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The Role of Cardiac Rehabilitation in Enhancing Secondary Prevention in CHD patients

The Role of Cardiac Rehabilitation in Enhancing Secondary Prevention in CHD patients


In order to enhance secondary prevention of Coronary Heart Disease (CHD) patients, it is necessary to implement cardiac rehabilitation programmes with psychological support by utilizing one of the nursing theories to build up the assessment tools and deliver a better nursing care for patients with post-myocardial infarction (MI). After using HADS scale based on RLT theory, we have detected that patients have witnessed quite good improvement in their psychological attitude towards life and society surrounding them, and patients' positive feedback at the end of the session was encouraging towards raising their self-esteem, which brought more confidence towards themselves, their family and the environment they are living in.

Secondary prevention of Coronary Heart Disease (CHD) is often poorly managed. However, the guidelines developed in the United Kingdom suggested that future cardiac rehabilitation programmes should provide more individualised care for patients' post-myocardial infarction (MI) (Clarke, Barbour & Macintyre, 2002). Many patients suffer from psychological effects after witnessing an MI attack, and these symptoms not only they increase after hospital discharge, but often remain throughout the first year after infarction with no preference in gender (Dixon et al, 2000, Clarke, 2003). In order to assess a patient's physical and psychological status we had to go back to the base of nursing theories in order to choose the most appropriate one that could fit our post-MI patients for cardiac rehabilitation. Other studies showed by applying cardiac rehabilitation to post MI patients can lead a significant improvements in Health Related Quality of Life (HRQOL) outcomes and exercise capacity.

The cardiac rehabilitation programs are crucial for patients with post MI. It has been proven that patients could achieve tremendous improvements after undergoing CRP exercises sessions in the outpatients CRP, based on a program format of 29 out of 38 exercise sessions that are chosen. With supervised and non-supervised exercise sessions in the outpatients CRP, and persisting for 38 weeks results have shown great improvements in post MI patients based on the selected outcomes as well as the psychological effects. However, before proceeding with our research paper there is a need to understand and evaluate all types of theories, and then we will choose the most appropriate one that could be applicable to our study.

The nursing theory is like a puzzle putting all the pieces together to form the whole picture into a meaningful use. It started by the late of 1960, and since then it kept evolving till nowadays. Scholars divided the nursing theory into four types from the most abstract ones 'metatheory' reaching to the most applicable one in our nursing practice 'practice theory' (Van & SellIoannis 2006). The four types of theories are: Metatheory, Grand theory, Middle range theory, and Practice theory (Appendix II). From the four types of theories we chose the Roper, Logan and Tierneyas (RLT) as our model because it is the most suitable for our patient Maggie [a fictitious name provided for her (Appendix III)] and others by providing the ground-floor in establishing communication between Maggie and the nurses, pave the way for care consistency between the hospital and community, provide clear access to Maggie's needs, and also is considered a flexible
model because it concentrates on providing help to put Maggie back on track to independence, or at least helping her to cope with the reduced levels of independence (Walsh 1998), and the model provides a teamwork of care supplemented by Maggie's carers, family and the MDT .

This paper will focus upon such psychological difficulties experienced by Maggie in practice, and we will critically analyse the nursing care she received within the cardiac rehabilitation (CR) nursing field. We will show the importance of adopting one of the models theories, the Roper, Logan and Tierneyas (RLT), and its contribution in providing us with the base in steering Maggie's management and cardiac rehabilitation.

The paper will then explain the stages of the nursing process by discussing the psychological nursing care provided for Maggie's recovery from an acute MI, which will highlight both the benefits and the constraints of what nurses faces with while providing care in a cardiac rehabilitation setting. The paper will consider the importance of effective communication in practice along with examining the inputs and the involvement of the multidisciplinary team in the nursing care provision. Following a critical evaluation of the nursing care in our post-MI patient, Maggie, further suggestions will be provided for the enhancement in delivering better cardiac rehabilitation care sessions for Maggie and other coming patients.

