Cardiac rehabilitation services have developed worldwide over the last few decades. The World Health Organization definitions of cardiac reha- bilitation of 1969 and 1993 outlined what was required of a cardiac rehabilitation service for patients with coronary heart disease. However, as might be expected, different countries and health provision services developed different styles of programs in response to local funding, available staff, and patient profiles. As a result of this, many international bodies developed their own guide- lines and policies for the provision of cardiac rehabilitation.1–4The CARINEX survey of current guidelines and practices within the European Union5 identified 20 professional guidelines since 1990, in nine languages across Europe alone. Twelve separate countries had national guidelines.
A variety of program types have been devel- oped. One strong common recommendation across the guidelines was that cardiac rehabilita- tion programs be multifactorial and multi- disciplinary in nature. The provision of a program of this nature requires a wide range of expertise and skills, and access to a multidisciplinary team may be difficult with restricted healthcare budgets and smaller centers. Nurses, who constitute the largest employee population of the health service workforce, are often recruited into these positions.
Several recent reviews of cardiac rehabilitation service provision assessed staffing, and nurses appear to play a significant role. Lewin et al.
assessed programs in the UK in 1998.6 They reviewed 263 programs and identified nurse
involvement in 89% of them. With the exception of physiotherapists, input from other disciplines was minimal. The British Association of Cardiac Rehabilitation indicated that in 1998 80% of cardiac rehabilitation services were coordinated by nurses.
The most recent review of cardiac rehabilita- tion services within the European Union, the CARINEX survey,7 was carried out in 1995.
Staffing was reviewed in centers which provided WHO-defined phase II and III cardiac rehabilita- tion. The staffing profile indicated that even though variation in the type of staff involvement was the norm across the European Union, nurses were involved in the majority of the programs.8,9 The appointment of nurses to coordinator roles can be very strategic. Nurses are professionals with good communication skills, they have significant experience of working with patients and families, and they have the ability to interact easily with other disciplines. The cardiac rehabil- itation service coordinator requires the skill to manage coronary heart disease which can result in a wide-range of residual symptoms depending on diagnosis.
Cardiac rehabilitation services are by definition
“comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk-factor modification, education and counsel- ing. These programs are designed to limit the physiological and psychological effect of cardiac illness, reduce the risk of sudden death or re- infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychological and vocational status of selected
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36
Prevention Programs: The Role of the Nurse
Alison Cahill
patients.”10Obviously, these rehabilitation activi- ties do not take place all at once. They are carried out at different stages of recovery. To facilitate this, a nurse leading a cardiac rehabilitation program needs to develop many roles.
Jillings described nursing interventions in cardiac rehabilitation as falling into six categories:
supportive, palliative, restorative, educative, pro- tective, and preventative.11While all cardiac reha- bilitation patients should be dealt with on the basis of individual needs, there are basic require- ments that need to be met in each of the various phases of cardiac rehabilitation.
The Role of the Nurse in Phase I Rehabilitation
This initial phase of rehabilitation begins at admission. It may be administered at ward level by ward staff. Evidence-based practice has shown that early intervention of a cardiac rehabilitation nature has a positive effect on recovery.12The key areas to be addressed at this phase of rehabilita- tion are reassurance and information/education.
If at all possible, partner or family involvement should be part of this phase.
Reassurance
Anxiety, depression, and reduced self-confidence are common reactions to a coronary event. Failure to address these issues means a prolonged nega- tive response from a patient toward their illness and poor psychological adjustment is predictive of subsequent mortality.13 The ideal means to reassure a patient is for the cardiac rehabilitation nurse to have an individual consultation with the patient and his or her family. It is important that the multidisciplinary approach is well coordi- nated with the involvement of all relevant staff as required.
Reassurance of patients and their families does elicit a positive attitude to recovery and can dispel the myths of “hearsay” often associated with cardiac illness. The best means to reassure patients is to inform and educate them about their illness and to provide a realistic approach to its management.
Information/Education
The education of the patient is the cornerstone of any cardiac rehabilitation program. Often the requirements of a patient are to change a lifestyle they have practiced since childhood. Educating patients requires more than knowledge acquisi- tion. Patient profiles may differ but they will always require clear, concise information to assist them with their recovery.
