The Role of the Nurse in Cardiac Rehabilitation Programmes

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

The Nurses' Role in the Cardiac Rehabilitation Team: Data From the Perfect-CR Study

BACKGROUND

Nurses constitute a central profession in the cardiac rehabilitation (CR) team delivering comprehensive CR to individuals with cardiovascular disease. We aimed to identify specific components reflecting the nurses' role in the CR team associated with attainment of risk factor targets post myocardial infarction.

METHODS

Center-level data (n = 78) was used from the Perfect-CR study, in which structure and processes applied at CR centers in Sweden (including details on the nurses' role) were surveyed. Patient-level data (n = 6755) was retrieved from the SWEDEHEART registry. Associations between structure/processes and target achievement for systolic blood pressure (BP) (<140 mm Hg) and low-density lipoprotein cholesterol (LDL-C, <1.8 mmol/L) at 1 year post myocardial infarction were assessed using logistic regression.

RESULTS

Structure and processes reflecting nurses' autonomy and role in the CR team associated with patients achieving systolic BP and/or LDL-C targets included the following: nurses having treatment algorithms to adjust BP medication (odds ratio [95% confidence interval]: systolic BP, 1.22 [1.05-1.42]; LDL-C, 1.17 [1.03-1.34]) and lipid-lowering medication (systolic BP, 1.14 [1.00-1.29]; LDL-C, 1.17 [1.05-1.30]), patients having the same nurse throughout follow-up (systolic BP, 1.07 [1.03-1.11]; LDL-C, 1.10 [1.06-1.14]), number of follow-up hours with a nurse (systolic BP, 1.13 [1.07-1.19]), having regular case rounds to discuss patient cases during follow-up (LDL-C, 1.22 [1.09-1.35]), and nurses having training in counseling methods (systolic BP, 1.06 [1.03-1.10]).

CONCLUSION

Components reflecting CR nurses' autonomy and role in the team are of importance for patients attaining risk factor targets post myocardial infarction. The results could provide guidance for optimizing nurses' competence and responsibilities within the CR team to improve patient care.

Group-based cardiac telerehabilitation interventions and health outcomes in coronary patients: A scoping review

OBJECTIVE

To explore the extent and type of evidence in relation to group-based cardiac telerehabilitation interventions and health outcomes in coronary artery disease patients.

DATA SOURCES

A literature search was conducted in August 2022 and July 2023 in databases including PubMed, CINAHL, Scopus and PsycINFO. The search process followed the scoping review methodology guided by the Joanna Briggs Institute for scoping reviews.

METHODS

The inclusion criteria were a peer-reviewed journal article published in English between 1 January 2017 and 15 August 2022 and updated to cover until 15 July 2023 concerning group-based cardiac telerehabilitation in adult coronary artery disease patients. All group-based cardiac telerehabilitation interventions and health outcome types were charted and summarized.

RESULTS

The researcher screened a total of 2089 articles, of which 22 were retained with a total of 1596 participants. Group-based cardiac telerehabilitation interventions were particularly useful for patients with multi-faceted technological applications and social support. The patients received guidance regarding cardiovascular disease risk factors. Physical fitness, psychological complaints and quality of life were often measured outcomes in the included studies.

CONCLUSIONS

This scoping review indicates the success of various rehabilitation interventions utilizing different technologies for coronary patients. Coronary patients were guided in making lifestyle changes, and positive findings were observed in the health outcomes measured after the telerehabilitation intervention. The findings of this review can provide valuable guidance for developing and evaluating sustainable group-based cardiac telerehabilitation programs that aim to benefit coronary patients.

Characteristics and correlates of disease-related knowledge and exercise self-efficacy among cardiac patients attending virtual cardiac rehabilitation during the first COVID-19 lockdown in Peru

BACKGROUND

Government responses and restrictions due to the COVID-19 pandemic (e.g., limits to non-urgent health care services, including non-urgent outpatient appointments) led to the suspension of center-based (in-person) cardiac rehabilitation (CR), with many programs switching to virtual delivery. This study aimed to understand the characteristics and correlates of disease-related knowledge and exercise self-efficacy in a group of patients attending a virtual CR program during the first COVID-19 lockdown in Peru.

METHODS

In this prospective observational study, 240 patients receiving virtual CR care (exercise instructions and patient education) between August/2020 and December/2021 completed questionnaires pre- and post-CR assessing disease-related knowledge (CADE-Q SV questionnaire) and self-efficacy (SE; Bandura's Exercise SE scale). Paired t tests were used to investigate changes pre/post-CR and Pearson correlation coefficients were used to determine the association between knowledge/SE and patients' characteristics.