From Maggie’s practice point of view, the psychological effects will be emphasized upon following MI, or what has been classified as post-traumatic stress disorder (Widiger, 2006), contributing to her co-morbidity after MI, and characterized with symptoms of mixed anxiety-depression (Denollet et al. 2006).

Studies have documented a three to six-fold increase risk of sudden cardiac death among highly anxious patients (Lim et al., 1998). This is supported by Strike et al. where they considered that depression in post MI patients has been identified as independent risk factors for increased morbidity and mortality among patients with first and recurrent MI, but these psychological effects, (Major/minor depressive disorder nor depressive symptoms) lacked the ahead prediction neither for mortality nor for re-infarction.

From the perspective Maggie's attitude towards life after suffering such a severe myocardial infarction, and the resultant psychological effects that emerged post MI attack is how far is Maggie able to control her own mind, despite the difficulty in doing so after the MI attack, by taking positive approach about the aim of getting out of this crises in collaboration and the assistance of the community, and the nursing care. The community representing family or relatives, or social worker and nursing homes-in case absence of relatives-plays an essential role in providing emotional and psychological stability and support about the methods in perceiving things about future life. Here it is important to emphasize on the role of Holistic doctrine and how this theory could be used within the nursing care and community? This could be achieved by encouraging Maggie to implement in her mind that 'what we need is different what we desire'. That means taking action more than just sitting and waiting for things to happen.

Thus, it is important to adopt the semantic/mental holism from Maggie's attitude point of view towards life. Mental holism is the result of view for belief content, even the whole of a person's belief system. The well known mental holism is the motivation for semantic/mental holism or confirmation holism [Appendix IV] (Block, 2006).

How can mental holism benefit Maggie's suffering from psychological effects as a result of post MI? Does mental holism or functional holism could affect her attitude in looking at things in different perspective? As For Maggie with her anxiety/depressive disorders, and/or symptoms, the Will of perseverance towards life is the dominant and powerful tool that enables post MI patients to utilize it in order to go forward with their normal lives, rather than falling into melancholic state of mind. Here the RTL model could fit into our nursing care for at least two reasons: its flexibility and its capacity to involve the hospital and the community. Without these two variables, this theory will have no place for its success in providing good assessment from the CR team in rehabilitating Maggie’s condition. However, the frameworks are needed to be correctly applied to individual patients such as Maggie (Kenny 1993). From this it may be plausible to suggest individualising the theory to meet patients’ needs with a high quality of nursing care may be achieved. As for Maggie, a sixty-three year old patient, after suffering an acute MI she was referred by her consultant to the CR team for assessment with a view on commencing her CR programme. She had previously suffered from angina and subsequently reduced her mobility and exercise over the past two years until she witnessed her first acute cardiac event.

The identification and management of her symptoms was associated with potentially life-threatening conditions, such as CHD, which is one of the key principles underpinning a large area of nursing care in the UK (Maher & Hemming, 2005), calling for nurses to be skilled and competent in assessing, planning and evaluating care on a systematic and logical, yet capable and flexible enough to allow individual patients, as will be used in our patient Maggie, to articulate and express her unique life positions and experiences (McEnvoy, 2000).

Utilizing certain nursing tools such as the nursing process and models is by assisting the nurse to formulate the assessment, organizing the enquiry in a systematic way, and ensure that basic information is obtained from Maggie, irrespective of the individual nurse's clinical experience. According to (Osse et al 2004) The importance of systemic frameworks such as the nursing process, paradigms or models in fostering a high quality of practice is evident when no such framework is used (McKenna 1997); while for Aggleton & Chalmers (2000) they asserted that the implementation of the nursing process without a theory is underpinning an empty approach towards any intended nursing care strategies. These theories drive the nurse to start thinking not only theoretically but practically as well about nursing. This may influence nurses' decisions, interpretation of data, and practice along with the acceleration in the shift of adherence to the medical model of practice and care.

