Asian Nursing Research 12 (2018) 251e257

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Asian Nursing Research

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Research Article

The Effect of a Telephone-Based Self-management Program Led by

Nurses on Self-care Behavior, Biological Index for Cardiac Function,
and Depression in Ambulatory Heart Failure Patients
Mi Kyoung Moon,1 JongEun Yim,2 Mi Yang Jeon3, *,*
1
Department of Nursing, Gyeongsang National University Hospital, Jinju, Republic of Korea
2
Department of Physical Therapy, Sahmyook University, Seoul, Republic of Korea
3
College of Nursing, Institute of Health Science, Gyengsang National University, Jinju, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study was conducted to examine the effects of a telephone-based self-management sup-
Received 26 March 2018 port program led by nurses on self-care behavior, biological index for cardiac function, and depression.
Received in revised form Methods: This study is a quasi-experiment in nonequivalent control group design. Thirty-eight heart
27 September 2018
failure patients underwent medical treatment at the hospital (18 heart failure patients in the experi-
Accepted 1 October 2018
mental group and 20 heart failure patients in the control group). The experimental group (n ¼ 18)
received the telephone-based self-management support program, which included a 30-minute face-to-
Keywords:
face education session and four telephone consultation and education sessions. The face-to-face edu-
depression
heart failure
cation session was conducted at the first visit to the outpatient clinic. Thereafter, weekly telephone
heart function tests consultations and education sessions were performed for 4 weeks. Data were analyzed using descriptive
self care statistics, Chi-square test, Fisher's exact test, independent t test, paired t test, and repeated measures
telephone analysis of variance using the SPSS/WIN 21.0.
Results: The participants in the experimental group showed significantly increased self-care behavior
scores (t ¼ 6.65, p < .001), decreased N-terminal pro-brain natriuretic peptide level (U ¼ 2.28, p ¼ .022),
improved left ventricular ejection fraction values (t ¼ 2.24, p ¼ .032), and decreased depression scores
(t ¼ 3.49, p ¼ .001) compared with the control group.
Conclusion: The findings indicate that the telephone-based self-management program is an effective
intervention to improve self-management in heart failure patients.
© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Physical symptoms of this disease are related to changes in N-

Heart failure is a complex clinical syndrome in which sufficient
blood is not circulated to meet the needs of the metabolic
tissues due to dysfunction of the heart or abnormally increased
diastolic pressure or volume to increase blood flow. Patients with
heart failure experience dyspnea, fatigue, and chest pain when they
exercise or work during the early stages of the disease [1]. When
the disease progresses, they experience palpitations or nighttime
paroxysmal dyspnea, epigastric discomfort, anorexia, or a combi-
nation of these symptoms in severe cases [2].
* Correspondence to: Mi Yang Jeon, Ph.D, College of Nursing, Institute of Health
Science, Gyeongsang National University, 816-15 Jinju-daero, Jinju, Gyeongsang-
nam-do, 52727, Republic of Korea.
E-mail address: miyangjeon@gnu.ac.kr
* However, so far, pharmacotherapy has been focused on for
ORCID: https://orcid.org/0000-0002-5058-9912
terminal pro-brain natriuretic peptide (NT-proBNP) levels, left
ventricular ejection fraction (LV EF), and left ventricular end-dia-
stolic pressure (LVEDP) [1]. About 20% of patients with heart failure
experience clinical depression; the likelihood of experiencing
depression increases with increase in the severity of heart failure
(as per the functional classification of the American Heart Associ-
ation) [3].
The European Society of Cardiology and American Heart Asso-
ciation emphasize the importance of self-care behaviors and self-
management skills to support pharmacotherapy and improve
symptoms and prognosis in heart failure patients [4,5]. The main
tenets of self-care behavior in patients with heart failure include
the recognition and management of heart failure symptoms, reg-
ular medication use, restriction of water intake, a low-salt diet,
smoking cessation, alcohol abstinence, and regular exercise [6].