RESULTS

Participants were mainly comprised of men, with a cardiac diagnosis of stable coronary artery disease, who underwent percutaneous coronary intervention or had a known diagnosis of hypertension and with at least one cardiovascular risk factor (95.8%). Mean total knowledge scores improved significantly at post-CR (12.9 ± 2.4 to 15.6 ± 2.0/20; p<0.001), as well as in 4/5 knowledge areas (cardiovascular risk factors, exercise, nutrition, and psychosocial risk; p<0.001). Mean SE scores improved significantly at post-CR (1.9 ± 0.9 to 3.0 ± 0.9/5; p = 0.01). Post-CR knowledge and SE were significantly correlated with cardiac diagnosis and surgical procedures (r = 0.17, p = 0.02 and r = 0.27, p = 0.02, respectively).

CONCLUSIONS

The virtual CR program improved disease-related knowledge and SE of cardiac patients during the first months of the COVID-19 pandemic. Post-CR outcomes were correlated with cardiac diagnosis and surgical procedures and more research with other characteristics is warrantied.

Theory-based nursing interventions in adults with coronary heart disease: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

This systematic review and meta-analysis aimed to synthesize the outcomes of theory-based nursing interventions for coronary heart disease management.

DESIGN AND METHODS

Web of Science, Scopus, Science Direct, and PubMed databases were electronically searched from January 2013 to August 2021. The Preferred Reporting Item for Systematic Reviews and Meta-analyses statement guidelines was followed for this meta-analysis. Randomized controlled trials on patients with coronary heart disease, using a theory-based nursing intervention were eligible. Methodological quality was examined by two authors using the Modified Jadad Scale. Based on the heterogeneity test, the results were analyzed using a pool of data with 95% confidence intervals, p-values, and fixed or random-effect models (PROSPERO registration number X).

FINDINGS

A total of 1030 studies were initially retrieved, and 8 randomized controlled trials were eventually included in the meta-analysis after screening. The big majority (81.3%) of participants were males, and the mean age was 54.8 (SD = 8.7) years. This meta-analysis found theory-based nursing interventions had no significant effect on blood lipid profile, blood pressure, and healthy lifestyle. However, these interventions significantly reduced fasting blood glucose, and body mass index and improved the physical and psychological domains of quality of life.

CONCLUSIONS

The evidence from this meta-analysis reveals that theory-based nursing interventions have a positive effect on fasting blood glucose, body mass index, and quality of life. However, their effects on blood lipid profile, blood pressure, and a healthy lifestyle are inconclusive. The results of this metanalysis are largely based on a few trials and were limited in terms of the number of outcomes. Conducting well-designed randomized controlled trials with adequate power is needed to make a firm conclusion on the influence of theory-based nursing interventions on patient outcomes in the CHD population.

CLINICAL RELEVANCE

Considering the high mortality and morbidity of coronary heart disease, nurses may play a significant role in coronary heart disease management by providing interventions that are based on a certain theoretical framework. This meta-analysis provides insights into the implementation of theory-based nursing interventions in heart attack survivors or those newly diagnosed with coronary heart disease led by nurses and lasting longer than 6 months in coronary heart disease. In addition, future studies should consider enhancing the content of training programs for a healthy lifestyle within the theory-based nursing interventions and compare the effects of these interventions on acute and chronic coronary syndromes.

Effectiveness of eHealth cardiac rehabilitation on health outcomes of coronary heart disease patients: a randomized controlled trial protocol

BACKGROUND

Cardiac rehabilitation (CR) uptake and adherence remain sub-optimal despite the apparent health benefits of modifying healthy behavior and slowing disease progression. eHealth is the use of information and communication technology (ICT) for health. eHealth lifestyle interventions and disease management have emerged as modalities to enhance CR accessibility, enable an individualized progress page, and enrich real-time contact, video-based information, and technology monitored functionality. This study aims to develop a nurse-led eHealth cardiac rehabilitation (NeCR) intervention and investigate its effectiveness on coronary heart disease (CHD) patients' health outcomes.

METHODS

This single-blinded two-arm parallel randomized controlled trial will randomize 146 patients from the inpatient cardiovascular units of a hospital in Wuhan, China to receive either the NeCR or the usual care. The NeCR intervention uses a hybrid approach consisting of a brief face-to-face preparatory phase and an empowerment phase delivered by health technology. The preparatory phase aims at identifying self-care needs, developing a goal-oriented patient centered action plan, incorporating a peer support network and orientation to the use of the e-platform. The empowerment phase includes use of the multi-media interactive NeCR for promoting symptom management, monitoring lifestyle changes and offering psychological support. A tele-care platform is also integrated to enhance health care dialogue with health professionals and peer groups. The control group will receive the usual care. An evaluation of lifestyle behavioral changes, self-efficacy, health-related quality of life, anxiety and depression, cardiovascular risk parameters, and unplanned health services use will be conducted at baseline, 6 weeks and 12 weeks post-intervention.