During our practical assessment, a supportive relationship was built up with Maggie, and the nursing care team. Communication between nurses and Maggie was sensitive which seemed to provide her with a platform describing the feelings underpinning her sense of having 'lost her life's direction'. Additionally in practice, using Roper's model as a framework for assessment, enabled biographical, health, subjective and objective data to be gathered from Maggie. The assessment consisted of a multi-system approach which incorporated biophysical and psychosocial components to gain a broad picture of her psychological status, and enables the CR to focus on the quality of her life's improvement both at the physical and emotional levels. Among the assessment tools we used the HADS. No consensus has been reached regarding the most appropriate instrumentation needed for the measurement of psychological well-being; nevertheless, the simplest and most widely used is the Hospital Anxiety and Depression Scale (HADS) (Harris 2005). Also, completion of this scale during clinical assessment allows nurses to identify patients with elevated anxiety and depression scores (Glazer 2002). The HADS scale was one among several assessment tools that we have applied in evaluating Maggie's psychological effects post MI. It is a useful and convenient self-rating assessment scale for patients complaining of anxiety and depression as a result of somatic or mental problems with a good sensitivity and specificity as other commonly self rating assessment tools are utilized (Herrmann, 1997; Bjelland et al., 2001). From a study performed in Norway on a huge population (over 9000 patients) showed that using this kind of self assessment scale, HADS, is considered a reliable and good from its structure form, inter-correlation, homogeneity and with internal consistency [Arnstein, Eystein, Alv, (2001); SIGN (2002)]. The CR team found it easy to understand, and evaluate Maggie's condition by using the HAD scale, which was used 6 weeks post MI. The CR team took time to explain to Maggie why they were using the HADS score, and why she was required to fill it out. They explained that patients often feel depressed following an MI; however, once they got the figures there was no immediate referral to a cognitive behavioural therapist, because it could take up to 10 weeks for a referral, which is too long for her to cope with her depressed mood during this gap period (Schrader 2006, 2004). Since research shows that a significant number of people suffer from depression following an MI, then surely it would be beneficial to have a counsellor as part of the CR team who could evaluate Maggie's psychological status by using the Center for Epidemiological Studies Depression Scale (CES-D) and communicate on regular basis during the CR programme with her and interconnecting with Maggie's GP even after the end of the programme to reduce her depression and anxiety. This continuous communication between the counsellor, the GP and Maggie proved to have a significant reduction in the proportion of patients with moderate to severe depression 12 months after cardiac hospitalisation (19% vs. 35%) (Wade et al. 2005)
In addition, when we used in practice the HAD scale it did raise questions related to the Maggie's self-esteem; also the assessment focused upon whether Maggie was easily distracted or depressed, and whether there were signs of suffering such as sadness, anger or frustration? Maggie explained that she suffered episodes of anxiety or depressed moods, and her biggest fear was due to the further cardiac events that might happen to her. Her feelings were exacerbated by her reduced mobility following her first MI. This resulted in her reluctance of returning to work or leaving her house. In return, Maggie's feelings were raised due to some kind of isolation within her, with the feeling of being useless due to her inability to complete her usual daily activities and household chores. She became less tolerant to her reduced mobility and found it very frustrating and concerning, which led to a decrease in her self-esteem. The CR team were willing to re-assess Maggie’s situation by using the HADS score if she is significantly depressed. However, Maggie felt lonely and quite depressed when she knew that the CR programme was coming to an end, and the CR nurses did advise her of a local cardiac group, and also gave her the number of CR team in case she needed advice etc. I do think it works well, but they do need a counselor as part of the team who had the time to really talk and explore issues of feelings and depression with patients.

The recovery time from an MI and returning to normal life is one of uncertainties, and emotional turmoil (Jaarsma et al. 1995). Furthermore, coping with such a sudden and frightening event requires, in Maggie’s case, to make major psychological adjustments, while some will meet this challenge with relatively at ease while others may not (Moser & Dracup 1995). In turn this may aid nurses to plan and implement a more holistic and patient-centred care approach rather than the prescriptive approach used by many CR programmes, which may not be suitable for patients with different needs. Although nurses acknowledged the psychological difficulties Maggie experienced, and instead discussing a rehabilitation care plan with her, she was informed just of what the pre-planned CR programme would entail. The plan was that Maggie must attend each health education session following the exercise class, whether she required that input or not. This calls to question the concept of individualised nursing care in cardiac rehabilitation. However, the CR programmes should provide services through individualised care rather than the standardisation of programmes currently observed (Clarke et al 2004).