https://doi.org/10.1016/j.anr.2018.10.001
p1976-1317 e2093-7482/© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
252 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257
treatment, whereas self-care behaviors have not been sufficiently
emphasized or systematically managed [7]. Thus, even though a
hospitalized patient may be discharged having gained temporary
symptomatic relief owing to pharmacotherapy, the disease may
aggravate because of insufficient awareness of the change in
symptoms and lack of self-care behavior, leading to rehospitaliza-
tion [8]. A previous study found that rehospitalization could be
reduced by up to 50% if patients continue to perform self-care be-
haviors and receive adequate social support [9]. However, because
it is time-consuming to change ingrained habits pertaining to tak-
ing medications, diet, and exercise, it is necessary to provide
continuous support so that patients with heart failure can perform
self-management of the disease [10].
Telephone self-management is a nursing intervention method
that can be used effectively by outpatient nurses to support pa-
tients with chronic illnesses who need to maintain continuous
health management behavior [11]. In particular, to improve the
self-care behavior of outpatients with heart failure, telephone-
based intervention methods that can be easily accessed and pro-
vide necessary education and consultation efficiently are effective
[12]. Similarly, research has been conducted to understand the ef-
fects of telephone-based support program [13e15] provided by
nurses about health awareness, symptom recognition, physical
condition, depression, anxiety, and quality of life in patients with
heart failure. The results of these studies [13e15] revealed that the
telephone self-management program significantly affected the
subjective index of patients with heart failure. However, the effect
of the telephone self-management program on the cardiac function
index that objectively measures cardiac function in patients with
heart failure has not been examined. The education for self-care
behavior is important, but motivation of patients is more essen-
tial to continue their self-care behavior and improve their health
status. The purpose of this study was to investigate the effects of
this program on self-care behavior, cardiac functional index, and
depression.
Methods
Study design
This study is a quasi-experiment in nonequivalent control
group with no-synchronized design to examine the effect of tele-
phone self-management program on self-care behavior, cardiac
function index, and depression in outpatients with heart failure
(Figure 1).
Setting and samples
The participants of this study were Korean outpatients with
heart failure who visited the outpatient department of the Cardi-
ology Internal Medicine division of Gyeongsang National University
Hospital located in Jinju city, Gyeongsangnam-do, from September
1 to November 6, 2015. Patients with heart failure were recruited by
convenience sampling of the population residing close to our
institution. G*Power 3.1.5 software program (Heinrich Heine Uni-
versity, Dusseldorf, Germany) was used to compare the mean of
differences in the self-care behavior score, NT-proBNP, LVEF, LVEDP,
and depression score between the two groups [16]. Given the two-
sided test, a significance level of .05, statistical power of .80, and an
effect size of 0.80, 42 participants were needed, and 42 study par-
ticipants were chosen [17]. The final number of participants to
analyze was 38.
The inclusion criteria were as follows: age between 60 and
75 years, heart failure diagnosed for at least 6 months to less than
10 years by a cardiologist, LV EF of <50%, New York Heart
Association (NYHA) function Class II/III, able to communicate, able
to understand the purpose of the study, and having agreed to
participate in the study.
Exclusion criteria were as follows: presence of respiratory dis-
eases such as chronic obstructive pulmonary disease or asthma,
diabetes, chronic kidney failure, stroke, or terminal cancer and
prior knowledge about telephone self-management programs for
heart failure.
Ethical considerations
The Institutional Review Board of Gyeongsang National Uni-
versity Hospital approved the study (Approval no. GNUH 2015-
07-023-001). The participants' agreement and consent to partic-
ipate in the study were also secured before the survey. Partici-
pants were informed that they could withdraw from the study at
any time.
Measurements
Self-care behavior
The European Heart Failure Self-care Behavior 9-item (EHFScB-
9) tool translated into Korean by Son et al [18] was used. The
EHFScB-9 tool consists of five items of self-care behavior such as
weight measurement, water restriction, low-salt diet, prescription
medication, and regular exercise and four items to be reported to
medical staff related to dyspnea, edema, fatigue, and weight in-
crease. Based on the 5-point Likert scale (1 point, not at all; 5 points,
very much), higher scores signify a higher level of self-care
behavior. The Cronbach's alpha of the translated EHFScB-9 tool
was .72 in the study by Son et al [18]. The Cronbach's alpha was .71
in this study.
Cardiac functional index
Measurement of NT-proBNP levels was performed by electro-
chemiluminescence immunoassay by a medical technologist.
Venous blood (5 cc) was collected before and 1 hour after
echocardiography and added to a tube containing ethyl-
enediaminetetraacetic acid (EDTA). The sample was then analyzed
using an Elecsys and Cobas e immunoassay analyzer (Roche Di-
agnostics International Ltd., Switzerland).
LV EF was measured by a nurse by transthoracic echocardiog-
raphy using the ViVid E 9 (GE Healthcare, USA) in accordance with
the recommendations of the Korean Society of Cardiology. The left
ventricular end-diastolic volume was calculated by the biplane
Simpson's method to analyze the 4-chamber and 2-chamber sec-
tions of the left ventricular end-diastolic volume, after the patient
was left undressed on the upper left side. The left ventricular end-
diastolic volume and the systolic volume were measured by the
disc summation method on the 4-chamber and 2-chamber sec-
tions, respectively. As a result, the left ventricular diastolic volume
was subtracted from the systolic volume, and the percentage of the
value divided by the volume was calculated.
Transthoracic echocardiography, performed using the ViVid E 9
(GE Healthcare) cardiac ultrasound, was also used to measure
LVEDP, in accordance with the recommendations of the Korean
Society of Echocardiography. The measurement was performed by a
pulsed Doppler ultrasound in the left lateral position of the patient,
and the mitral inflow velocity (E velocity) at the initial relaxation
was recorded. The ratio (E/E0 ) of the velocities (E0 velocity: velocity
at the mitral annulus) was calculated.
Depression
The Center for Epidemiologic Studies-Depression Scale (CES-D)
was a self-reported questionnaire consisting of 20 items on a 4-
 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257 253