DISCUSSION

This protocol proposes an individualized, comprehensive, and interactive NeCR delivered using a hybrid approach and guided by an empowerment model to optimize health outcomes of CHD patients. The intervention content and web-design is based on international health guidelines to improve credibility, comprehensibility and implementation. This study also proposes a new method of peer support in which the researcher shares participants' progress toward goal attainment with the peer group. Results of this research have the potential to increase accessibility and availability of CR, improve cardiac rehabilitation service development in China, and inform eHealth lifestyle interventions.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800020411; Date of registration: December 28, 2018.

Effectiveness of nurse-led patient-centered care behavioral risk modification on secondary prevention of coronary heart disease: A systematic review

BACKGROUND

Despite establishment of advocacies centered on using patient-centered care to improve disease-related behavioral changes and health outcomes, studies have seldom discussed incorporation of patient-centered care concept in the design of secondary cardiac prevention.

OBJECTIVES

This review aimed to identify, appraise, and examine existing evidence on the effectiveness of nurse-led patient-centered care for secondary cardiac prevention in patients with coronary heart disease.

DESIGN

A systematic review of randomized controlled trials focusing on nurse-led patient-centered care for secondary cardiac prevention was conducted. Primary outcomes were behavioral risks (e.g. smoking, physical activity), secondary outcomes were clinically relevant physiological parameters (e.g. body weight, blood pressure, blood glucose, blood lipoproteins), health-related quality of life, mortality, and self efficacy.

DATA SOURCES

Twenty-three English and seven Chinese electronic databases were searched to identify the trials.

REVIEW METHODS

The studies' eligibility and methodological quality were assessed by two reviewers independently according to the Joanna Briggs Institute guidelines. Statistical heterogeneities of the included studies were assessed by Higgins I2 and quantitative pooling was performed when studies showed sufficient comparability.

RESULTS

15 articles on 12 randomized controlled trials were included in this review. Methodological quality of the included studies was fair. Based on the Joanna Briggs Institute critical appraisal tool for experimental studies, the included studies had met a mean of six criteria out the ten in this appraisal tool. The meta-analyses of the included studies revealed that nurse-led patient-centered care had significantly improved patients' smoking habits, adherence toward physical activity advices, and total cholesterol level with medical regime optimization, in short- to medium-term. The intervention was also favorable in improving the patients' health-related quality of life in several domains of SF-36. Furthermore, from single-study results, the intervention was favorable in improving the patients' weight management and alcohol consumption. However, it did not show significant effects on improving the patient's dietary habits, certain cardiac physiological parameters, mortality and self-efficacy. Currently, no addition long-term benefit of the intervention on secondary cardiac prevention was identified.

CONCLUSION

This review has systematically analyzed the effects of nurse-led patient-centered care on patients' behavioral risks, cardiac physiological parameters, mortality, health-related quality of life and self-efficacy. Given limited quantity of existing evidence regarding certain outcomes and long-term follow-up period; cross-trial heterogeneity of the interventions, measurement methods and statistical results; high or unclear risk of bias in some quality dimensions, the effectiveness of the intervention on secondary cardiac prevention remains inconclusive and subject to additional trials and evidences.

Development of an evaluation scale for self-management behavior related to physical activity of patients with coronary heart disease

BACKGROUND

To provide patients with effective self-management education that takes their lifestyle into account, medical personnel need to provide education and evaluation of self-management behaviors which patients can apply to their daily life.

AIM

This study aimed to assess the reliability and validity of the evaluation scale for self-management behavior related to physical activity of patients with coronary heart disease (ES-SMBPA-CHD).

METHODS AND RESULTS

Outpatients with coronary heart disease (n = 76) completed a self-administered questionnaire supported by a previous study of ours. The ES-SMBPA-CHD was divided into two domains, the first dealing with self-management behavior to enhance physical activity in daily life and the second with behavior to maintain the level of physical activity. Factor analysis showed that the first part comprised four factors and the second five. The ES-SMBPA-CHD was associated with the International Physical Activity Questionnaire (IPAQ) subscales and activity energy expenditure (measured by Lifecorder EX). Cronbach's α coefficient was between 0.71 and 0.90. The intraclass test-retest correlation coefficient of the subscale was between 0.75 and 0.93.

CONCLUSIONS

The ES-SMBPA-CHD is reasonably reliable and valid and is expected to prove useful for the assessment of patients' self-management behavior and for individualized instruction.