In terms of Maggie's psychological concerns, the nurses' plan was to assist in
building up her confidence, and becoming more self-empowered towards regaining control of her life. The need for psychological input from the CR services is clearly detailed in NSF for CHD (DoH, 2000), that is a comprehensive rehabilitation involving education and psychological input, as well as early regular exercise training followed during 2 to 3 months induced beneficial effects which were still present 9 to 10 months later (Detry 2001), can reduce mortality by 20-25 per cent over three years. The CR will help to reduce risk factors in patients with CHD such as with Maggie's by increasing functional capacity, and improving quality of life both physically and emotionally (Maines 1997), where the CR programmes should include both educational and psychological interventions as part of the comprehensive rehabilitation (Meta-analysis trial-Appendix IV ; Harrison 2005). One could suggest from this trial that by helping Maggie to adapt to change, and regaining control through education and psychological interventions, may aid her to learn how to reorganise her life within the framework of her altered identity, leading to self-empowerment, increasing her well-being, fostering a sense of fulfilment and aiding in her recovery.

In practice, the information that was shared—with Maggie's consent—with the occupational therapist (OT), and the CR nurses focused on stress and relaxation techniques. Hence, with a well coordinated multidisciplinary approach, Maggie was also provided with information about medications, behavioural changes (i.e. dietary and smoking cessation) and exercise procedures. One of the assessments that Maggie attended were: An exercise physiologist checked patients' exercise tolerance by walking between two lines at increasing speed. A nurse went through patients' medications etc. An OT used another psychological assessment test that looked at stress/depression levels using a smiley/sad face scale. My impression was good that they tried to ascertain psychological health, and the person who performed it seemed very approachable. Also, OT tried to reassure patients that it was natural to feel upset/anxious etc. However, I believe that the set up was not the best for psychological assessment. The room was very big & cold–temperature and atmosphere–and there were loads of other people around & lots of interruptions. Also, people didn't really seem to use their own words to express how they felt; therefore, it is possible that the scale may not have uncovered their own individual concerns. Later the following session was more of a treatment/implementation day at Plas Madoc. First of all, patients had BP & HR checked followed by taking part in exercise programme in the gym, and then had a talk with the OT about managing their stresses. I think this was one of the methods of talking, with different talks on different subjects for each of the weeks they attended the programme. The talk was given to about 15 or so people. The OT did most of the talking. Again, Maggie did not really voice her own concerns–more listening to what the OT had to say. Therefore, it was not at all individualised to Maggie. I don't know whether Maggie had other opportunities for more individual follow up if she wanted furthermore.

In relation to the CR programme in practice, the key element in order to help empower individuals is by regaining a level of independence with a meaningful quality of life along a coordinated and effective multidisciplinary approach (Webber 2002). It is necessary to utilise all healthcare team's expertise, and it is vital not just to provide a holistic approach to care, but be able to think, problem-solve and understand key issues within the scope of their own professional practice. Considering further multidisciplinary collaboration, communication level is a vital thing. However, in some areas of practice there is breakdown in communication, and lack in understanding of the roles and function of other disciplines (Webster 2002), and often team members have little understanding of each others' roles, and that effective coordination will reflect on Maggie's as an individual's care, which will be difficult to be achieved (McCormack 2001; Moroney & Knowles 2006). In some areas of practice, this has been observed by me but exploration of such areas is beyond the scope of this essay. However, in patient care situation I consider it is important to highlight the collaboration between the multidisciplinary teams, which will enable and increase the support (both practical and psychological) for Maggie's requirements. Continual review and feedback from the multi-disciplinary team will reinforce the message and advices for those being offered to Maggie, and bring her out of the confusion is she suffering from. One could argue that this collaboration reflects a more inter-disciplinary method of work, which was addressed by researchers and considered that the key principle is the blurring of professional roles Clay & Wade (2003). This was reflected in practice by the CR nurses and OTs engagement in basic psychological therapy while still preserving the separate identity and expertise of their individual professions.