Figure 1. Flow diagram of the experimental procedure.

point Likert scale (0 point, 1 day; 1 point, 1e2 days; 2 points,
3e4 days; 3 points, 5e7 days). The score ranged from 0 to 60, and a
higher score signified a higher degree of depression. The Cron-
bach's alpha of the Korean version CES-D tool was .72 in the study
by Son et al [18]. The Cronbach's alpha was .79 in this study.
Development of a telephone-based self-management program
In this study, the subject, structure, and contents of the tele-
phone-based self-management program were developed based on
requirements of outpatients with heart failure, reports of previous
research [13e15], and the manual of the Korean Heart Association
Heart Failure Research Society. The contents of the program were
reviewed, and face-to-face education and telephone counseling
methods were established. The content of weekly session was
selected based on the manuscript of the Korean Heart Failure
document (2015). The participants were provided with an educa-
tional booklet with information about heart failure, self-reported
symptoms, and self-care behavior. The content validity of the
developed telephone-based self-management program was veri-
fied by a professor from the cardiology department and a professor
from the nursing department [19,20]. The specific structure and
contents of the telephone-based self-management program are
presented in Table 1.
Data collection
The data collection of this study was carried out from
September 1, 2015 to November 6, 2015. The data were collected
using structured questionnaires (general and disease-related
characteristics, self-care behavior, and depression). The partici-
pants who were able to complete their own questionnaires were
allowed to do so, whereas those unable to complete the ques-
tionnaire themselves were aided by a research assistant who read
the questionnaire and recorded participant responses in writing.
254 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257

Table 1 Description of Intervention.

Sessions Educational methods Theme Contents Duration (mins)

