A pilot randomised controlled trial investigating a mindfulness-based stress reduction (MBSR) intervention in individuals with pulmonary arterial hypertension (PAH): the PATHWAYS study

BACKGROUND

Pulmonary arterial hypertension (PAH) is an uncommon condition with progressive heart failure and premature death. Treatment costs up to £120,000 per patient per year, and the psychological burden of PAH is substantial. Mindfulness-based stress reduction (MBSR) is an intervention with the potential to reduce this burden, but to date, it has not been applied to people with pulmonary hypertension. We wished to determine whether a trial of MBSR for people with PAH would be feasible.

METHODS

A customised gentle MBSR programme of eight sessions was developed for people with physical disability due to PAH, and they were randomised to group-based MBSR or treatment as usual. The completeness of outcome measures including Beck Anxiety Index, Beck Depression Inventory and standard physical assessment at 3 months after randomisation were recorded. Health care utilisation was measured. Attendance at the sessions and the costs involved in delivering the intervention were assessed. Semi-structured interviews were conducted to explore the acceptability of the MBSR intervention and when appropriate the reasons for trial non-participation.

RESULTS

Fifty-two patients were recruited, but only 34 were randomised due to patients finding it difficult to travel to sessions. Twenty-two completed all questionnaires and attended all clinics, both routine and additional in order to collect outcomes measures. The MSBR sessions were delivered in Bristol, Cardiff and London, costing, on average, between £2234 (Cardiff) and £4128 (London) per patient to deliver. Attendance at each session averaged between two patients in Bristol and Cardiff and three in London. For those receiving treatment as usual, clinician blinding was achievable. Interviews revealed that people who attended MBSR found it interesting and helpful in managing their symptoms and minimising the psychological component of their disease.

CONCLUSIONS

We found that attendance at group MBSR was poor in people with chronic PAH within the context of a trial. Achieving better MBSR intervention attendance or use of an Internet-based programme might maximise the benefit of MBSR.

Exploring the Patient's Experiences of Learning to Live with an Implantable Cardioverter Defibrillator (ICD) from One UK Centre: A Qualitative Study

BACKGROUND

International expansion of indications for implantable cardioverter defibrillator (ICD) implant means increasing numbers of patients with devices worldwide. However, smaller numbers of patients with ICDs in the UK has meant that clinical expertise available to care for this specialized group is limited. Whilst North American patients' experiences of living with an ICD are well documented, European perspectives remain underrepresented.

AIM

The aim of this study was to explore and describe patient's experiences around the time of their ICD device implant and after they returned home from one UK centre.

METHODS AND RESULTS

Eligible patients were recruited from one regional cardiothoracic centre and interviewed in their own homes using semi-structured schedules. Analysis of data elicited three themes; non-individualised nature of information, adjustments to living with the device and future outlook. Unique findings identified were; (a) concealment of concerns and symptoms; (b) funding issues; and (c) unavailability of appropriate support and advice during and after time in hospital.

CONCLUSION

Individualized care and support for these ICD patients appeared lacking according to respondents. Opportunities to discuss concerns appeared non-existent, which may indicate that UK patients are disadvantaged in the domain of psychological support compared with their European and North American counterparts. Findings remain tentative until explored with a larger, more representative and international sample.

Partners of ICD Patients—An Exploratory Study of Their Experiences

BACKGROUND

The experiences of partners who care for and support the needs of a loved one with an implantable cardiac defibrillator (ICD) remain largely unknown within Europe.

AIMS

This study explored the nature of partner's experiences from the pre-ICD implantation phase up until a maximum of 20 months at home.

METHODS

Eight partners cohabiting with a recipient of an ICD were interviewed using a semistructured schedule. All interviews were transcribed and content analysed for emerging categories and themes.

FINDINGS

Four themes representing 11 categories conceptualised the partners' experiences, these included: Acknowledging the patient's need for the device, reactions to the device, safeguarding the patient, and returning to normality.

CONCLUSION

This qualitative study suggests that partners of ICD recipients progress through various difficult and adaptive stages when learning how best to support the patient. A point is reached when most are able to assume control and normalise their lives. This transformation is slow; however, to improve this process and empower partners, nurses should provide relevant information and include them in decisions affecting the patient. Further research into the unique needs of partners, which includes international perspectives, would be significant in developing practice and theory in this area.

It has certainly been good just to talk: An interpretative phenomenological analysis of coping with myocardial infarction

OBJECTIVES

The experience of a myocardial infarction (MI), its potential meaning and consequences arouse a high level of emotional responsiveness in the individual. Researchers to date have argued that implementing adaptive coping strategies is necessary for emotional adjustment. This study aimed to advance coping research by providing more detailed insight into middle-aged men's personal experiences of coping with MI and the meaning they ascribe to these experiences.

DESIGN

Interpretative Phenomenological Analysis (IPA) was used to conduct an in-depth study of a small sample of patients who had suffered their first MI.