Additionally, effective multi-disciplinary team performance is needed to target Maggie's empowerment (Hughes, 2004). Patients like Maggie accessing the CR program should be person-centred, and individualisation should be at the core of professional practice (Ford 2000 & Price 2006). Watkins et al. (2005) valued the presence of 'working partnership' in any multi-disciplinary team, an approach enables and empowers individuals such as Maggie either to regain independence post-illness or adjust to a new way of living, as I have witnessed in practice this 'working partnership'. Multi-professional collaboration with Maggie's care programme resulted in a sense of achievement in her fitness and renewed her confidence in her physical body through the exercise classes and educational sessions. She also stated that participation within the CR programme had decreased her sense of isolation. Furthermore, Maggie's empowerment could be achieved more with the social support in buffering the impact of depression on mortality but not directly related to survival and the high levels of social support does predict enhancement in depression symptoms throughout and over the first post-MI year in depressed patients ( Frasure-Smith N 2000). AS for the CRP team structure they were: specialist nurses, OT, Physio, pharamacist, the consultant and his team where they were always available if nurses needed their help or guidance. Close working did help with communication, and reinforced team approach towards Maggie as well to others. I believe the team did deliver a high standard of care. In addition, establishing the Nurse-Led-Clinics is a very good idea, not to mention the consultants and doctors they are excellent as well; however, during consultations they often have little time to dedicate for Maggie and others. Maggie stated that often doctors seemed unapproachable and spoke in terms that she did not understood what they were talking about; whereas the CR team appeared to be very approachable as they spoke in laymans terms. It is considered a priority for practicing nurses to acquire multi-professional collaboration in order to meet Maggie's various needs. In turn, this may result in more comprehensive care interventions and outcomes in relation to her therapy.

Having considered the interventions in practice being provided to Maggie, an evaluation and suggestions for future care will follow.
Maggie was initially assessed in the hospital, and I think this was quite off putting for her, where she expected that the CR team would discuss things about her MI, yet they requested a summary about her life prior the MI incident. As they proceeded, the Roper, Logan and Tierney Model was used by asking questions in maintaining a safe environment for Maggie, and how far she felt that she could walk before she experienced pain, eating drinking, sleeping and psychological issues (all of these are part of the RLT model). Maggie's goals were determined between herself and the CR team, and she wanted to become independent in the activities of living, such as cooking and cleaning. At that time, she felt fearful that if she went back to her normal routine life will risk herself of having another MI. In return, the CR team felt that she would benefit from some health education about MI, post effects of MI as well as the life style change. The CR team also saw that Maggie would benefit from the exercise classes, as patients are monitored by trained staff, and she could realize then that she can push her body far more then she realized. The social side of the group would help her feel less lonely, and also they encouraged her to join the cardiac help group, after the sessions had finished, in order to keep up sustaining friendships and diminishing the idea about feeling lonely.

Hence, the nursing process is a constant re-evaluation of patient's care, and nurses should have been constantly re-evaluating Maggie’s psychological situation. However, when Maggie entered the CR programme it was for her to rehabilitate her physical condition, which was affected by her psychological status as a result of MI. The re-evaluation should have persisted, yet once the 7 weeks were over the re-evaluation seized to exist. Therefore, it would appear that this one Cardiac Rehab programme fits all, and individualized care was stopped at that point. Nonetheless, the CR team does encourage fitness after the cessation of the programme, and encouraged Maggie to seek consultation prescription for exercises from her GP i.e. she can attend the council gym with free subscription. In practice, evaluation occurred on completion of the target dates at the seven week of CR programme. In relation to Maggie, the evaluation highlighted only a partial achievement of her goals. She was physically fitter, her confidence of her body’s capabilities had increased, and during the programme her sense of isolation had decreased. However, she felt that more could have been done to help her deal with her 'worries' as a result of the stresses in life, which she felt beyond her control that led to her MI, according to her beliefs. Additionally, she felt concerned about her ability to motivate herself, now that the programme had finished.