1 Face-to-face education Understanding and 1. Introduction 5

session self-management of 2. Education 20
heart failure 1) Understanding of heart failure
- Definition, etiology, symptoms, complications, diagnosis, and
treatment
2) Description of the patient's disease status
- Diagnosis, treatment, complications, and medication
3) Self-management of heart failure
- Management of symptoms, medication, nutrition, and daily life
4) Demonstration and training on how to use the self-symptom
checklists and self-care behaviors calendar
3. Questions and answers (Q & A) 5
2 The telephone Symptoms 1. Consultations 10
consultation and 1) Check symptoms for a week
education - Check the aggravate and assuage factors for symptoms
2) Confirm self-symptom checklists and self-care behaviors calendar
- Check the problems and retraining management methods
2. Education 15
1) Symptoms of heart failure, measure
2) Emergency symptoms of heart failure, measure
3. Q & A 5
3 The telephone Medication 1. Consultations 10
consultation and 1) Check symptoms for a week
education 2) Confirm self-symptom checklists and self-care behaviors calendar
- Check the problems and retraining management methods
2. Education 15
1) Types of heart failure patients' medication, effects, and side effects
2) Side effects and toxicity of drug of heart failure
3) Understanding and checking about the medication
- Explanation about the medication
- Check the difficulty and side effect about the medication
4) Make a habit of regular medication by using self-care behaviors
calendar
3. Q & A 5
4 The telephone Nutrition 1. Consultations 10
consultations and 1) Check symptoms for a week
educations 2) Confirm self-symptom checklists and self-care behaviors calendar
- Check the problems and retraining management methods
2. Education 15
1) The nutrition of heart failure patients
- Diet limit of cholesterol, water, and salt
- Attention to the diet when taking warfarin
2) Make a habit of checking daily weight and using self-care behaviors
calendar
3. Q & A 5
5 The telephone Daily life 1. Consultations 10
consultations and 1) Check symptoms for a week
educations 2) Confirm self-symptom checklists and self-care behaviors calendar
- Check the problems and retraining management methods
2. Education 15
1) Exercise, no smoking. and no alcohol
2) Relaxation, stress management, and immunization
3) Make a habit of regular exercise by using self-care behaviors calendar
3. Q & A 5
Outpatient schedule confirmation

After the questionnaire was completed, the LV EF and LVEDP were
measured using the ViVid E 9 (GE Healthcare, USA) cardiac ul-
trasound equipment. Within 1 hour after the echocardiography,
5 cc of venous blood was collected in an EDTA-containing bottle
in the blood sampling room and analyzed. The results of NT-
proBNP analysis were confirmed as per electronic medical
records.
After the preliminary study, the educational booklet was used
to educate the participants about heart failure and self-
management of heart failure for 30 minutes in the first face-to-
face training session, which was conducted in a separate section
of the cardiac ultrasound room. After 1 week, telephone consul-
tation and education session were conducted for 15e30 minutes.
Telephone consultation and education sessions were conducted
once a week for a total of 4 weeks. All the sessions were conducted
using an educational booklet, electronic medical records, a self-
symptom checklist, and self-care behavior calendars and
included counseling, education, and question and answer sections
during every session.
After 5 weeks, 5 cc of venous blood was collected in an EDTA-
containing bottle in the same manner as in the preliminary
study and analyzed by immunoassay. The results were confirmed
using electronic medical records. The LV EF and LVEDP were
measured using the same cardiac ultrasound equipment as in the
previous study within one hour after blood sample collection.
Data were collected using self-care behavior and depression
 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257 255

instruments by the same research assistant who conducted the Results

preliminary survey in a separate section of the cardiac ultrasound
room. Homogeneity

Data analysis
Data analysis was performed using the SPSS/WIN 21.0 program
(IBM Corp., Armonk, NY, USA). The general characteristics and
disease-related characteristics of the experimental group and the
control group were analyzed for differences in frequency, per-
centage, mean, and standard deviation between the two groups.
Analysis of these characteristics and study result homogeneity was
performed by using the following methods: Chi-square test,
Fisher's exact test, t test, and the ManneWhitney U test. The
ShapiroeWilk test was used to verify the normality of study vari-
ables. NT-proBNP and LVEDP were not normally distributed. Non-
normal distribution of research variables (NT-proBNP and LVEDP)
was performed using the ManneWhitney U test. Reliability of in-
struments (depression and self-care behaviors) was analyzed by
Cronbach's a parameter.
There was no significant difference between the two groups in
general characteristics and study variables (Table 2 and Table 3).
Self-care behavior
The self-care behaviors of the experimental group using the
telephone-based self-management program were statistically
significantly higher than the self-care behaviors of the control
group (t ¼ 8.22, p < .001) (Table 4).
Cardiac functional index
The NT-proBNP levels of the experimental group to which the
telephone self-management program was applied decreased sta-
tistically compared with the NT-proBNP levels of the control group
(U ¼ 2.28, p ¼ .022). The LV EF of the experimental group to which

Table 2 Homogeneity Test of General Characteristics and Disease Characteristics between the Experimental and Control Groups (N ¼ 38).

