Gerald S. Bowman

Cardiac rehabilitation in the United Kingdom: guidelines and audit standards. National Institute for Nursing, the British Cardiac Society and the Royal College of Physicians of London.

This paper summarises a multidisciplinary workshop convened to prepare clinical guidelines and audit standards in cardiac rehabilitation in the United Kingdom. The workshop developed a three element model of the rehabilitation process and identified needs relating to medical and psychosocial care and the potential contributions of exercise, education, secondary prevention, and vocational advice. Draft clinical standards are proposed as a basis for locally developed guidelines and further research.

Cardiac rehabilitation services in England and Wales: a national survey

We sent a short postal questionnaire to 244 centres in England and Wales that admitted patients with cardiac conditions. In total, 199 (81%) of the centres claimed to provide a cardiac rehabilitation service. Of these, 25 were randomly selected as a representative sample and visited in order to obtain detailed information concerning the provision of services. Most (18 (72%)) of the centres had commenced their rehabilitation programme within the previous 5 years, usually at the instigation of interested staff. Patient entry to cardiac rehabilitation programmes was restricted; women (who represented only 15% of attenders), elderly people (excluded in 10 (40%) centres), and those with more complex problems, such as angina or heart failure, were under-represented. The central components of all programmes were education and exercise training but there was a wide range in the quantity and quality of service provision. Most (22 (88%)) programmes were hospital out-patient based, one (4%) was hospital in-patient based, one (4%) was community-based and one (4%) was home-based. The staffing and funding of programmes was variable, with 7 (28%) having no identified funding. There are wide variations in the resources currently available for the rehabilitation of patients with coronary heart disease. There is a need for clearer direction of these services, in particular to determine minimum service provision. Guidelines are necessary to give a framework for this relatively new and rapidly expanding service.

Decision making in Greek and English registered nurses in coronary care units

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.

Coping with stroke at home

Relatives of stroke patients were asked about their knowledge and anxieties about strokes at three points in time: 72 hours after hospital admission, immediately prior to discharge, and 6 months post-discharge. During the period of hospitalization relatives were provided with information and encouraged to participate in patient care with the aim of increasing their skills in coping with the stroke patient at home. The relatives reported to be coping with the practical problems of care, but all reported problems with the emotional aspects of caring for the stroke patient.

Reliability testing of the hospital anxiety and depression (HAD) scale in the English, Maltese and back-translation versions.

This paper discusses the translation of the hospital anxiety and depression (HAD) scale (Zigmond, Snaith, Acta Psychiatr. Scand. 67 (1983) 361) into the Maltese language. The HAD scale is a well-validated and reliable measure of anxiety and depression originating in the United Kingdom. To ensure accuracy in the translation of the tool, the translation process was based on the Maltese Translation Guidelines issued by Chetcuti (Tahrig ghall-ezamijiet tal-Malti. Biex taghmel traduzzjoni tajba, Veritas Press, Malta, 1975, pp. 9-10) and those of Sechrest et al. (J. Cross-Cultural Psychol., 3 (1) (1972) 41). The composition of the Maltese language, which is Semitic in nature, is described and examples from different languages are given. The Maltese version of the HAD scale will facilitate the investigation of mood states in future studies on patients. Reliability testing of the HAD scale is then performed on the English version, the Maltese version and on the back-translation. The test-retest reliability of the three versions is examined using cross-tabulations of each item (pre values with post values), all of which gave highly significant values of chi-squared (p=0.0000). These cross-tabulations also yielded high values for the Kappa measure of reliability and for Spearmans coefficient of correlation ( kappa > or =0.8 and rho > or =0.9 for most items of anxiety and depression in all the three versions). The internal consistency of the three versions is also examined statistically using Cronbachs alpha and factor analysis. Both the anxiety and the depression subscales in the Maltese version can each be parsimoniously described by one factor. Each subscale therefore has a dimensionality of one. This explains why good levels of internal consistency are observed for the Maltese translation of the HAD scale ( alpha=0.79 for the anxiety subscale, 0.70 for depression, and 0.85 for both subscales together). This validates the Maltese version of the HAD scale, which can thus be used safely in future studies on Maltese patients. The anxiety subscale is also unidimensional in the original and in the back-translation, and also showed satisfactory values for Cronbachs alpha (0.73 and 0.74, respectively).Unfortunately, for the depression subscale, correlations between its items were rather low, thus leading to low alphas (about 0.45 and 0.51, respectively) for the internal consistency of this subscale in these versions.

Evidence for the effectiveness of cardiac rehabilitation

Cardiac rehabilitation is a relatively recent development and, though it is increasingly being recognized as an important part of comprehensive cardiac care, there remains some scepticism regarding its effectiveness and some ignorance of its potential. This article reviews the literature pertaining to the effectiveness of cardiac rehabilitation for patients with coronary heart disease (CHD).

Evidence of life quality inCAPD patients and implications for nursing care: a systematic review

Continuous ambulatory peritoneal dialysis (CAPD) maintains biological integritywithout restoring full health. The number of patients treated by CAPD is on the increase, the largest group treated are those with diabetic nephropathy. Quality of life is a major concern for these patients. A systematic review of CAPD and quality of life was undertaken using electronic data bases and other methods. Only two papers utilized a longitudinal research design, and in a random sample of 25 papers 69 different instruments were identified that measured quality of life. Eighty-five papers were selected for the review. Limitations of research designs and variety of measures used was highlighted. Caution in the interpretation of findings was necessary, the weight of evidence in most quality-of-life issues can only be interpreted as trends. No CAPD quality-of-life research exists that enables nurses to introduce effective supportive intervention. Psychosocial factors such as depression, anxiety and support, are more likely to influence quality of life than physiological aspects of CAPD-like dialysis adequacy. Quality of life for significant others is generally good and probably influenced by severity of patient problems.

Progress with a strategy for developing research in practice

This paper reports progress with a strategy for developing research in practice. Since the original paper (Knight et al., 1997), which outlined the strategy, a research development facilitator has been appointed, a proposal has been put forward for a centre for nursing research, and the partnership between an acute hospital trust and a university has been consolidated. The paper also addresses the issues raised in a Commentary (Bartlett, 1997) that accompanied the publication of the original paper. The strategy is planned to be evolutionary, and aims to focus on research related to practice, taking into account also organisational and external factors.

Why are patients with heart failure not routinely offered cardiac rehabilitation

Summary This paper considers the key issues of cardiac rehabilitation for patients with heart failure and discusses the current prospects of providing this service. The number of people with heart failure is rising, and the cost of treatment increases as symptoms become more pronounced. In addition, the quality of life for both the patient and partner deteriorates as the patients condition worsens. It is now possible to include safely the patient with heart failure in the exercise component of cardiac rehabilitation, provided appropriate assessment is carried out. The patient with mild-to-moderate heart failure can expect to gain most from rehabilitation and, as a result, symptoms can be reduced and exercise tolerance and functional capacity improved. The psychosocial impact of heart failure is generally greater than that experienced by other cardiac patients, yet there is a dearth of research. Despite the possible benefits for this group of patients, entry to programmes may not be possible because of a lack of resources.