When planning any information/education service there are some very important issues to be addressed regardless of who provides the service:
1. Identify any material, linguistic, and cultural barriers to learning.
2. All information and advice should be pre- sented and delivered by both written and verbal means. If designing written information, the editing suggestions from Cox14and Pocinki15may prove useful. It is necessary to ensure that any written information provided is “user-friendly” to the overall patient population. Provisions (video- or audio-tapes) for patients with learning difficulties, for example visual/hearing difficulties, must be made.
Information Requirements
Information requirements may differ greatly between patients, hence the benefit of individual counseling, but nonetheless there are some inte- gral components that must be included:
Risk Factor Profile
This activity is often described by patients as one of the most important pieces of information required.16The amount and type of data collected can vary and often might be dictated by the audit- ing policies in place. The identification of specific coronary risk factors must be performed for each patient. The information may be collected as per the British Cardiac Rehabilitation Association Guidelines.3
Diagnosis
Explanation of anatomy and physiology and definition of a clear diagnosis will help to clarify the rationale for treatment and future rehabilita- tion interventions. The cardiac rehabilitation
nurse or medical team should liaise with each other so they are unified in their presentation to the patient.
Multidisciplinary Approach
The cardiac rehabilitation nurse, in their role as program coordinator, should use the consulta- tion with the patient to identify those that need specific intervention from particular team disci- plines; for example, patients are often concerned about vocational issues such as job suitability, job security, and financial aspects. By liaising with the vocational officer and medical team at an early stage, the patient may be reassured, providing a more positive approach to recovery and alleviat- ing anxiety.
Advice Regarding Activities
Providing patients and their families with appro- priate advice on activity levels, both the activities of daily living and social and leisure in nature, is necessary. Advising patients on activities after discharge can help identify patients who may need assistance in the early discharge period – the elderly, those living alone, or those with significant dependants. Social workers, occupa- tional therapists, physiotherapists, and vocational counselors can be consulted on these issues. Pro- viding patients with an exercise program for post discharge will ensure that recovery progresses at a suitable pace.
Symptom Management
Potential future symptoms and their management should be discussed prior to discharge to avoid panic and anxiety in the instance of their occur- rence. Proper instruction on intervention tech- niques, for example the use of glyceryl trinitrate spray, and early medical attention should be addressed.
Further Rehabilitation
Outlining the rehabilitation process planned for the patient with the patient’s family will provide structure for their recovery and help to maintain and promote motivation and compliance to advice given.
The Role of the Nurse in Phase II Rehabilitation
Phase II usually comprises a structured program of patient participation. Program formats can vary significantly. They can be residential, hospi- tal based, or community based. Even though most are exercise based, coordination of all services into this program is essential. Most European countries follow the outpatient-based formula and even still display significant differences, i.e. program length, the use of ECG monitoring, supervising disciplines. The coordinator should be mindful that each patient should still be treated individually and progress monitored.
It is well established that the program should be multidisciplinary in nature and the nurse, as coordinator, should devise a program which encompasses all aspects of rehabilitation. Liaising with the other disciplines is required to develop a program that meets these needs, for example nutritional guidance, vocational guidance, psy- chological support, and education regarding medications.
Physical
Before commencing any physical program, an appropriate baseline assessment should be per- formed on every participant. This allows for individual prescription of exercise in a safe and efficient manner. The most basic of assessments should include the following: baseline physical assessment (risk factor profile, diagnosis, current symptoms, and previous or other associated medical history); inclusion and exclusion criteria for exercising as per the recognized guidelines (ACSM,17AACVPR2); risk stratification of patients should be performed according to recognized guidelines1; baseline exercise capacity assessment by an exercise stress test performed on a treadmill or bicycle, carried out according to National Cardiac Society recommendations.18
Once collected, these data provide the nurse with detailed information to devise a specific program. All programs should include the follow- ing features:
• Individual exercise prescription for the super- vised exercise class.
• Baseline vital sign assessment at each session.