Characteristics Categories Total (n ¼ 38) Exp. (n ¼ 18) Cont. (n ¼ 20) c2 or t p

n (%) or M ± SD n (%) or M ± SD n (%) or M ± SD

Gender Men 23 (60.5) 11 (61.1) 12 (60.0) 0.01 >.999

Women 15 (39.5) 7 (38.9) 8 (40.0)
a
Age (yrs) 60e64 13 (34.2) 8 (44.4) 5 (25.0) 1.65 .477
65e69 7 (18.4) 3 (16.7) 4 (20.0)
70e75 18 (47.4) 7 (38.9) 11 (55.0)
68.16 ± 5.86 67.06 ± 6.59 69.15 ± 5.08 1.10 .277
Job No 24 (63.2) 9 (50.0) 15 (75.0) 2.55 .179
Yes 14 (36.8) 9 (50.0) 5 (25.0)
Educationa None 11 (28.9) 5 (27.8) 6 (30.0) 1.86 .519
Elementary school 13 (34.2) 7 (38.9) 6 (30.0)
Middle school 7 (18.4) 2 (11.1) 5 (25.0)
High school 5 (13.2) 3 (16.7) 2 (10.0)
 Graduate 2 (5.3) 1 (5.6) 1 (5.0)
Economya High 0 (0.0) 0 (0.0) 0 (0.0) 0.23 .734
Moderate 26 (68.4) 13 (72.2) 13 (65.0)
Low 12 (31.6) 5 (27.8) 7 (35.0)
Living witha No one 5 (13.2) 2 (11.1) 3 (15.0) 0.31 >.999
Spouse 22 (57.9) 11 (61.1) 11 (55.5)
Children 11 (28.9) 5 (27.8) 6 (30.0)
Diagnosis duration (months) 6e12 13 (34.2) 8 (44.4) 5 (25.0) 1.65 .477*
13e60 7 (18.4) 3 (16.7) 4 (20.0)
61e120 18 (47.4) 7 (38.9) 11 (55.0)
35.05 ± 23.50 33.22 ± 22.39 36.70 ± 24.92 0.45 .655
Symptom No 6 (15.8) 1 (5.6) 5 (25.0) 2.69 .184
Yes 32 (84.2) 17 (94.4) 15 (75.0)
Other diseases No 12 (31.6) 4 (22.2) 8 (40.0) 6.58 .361
Yes 26 (68.4) 14 (77.8) 12 (60.0)
Number of drugs 3.58 ± 1.15 3.50 ± 1.20 3.65 ± 1.14 0.40 .695

Note. Cont. ¼ Control Group; Exp. ¼ Experimental Group; M ¼ mean; SD ¼ standard deviation; yrs ¼ years.
a
Fisher's exact test.

Table 3 Homogeneity of Study Variables (N ¼ 38).

Variables Total (n ¼ 38) Exp. (n ¼ 18) Cont. (n ¼ 20) t or Z p

M ± SD M ± SD M ± SD

Self-care behavior (score) 17.68 ± 5.01 16.06 ± 4.83 19.15 ± 4.83 1.97 .056
NT-proBNPa (pg/mL) 1076.79 ± 1241.82 1488.10 ± 1610.85 706.62 ± 613.89 1.64 .102
LV EF (%) 40.06 ± 6.57 40.83 ± 5.78 39.37 ± 7.29 0.68 .500
LVEDP* 14.93 ± 6.14 15.01 ± 5.9 14.83 ± 6.53 0.21 .838
Depression (score) 20.34 ± 7.76 20.56 ± 9.64 20.15 ± 5.82 0.16 .875

Note. Cont. ¼ Control Group; Exp. ¼ Experimental Group; LV EF ¼ left ventricular ejection fraction; LVEDP ¼ left ventricular end-diastolic pressure; M ¼ mean; NT-
proBNP ¼ N-terminal pro-brain natriuretic peptide; SD ¼ standard deviation.
a
ManneWhitney U test.
256 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257

Table 4 Differences in Study Variables Between Groups (N ¼ 38).

