evans, C.J., 2022. The
acceptability and effectiveness of ehealth interventions to support assessment and decision-
making for people with dementia living in care homes: A systematic review. Frontiers in
Dementia 1, 1:9775.
Urbich, M., Globe, G., Pantiri, K., Heisen, M., Bennison, C., Wirtz, H.S., Di Tanna, G.L., 2020. A
systematic review of medical costs associated with heart failure in the USA (2014–2020).
PharmacoEconomics 38 (11), 1219-1236.
Valle, R., Aspromonte, N., Barro, S., Canali, C., Carbonieri, E., Ceci, V., Chinellato, M., Gallo, G.,
Giovinazzo, P., Ricci, R., Milani, L., 2005. The nt-probnp assay identifies very elderly nursing
home residents suffering from pre-clinical heart failure. European Journal of Heart Failure 7
(4), 542-551.
Wachter, R., Rommel, K.P., 2022. Hospitalization for heart failure: A window of opportunity.
European Heart Journal 43 (23), 2235-2236.
World Health Organisation, 2018. Classification of digital health interventions. Retrieved 13 June,
2023, from https://saluddigital.com/wp-
content/uploads/2019/09/DigitalHealthClassificationsBooklet.pdf
Zhao, Y., Liu, L., Chan, H.Y.L., 2021. Dementia care education interventions on healthcare providers'
outcomes in the nursing home setting: A systematic review. Research in Nursing & Health 44
(6), 891-905.
Zhang, X., Dou, Q., Zhang, W., et al. (2019). Frailty as a predictor of all-cause mortality among older
nursing home residents: A systematic review and meta-analysis. Journal of the American
Medical Directors Association, 20, 657–663.

29
 V5

Declaration of interests

☒ The authors declare that they have no known competing financial interests or personal
relationships that could have appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be
considered as potential competing interests:

30