Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation





First Advisor

Dr. Debra Moser


Patients with heart failure (HF) suffer from chronic and progressive symptoms. Failure to respond appropriately to escalating symptoms of HF causes a delay in seeking care, which results in worse symptom status, frequent rehospitalizations, and contributes to higher mortality. In order to enhance HF self-care, promote timely care-seeking, and improve outcomes, identification of factors that affect patients’ responses to symptoms and their decisions to seek care is essential. Thus, the purposes of this dissertation were to (1) identify factors associated with patients’ responses to worsening HF symptoms, and (2) determine the impact of responses to symptoms on outcomes in patients with HF.

A mixed-methods and three quantitative research studies were conducted in this dissertation. The first study was a cross-sectional comparative, mixed-methods study to (1) compare perceptions, evaluations, and responses to worsening HF symptoms before a hospital admission between older and younger patients and (2) examine patients’ responses when they perceived higher symptom distress. The second study was a cross-sectional exploratory study to (1) investigate patients’ reasons for delay in seeking medical care and (2) determine which of the delay reasons were predicted by psychological factors. The third study was a longitudinal predictive study to (1) identify factors predicting care-seeking delay and (2) determine the impact of care-seeking delay on subsequent cardiac events. The fourth study was a cross-sectional correlational study to evaluate the associations of perceived control to symptom status, of perceived control to self-care, and of self-care to symptom status.

Results from the first research study indicated that despite few age-related differences in somatic awareness and symptom experience between older and younger patients, the majority of patients, regardless of age, failed to recognize, interpret, and respond appropriately to their escalating HF symptoms. The second study found that the most common reasons patients cited for delays were symptom-related and included “symptoms seemed vague”, “not sure of symptoms”, “symptoms didn’t seem to be serious enough”, and “symptoms were different from the last episode”. Depressive symptoms and anxiety predicted patients’ reasons for delay in seeking medical care. In the third study, New York Heart Association functional class, depressive symptoms, HF knowledge, and HF somatic awareness were significant predictors of delay in seeking medical care. Delay in seeking medical care predicted subsequent cardiac rehospitalization and death. The final study demonstrated that higher levels of perceived control were associated with better self-care, and better self-care was associated with better symptom status in patients with HF.

The findings of this dissertation suggest the importance of prompt symptom responses among patients, enhancement in patients’ symptom appraisal abilities, improvement in patients’ mental health, timely care-seeking, and appropriate HF self-care to avoid further deterioration. Subsequently, an effective intervention should be developed and tested to promote HF self-care focused on a timely response to worsening HF symptoms to improve outcomes in patients with HF.

Digital Object Identifier (DOI)

Funding Information

The American Nurses Foundation (2013-2014)