METHOD

Semi-structured interviews were conducted with six men within 6 months of their first MI. Verbatim transcripts of these interviews were analysed using IPA.

RESULTS

Three superordinate themes emerged, which are described under the headings of 'Difficulty in Reflecting', 'Needing to Talk' and 'Back to Normal'.

CONCLUSIONS

Participants seemed to share difficulties in reflecting on their coping strategies and the concept of coping generally, but were keen to talk about specific events in relation to the MI. The findings suggest that cardiac rehabilitation needs to focus on individual priorities for recovery. Providing opportunities for patients to talk through their experiences individually may be an important aspect of such care. Further research is needed to investigate the challenges that patients confront and the support they require post-MI.

Using evidence-based practice to address gaps in nursing knowledge

Implementing evidence based-practice and research findings into nursing care has been identified as a challenge to nursing staff. This article identifies key barriers to the use of research in the international literature, however, there are limited suggestions as to how to improve this in the clinical arena. This article aims to identify how nurses could optimize the implementation of evidence and research into their clinical care and reviews barriers to implementing and undertaking nursing research, suggesting a framework for improvement. It considers the widely varied levels of knowledge of research and equally varied critical appraisal skills present both at a pre and post-registration nursing level. The authors discuss an innovative, collaborative approach that considers the role of the nurse consultant, clinical academic and research facilitator posts. To ensure quality evidence-based practice is implemented into clinical nursing care a realistic and practical structure must be applied. With the appropriate framework, clinical structure and organizational support, promotion of evidence-based practice and research for patient benefit can be optimized. The implications for practice are also discussed. The implementation of a realistic research framework into clinical nursing practice has the potential to influence and develop a more active nursing research culture and promote evidence-based care within the workplace.

Bed-rest post-femoral arterial sheath removal - What is safe practice? A clinical audit

Numbers of patients undergoing coronary angiography and angioplasty procedures have increased in England due to targets within the National Service Framework for Coronary Heart Disease. Little evidence is available regarding optimal bed-rest duration for patients post-femoral arterial sheath removal following these procedures. Through literature review and clinical benchmarking, we aimed to identify what best practice was in the UK and whether bed rest times at our centre could be reduced without increasing complications to enable increased day case procedures. An audit tool was designed to collect data regarding method of obtaining haemostasis, length of bed-rest post-sheath removal and any post-procedural complications experienced by the patient. From a convenience sample of consecutive patients, 195 complete sets of baseline data revealed an average (median) period of 6-h bed rest. This was reduced to 3h and audit repeated yielding 176 complete data sets using the same audit tool. Femoral wound site complication rates were not significantly affected by reducing bed-rest time for diagnostic or interventional procedures. These findings contributed to an important change in practice, reducing length of stay post-procedure and should be re-explored due to increased use of femoral arterial closure devices.

Can nurses in cardiology areas prepare patients for implantable cardioverter defibrillator implant and life at home?

This study explored nurses' confidence and competence in preparing patients for having an implantable cardioverter defibrillator implanted and for life at home after discharge. Whilst research has identified various physical and psychosocial effects to patients and their partners associated with device implant and subsequent lifestyle adjustments, no research has explored nurses' knowledge of the device or these effects. A survey was designed using a purposive sample of 152 nurses from cardiology areas in four large teaching hospitals and a 28-point postal questionnaire to explore knowledge of the device and its impact. Most subjects were not confident in their abilities to prepare patients for implant or life at home after implant. Knowledge of the device and its effects appeared poorly understood by all nurses, irrespective of additional qualifications, length of time since qualifying or area of work. Many participants were aware of the poor knowledge level of nurses and identified it as a weakness in current care practices. Lack of understanding may impair preparation of patients for implantation of or for living with an implantable cardioverter defibrillator, and feasible strategies to change this situation will require careful consideration and further investment.

Implantable cardioverter defibrillators: developing evidence-based care

BACKGROUND

In the UK, access to psychological support for people with implantable cardioverter defibrillators (ICDs) is arbitrary, despite the fact that the National Institute for Clinical Excellence (NICE) recognises that the provision of adequate support can positively affect recovery. The author evaluates the available literature.

CONCLUSION

This review identifies that, although a lot of information is available about the effects of ICD technology on patients, there have been few systematic evaluations of care interventions that aid adjustment to living with an ICD. Equally, it has not yet been established whether nurses are equipped to effectively assess and meet the complex care needs of this patient population. The development and evaluation of national standards of care, in association with ICD patients and their families, is recommended.

Caring for patients with an ICD

The internal cardioverter defibrillator corrects life-threatening arrhythmias by providing antitachycardia pacing, pacing for bradycardia, and cardioversion or defibrillation shocks. However, there is little warning that the device may fire, which can cause physical, social and psychological problems for the patient. Nurses caring for ICD patients in the community and in hospital need to know what it is like to live with this device, how it works and the implications for other treatments.