Going back to Maggie's initial assessment in hospital on the 4thday after her MI, where she did seem shocked when the questions were based on activities of living, and the psychological questions did relate with her depression etc. Maggie expected the 'talk' will address "what is an MI and best ways to reduce the risk" etc. The initial assessment was based on the Roper, Logan and Tierney (1996) model as they discussed activities of living, mobility, sleeping and eating, and psychological issues. Many of patients' psychological concerns, including Maggie's, are the feelings of isolation which were apparent during assessment and were exacerbated, according to her, from the time she had to wait post-hospital discharge until embarking upon the CR programme. Maggie was not assessed until five weeks post-discharge, a time-frame she considered to be too long; however, it is the required time for her physical condition to recover before she commences her strenuous exercises. There is a need for more supportive way during this gap period, such as home nurse visits or social worker, interim education or supportive programme that should be facilitated before entering the CR programme. Maggie did state that she felt unsure how she would manage at home. The CR nurses did give their phone numbers; however, they are present for help only during the working office hours, which might limit their scope of assistance towards Maggie. However, the effectiveness and safety of nurse telephone consultation in out of hours' primary care could be applied for patients with post MI in their waiting period before commencement on their CR programme (Lattimer et al., 1998), which will prove to be effective in Maggie's situation.

To understand Maggie's situation, an earlier screening with the HADS scale i.e., prior discharge from hospital could have provided the CR team with any psychological concerns inherent in her and could led to earlier nursing interventions. Moreover, a timely entry into the CR programmes can help to reduce the HADS scores in post-MI patients (Harrison 2005). Supporting this, the timing of psychological assessment is important, and the guidelines on CR recommends that screening for anxiety and depression should take place straight after discharge from hospital (SIGN, 2002). However, Maggie's anxiety was provoked because she felt she is being supervised or monitored with less staff i.e., no-one is keeping an eye on her; hence she felt of being neglected, raising the feeling of being left alone to deal with her own fears within. If we measure Maggie's psychological symptoms during this time period, the psychological assessment might be related most probably to the cause of receiving less attention from the team rather than the fears as a result of post-traumatic cause. However, we cannot be assured on this aspect unless a comparative assessment was performed before entering the CR program and during the 7 weeks therapy by using two different assessment tools. Hence, this highlights the appropriateness of individualised care. Hence, it is more effective to direct therapy to those identified as "more distressed" than to deliver all aspects of the programme to every patient (SIGN 2002). This reflects the holistic nursing and RLT's model where all the variables are considered, and then coming up with a plan of care that reflects the individual patients' needs. If a proposal to this effect was implemented, one may argue that appropriate psychological nursing care interventions could have been implemented far quicker, and possibly have resulted in a far less anxiety, loneliness and depression such as in Maggie's situation as well as with others; thus, leading to more effective care management for all. Less effective psychological care in practice was noted by (Ford et al.2000) stated that nurses were good at taking patients' histories but less effective at exploring patients' perceptions and understanding of heart disease. Price supported (2003) and stated that understanding of cardiac patients by professionals is often poor and it is important that listening skills are used to elicit patients' own beliefs and fears. In terms of the recommendations of the NSF for CHD (DoH, 2000) this is an area where nurses should direct furthermore their attention too.