Variables Group Pretest Posttest Difference t or Z p

M ± SD M ± SD M ± SD

Self-care behavior (score) Exp. 16.06 ± 4.83 23.61 ± 4.88 7.56 ± 3.90 6.65 <.001
Cont. 19.15 ± 4.83 18.40 ± 3.73 0.75 ± 3.80
NT-proBNPa (pg/mL) Exp. 1488.10 ± 1610.85 1279.05 ± 2084.81 209.05 ± 929.30 2.28 .022
Cont. 706.62 ± 613.89 835.41 ± 833.84 128.79 ± 450.73
LV EF (%) Exp. 40.83 ± 5.78 44.72 ± 6.80 3.89 ± 3.79 2.24 .032
Cont. 39.37 ± 7.29 40.05 ± 7.88 0.68 ± 4.91
a
LVEDP Exp. 15.04 ± 5.88 14.26 ± 8.22 0.79 ± 4.66 1.48 .141
Cont. 14.83 ± 6.53 14.39 ± 6.27 0.44 ± 4.09
Depression (score) Exp. 20.56 ± 9.65 15.61 ± 8.39 4.94 ± 5.89 3.49 .001
Cont. 20.15 ± 5.82 22.40 ± 8.32 2.25 ± 6.73

Note. Cont. ¼ control group; Exp. ¼ experimental group; LV EF ¼ left ventricular ejection fraction; LVEDP ¼ left ventricular end-diastolic pressure; M ¼ mean; NT-proBNP ¼ N-
terminal pro-brain natriuretic peptide; SD ¼ standard deviation.
a
Mann-Whitney U test.