The other side of the coin: perceived positive effects of illness in women following acute myocardial infarction

BACKGROUND

Although myocardial infarction (MI) is linked with both physical and psychological impairments, the possibility of patients also experiencing positive outcomes of MI has received far less attention in research and in clinical practice. In particular, this aspect has been under-investigated in older persons and in women.

AIM

The purpose of this study was to investigate possible positive effects of illness, describe the patient characteristics and explore the nature and frequency of these effects in older women after MI.

METHODS

A cross-sectional postal survey was conducted in 145 women aged 62-80 years, three months to five years after MI. Self-reported socio-demographic and clinical data, in addition to data from medical records, were collected. A single-item question--"All in all, was there anything positive about experiencing an MI?"--was used to assess positive effects of illness, in addition to an open-ended question on the nature of possible positive effects.

RESULTS

A majority of the women (65%) reported positive effects from their MI experience. The women perceiving positive effects did not differ from those who did not on socio-demographic and clinical variables, except for being older (p=0.007) and less often readmitted (p=0.029). The groups did not differ significantly as to disease severity and time since MI. Four themes emerged from the open-ended questioning on the nature of perceived positive effects of the illness: Appreciating Life (55%), Getting Health Care (42%), Making Lifestyle Changes (36%), and Taking More Care of Self and Others (29%).

CONCLUSIONS

The findings contribute to a more complete picture of psychosocial issues in women after MI by providing evidence that positive effects are often experienced despite physical limitations. Nurses may use this knowledge as a tool in patient education and communication, although further research is needed to determine the most optimal interventions for MI patients.

Cardiovascular risk estimation by professionally active cardiovascular nurses: results from the Basel 2005 Nurses Cohort

BACKGROUND

Nurses play a key role in the prevention of cardiovascular disease (CVD) and one would, therefore, expect them to have a heightened awareness of the need for systematic screening and their own CVD risk profile. The aim of this study was to examine personal awareness of CVD risk among a cohort of cardiovascular nurses attending a European conference.

METHODS

Of the 340 delegates attending the 5th annual Spring Meeting on Cardiovascular Nursing (Basel, Switzerland, 2005), 287 (83%) completed a self-report questionnaire to assess their own risk factors for CVD. Delegates were also asked to give an estimation of their absolute total risk of experiencing a fatal CVD event in the next 10 years. Level of agreement between self-reported CVD risk estimation and their actual risk according to the SCORE risk assessment system was compared by calculating weighted Kappa (kappa(w)).

RESULTS

Overall, 109 responders (38%) self-reported having either pre-existing CVD (only 2%), one or more markedly raised CVD risk factors, a high total risk of fatal CVD (> or =5% in 10 years) or a strong family history of CVD. About half of this cohort (53%) did not know their own total cholesterol level. Less than half (45%) reported having a 10-year risk of fatal CVD of <1%, while 13% reported having a risk > or =5%. Based on the SCORE risk function, the estimated 10-year risk of a fatal CVD event was <1% for 96% of responders: only 2% had a > or =5% risk of such an event. Overall, less than half (46%) of this cohort's self-reported CVD risk corresponded with that calculated using the SCORE risk function (kappa(w)=0.27).

CONCLUSION

Most cardiovascular nurses attending a European conference in 2005 poorly understood their own CVD risk profile, and the agreement between their self-reported 10-year risk of a fatal CVD and their CVD risk using SCORE was only fair. Given the specialist nature of this conference, our findings clearly demonstrate a need to improve overall nursing awareness of the role and importance of systematic CVD risk assessment.

Depressive mood after a cardiac event: gender inequality and participation in rehabilitation programme

BACKGROUND

Depressive mood after a cardiac event is common with serious consequences for the patient.

AIMS

To compare gender in depressive mood during the first year after a cardiac event and to evaluate the effect of participating in a multidimensional secondary prevention program on depressive mood.

METHODS

166 men and 54 women, <73 years, consecutively answered a questionnaire concerning depressive mood at 2 weeks, 6 weeks, 5 months and 1 year after discharge after a cardiac event. At 2 weeks, each patient met a nurse, and was informed about the disease and received individual support about lifestyle changes. Of those invited to participate in a secondary prevention program, 127 patients accepted, and 93 declined participation.

RESULTS

At each of the four follow-ups, women had significantly higher depression scores than men. Depressive mood in both women and men was significantly reduced at 6 weeks. Thereafter, it increased to the 2-week level in women and to above the 2-week level in men. No differences were seen in patients participating or not in secondary prevention programs.

CONCLUSION

Women had higher depressive mood scores than men and secondary prevention programs failed to improve depressive mood in both women and men.