• Each exercise session should include a warm-up phase, aerobic exercise at a submaximal level, some resistance training and a cool-down period.
• All emergency responses should be in place.
• Staff to patient ratios will depend on the patient profile.
• Appropriately qualified staff should be in situ for class monitoring.
• Nutritional guidance should be included in the program.
• Psychological support should be included.
• Educational classes on coronary heart disease and its implications.
• Education regarding medications.
On completion of the formal program, a sub- sequent exercise stress test should be performed for comparison purposes.
Psychological Aspects
When coordinating the program, the cardiac reha- bilitation nurse must ensure that psychological support is provided as part of the mainstream service. The psychological aspect should consist of group sessions or individual counseling, where appropriate. The most common evaluation is screening for levels of anxiety and depression and the most common assessment tools are the Hos- pital Anxiety and Depression Scale (HADS) and the Short Form 36 questionnaire (SF-36). Ideally a psychologist should provide this service and the nurse as coordinator will liaise with them to inte- grate the sessions into the program. In the absence of a psychologist, with appropriate training, the nurse would be able to provide the basic require- ments of the service, but screening for patients who need further intervention must be carried out and patients referred on to specialists as required.
The Role of the Nurse in Phase III Rehabilitation
By its definition, the cardiac rehabilitation service promotes lifestyle amendments for patients but specifies that it must be by their own efforts. The
goal of the cardiac rehabilitation nurse is to educate patients in the means to do this. Phase III rehabilitation mostly concerns maintenance of a heart-healthy lifestyle. The nurse can encourage this by completing the formal aspects to the reha- bilitation program. This should include the fol- lowing recommendations:
• Send a report of the patient’s rehabilitation program containing all results and comments to the referring cardiologist and general practitioner.
• Arrange medical review for all patients on com- pletion of the program.
• Ensure appropriate follow-up with the neces- sary disciplines as required, for example dietit- ian review, psychological follow-up.
• Ensure that the patient has formulated a plan for long-term maintenance and discuss this with them.
• Arrange return group sessions in some centers for patients at approximately 6 months and conduct some measurements – lipid profiles, psychological screening. This may depend on staffing issues or time constraints of existing staff.
There are some community-based exercise pro- grams which offer long-term continued incentives for the patient but these are scarce. A “Heart- watch” program (Ireland) is a nurse-led program which was developed to assist in the continuous monitoring of coronary risk factors; patients should be encouraged to avail themselves of such services where they are available.
Training
As early as 1992, the British Cardiac Society Working Party Report on cardiac rehabilitation19 identified the need for formal training for cardiac rehabilitation coordinators. At policy level, the Irish National Cardiovascular Health Strategy (“Building Healthier Hearts” 1999) is an example of a national directive which recommended trained coordinators be part of every cardiac rehabilitation program.20 Appropriate training for the coordinator’s role seems a logical step.
In response to this need, a training program was published,9 outlining the multidisciplinary
approach to training. The authors identified that
“formalized training contributes to acceptable standards of both clinical practice and service delivery and advances expertise in audit and service representation.” This training program is now conducted to a Masters degree level.
Training is provided worldwide by the British Association of Cardiac Rehabilitation and other national societies, European Society of Cardiol- ogy, the American Association of Cardiopul- monary Rehabilitation etc (see also Chapter 1).
Conclusions
Cardiac rehabilitation is a multidisciplinary service which needs to be delivered over a long period in the course of recovery from cardiac events and procedures. Such a program needs skilled coordination to ensure effective, efficient, and ongoing program delivery for all who can benefit. While many professional groups can coor- dinate such activities, nurses are well placed because of their broad-based training and likely availability in cardiac settings. Often cardiac reha- bilitation programs do not commence or falter through poor coordination. Medical leadership is essential and frequently found in most European programs but less often is the coordination of the day-to-day services the sole commitment of a program director. In small centers where coordination requires only part-time staffing, the role of the cardiac rehabilitation coordinator can be easily facilitated as part of a senior cardiac nurse’s role. Service provision can be enhanced by capitalizing on the broad-based training and holistic perspective of experienced cardiac nurses.
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