the telephone-based self-management program was applied was
statistically significantly higher than the LV EF of the control group
(t ¼ 2.24, p ¼ .032). The LVEDP of the experimental group to which
the telephone-based self-management program was applied did
not increase statistically significantly compared with the LVEDP of
the control group (U ¼ 1.48, p ¼ .141) (Table 4).
Depression
The depression of the experimental group to which the tele-
phone-based self-management program was applied was statisti-
cally significantly decreased compared with the LV EF of the control
group (t ¼ 3.49, p ¼ .001) (Table 4).
Discussion
The purpose of this study was to develop a program to help
nurses to promote self-care behaviors in outpatients with heart
failure and to verify the effectiveness of the program. In this study,
the telephone-based self-management program for outpatients
with heart failure consisted of a face-to-face education session as
well as telephone counseling and education sessions. The efficacy
was evaluated by assessing self-care behaviors, cardiac function
indicators (NT-proBNP, LV EF, and LVEDP), and depression.
In the present study, self-care behaviors promoted through the
telephone-based self-management program increased in the
experimental group and decreased in the control group. The change
in self-care behaviors in the experimental group was larger than
that in the control group. This result was consistent with the results
of previous studies in which the self-management performance
measured by self-care behaviors of the telephone-monitored
experimental group was statistically significantly higher than that
of the control group [15]. Among self-care behaviors, “weight
measurement” showed the most significant change compared with
other items. Weight measurement is an important self-care
behavior, and body weight is a readily identifiable index of edema,
an important symptom in heart failure patients. A significant in-
crease in the main component items such as “taking medication”,
“water restriction”, and “regular exercise” was also observed. This
result thus shows that the telephone-based self-management pro-
gram is an effective program for promoting self-care behaviors.
In this study, cardiac function indices such as NT-proBNP levels,
LV EF, and LVEDP were measured to identify the effect of the tele-
phone-based self-management program objectively. In the present
study, NT-proBNP levels decreased significantly in the experi-
mental group, whereas they increased significantly in the control
group. Therefore, we concluded that the telephone-based self-
management program was effective in reducing NT-proBNP levels
in patients with heart failure. In this study, the decrease in NT-
proBNP levels in the experimental group was attributed to the
fact that body weight was measured during the self-care behaviors
to confirm the presence of edema and that the patients may have
practiced water and salt restriction, leading to a beneficial decrease
in body fluid.
In this study, the LV EF was measured as an index of cardiac
function to assess the effect of the telephone-based self-management
program. The LV EF of the experimental group increased significantly
after the telephone self-management program, and the change in LV
EF of the experimental group during the study period was signifi-
cantly higher than that of the control group. The LV EF is a variable
related to diuretic and cardiotonic drugs used by patients with heart
failure. We speculate that the significant increase in LV EF in this study
may be due to the increased regularity with which the experimental
group may have followed the medication schedule as supported by
the telephone-based self-management program.
In this study, there was no statistically significant difference
between the control group and the experimental group in LVEDP.
We speculate that the telephone-based self-management program
was not effective in this regard because the absolute value of E/E0
was not large by itself. Therefore, it is necessary to investigate the
change of LVEDP in patients with heart failure by repeating the
follow-up study or adjusting the number of interventions.
In the present study, the incidence of depression significantly
decreased from 20.56 to 15.61 in the experimental group and
increased to 22.40 from 20.15 in the control group. In the Korean
version of the CES-D scale, a score lower than 16 is designated as
“normal”, whereas a score between 16 and 24 signifies a “melan-
choly tendency” and a score of 25 and higher signifies “depression”
[21]. In the control group, there was no significant change in scores
from the prestudy to poststudy value (20.15 points to 22.40 points,
respectively), which were all classified as “melancholy tendency”.
However, in the experimental group, the score decreased during
the study period, with a prestudy score of 20.56 points to a post-
study score of 15.61 points, which indicated a change from
“depressed” to “normal”. This result is in agreement with that of a
study by Lee et al [22] of 31 hospitalized heart failure patients who
were scheduled to be discharged. Such patients, after a 1-hour face-
to-face education session and six telephone counseling sessions,
showed a gradual decrease in depression. Based on these results, it
can be concluded that the telephone-based self-management
program is an effective nursing intervention to relieve depression
in patients with heart failure.
In this study, telephonic access to the participants was used,
which enabled a more rapid development of a rapport between the
medical staff and the participants, leading to improved reliability.
Unlike the hospital's outpatient environment, where medication is
 M.K. Moon et al. / Asian Nursing Research 12 (2018) 251e257
delivered once a day per the outpatient schedule, the participants in
the study were contacted over the telephone at the appointed time to
ensure adherence to medication schedules. This communication
method, with a personal inclination, may have led to the increased
cardiac function index and reduced depression in this study. Because
educational booklets for face-to-face education and telephone edu-
cation were used, patients who could not read the prescribed
booklets were excluded during the selection process. However, it is
also necessary to develop an intervention method that can promote
self-care behaviors using educational methods other than by
brochures for patients who may not be able to read well and for
elderly patients. In addition, it is essential to develop a program to
promote self-care behaviors, which includes participation of patients
as well as their family members, and to verify the effectiveness such
programs, so that heart failure patients may continue disease self-
management. In this study, through the sample size calculation, 42
participants were needed. But, the final number of participants to
analyze was 38. It may make the effect of intervention weaken a little.
In addition, the intervention period of 5 weeks for the study was not
enough to grasp the long-term and microscopic effects of the pro-
gram. Finally, because the tools used in this study are subjective re-
sults reported by the subject's recall with self-report measures, bias
may be involved in gathering accurate data. Despite these limita-
tions, this study once again emphasizes the importance of education
programs for self-care behaviors in patients with heart failure.
Conclusion
In conclusion, a telephone-based self-management program
conducted by nurses can improve self-care behaviors, improve
cardiac function index as indicated by decreased NT-proBNP levels
and increased LV EF, and reduce depression in patients with heart
failure. Unlike inpatients, outpatients have been hard to control
regular and accurate drug administration, exercise, and dietary;
therefore, effective management methods are required for them.
From this perspective, it has been proven through this study that
regular phone-based patient care and education is a very suitable
and effective program for effective and safe self-care behaviors.
Therefore, this program is recommended as a nursing intervention
that can be used to manage and educate outpatients with heart
failure.
Conflicts of interest
The authors declare that they have no conflict of interest.
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