Taking this discussion further, Maggie attempted to describe what she was experiencing, but the labels she gave to her disease did not necessarily reflect how others would describe her underlying biological or psychological state (Clarke 2003). This raises the issue of how similar she lays her perspective of the difficulties she experienced after MI, which is totally different to the perspectives held by professionals. The differences between laying and professional groups occur frequently in health care, and suggests that this should be borne in nurses' mind while caring for Maggie as both they may have different knowledge bases, systems of thought, preferences and values (Nettleton & Watson 1998). On one hand, the CR group concentrated on Maggie's previous medical history prior her MI, and tried to know how she was coping with her heart disease during her daily activity, and then drew a psychological therapy. On the other hand, Maggie was more concerned about her fears, feeling loneliness, agitated of not being able to go back to normal life. The issue of disparity between health professionals in understanding patients' psychological difficulties post MI, such in Maggie's case, is due to the scarcity of literature in this field (Owens, Koutsakis & Benner 2001). Here lies the importance of Maggie's support groups such as the peer support that would possibly be of more benefit than professional support. The CR team can be successful with more than the weekly exercise session, education, and the support element to bring Maggie together with other patients, discussing their fears about their inability in resuming their normal life, fear of left alone in the occurrence of another MI attack, and what should be done in case they are alone with no one to assist them medically. However, it is interesting to see Maggie showing more accurate insights than the health professionals towards her needs and emotional conditions (Turton, 1998). Furthermore, during the psychological aspects of Maggie's programme, nurses focused upon the terms such as 'stress' and 'post-traumatic stress disorder' while she used less medical terms such as feeling frightened and vulnerable, being worried and isolated. Her terms seemed to be at odds how the psychological care, after infarction, was described to her by the CR team. Here, there is disparity between lay and professional language suggesting that it is important for nurses to be attune to the language Maggie is using in describing her difficulties. Hence, it may be beneficial to use lay terms in therapeutic interactions such as utilizing common local medical language rather than using pure medical language, because that will confuse Maggie and others due to her lack of knowledge about serious medical terms. Thus, inadequate knowledge of factors, meanings and values that inform patients' perspectives and decisions about CHD, can limit the effectiveness of nursing interventions (Horne & Weinman 1999). In practice, Maggie believed 'stress' was beyond her control – "people become stressed and there's nothing you can do about it". Therefore, when nursing interventions used to reduce 'stresses', they are not seen as viable by her. At the end of the programme Maggie remained very anxious about her future health and fearing, without the support of healthcare staff and the CR programme, that the anxieties would increase and lead to a further MI. Therefore, it is important for nurses to understand patients' own views about stress, because may influence the outcomes of psychological educational interventions (Walsh & Shaw 2000). Here, it is of outmost importance that nurses enhance empowering Maggie through patient led support groups, utilizing a phone service by ringing the nurses at any point in the future with queries and advices ( Lattimer et al., 1998), using her own hand held record (green books) containing all her information like medical history, medications, as well as advices where it can empower herself to participate and take some responsibility of her own care. Furthermore, that contributed to Maggie's depression is that her husband died a year earlier, and she had no children, and through her non-return to work she had lost contact with many colleagues and friends (Appendix VI). Maggie's anxiety at the completion of the programmes is reflected in the person-environment transactional model where it considers an individual's perceptions of interaction is between their world and themselves (Lazarus & Folkman 1984). The aim would be to increase nurses' understanding and clarity of patients' perceptions. Hence, the RLT's model could be enhanced by the use of specific tools such as Health Related Quality of Life (HRQOL), which consists of 38 exercises and variable outcomes to assess these stressors and psychological aspects.

It is pertinent to highlight the policy and clinical guidelines implemented by the NHS Centre for Reviews and Dissemination (1998) and (DoH, 2000). These widely support the inclusions of psychological therapy and stresses on management components in the CR programmes. A recent evidence based guidelines has described a range of effective psychological therapies on anxiety and depression (DoH, 2001). Psychological therapy encompass a continuum of generic counselling, where practitioners use psychological methods but lack the level of specialists training, like psycho-therapeutic practitioners, by using specific theoretical models due to lack of financial resources (Gould et al.2004; Pedder1998). However, the British Association for Cardiac Rehabilitation/British Heart Foundation did review the CR services in the UK, and has identified that some disciplines are under-represented (Bethel et al, 2001). The current CR programmes have limited access to trained psychological therapies, which has implications for the outcome for those with marked psychological distress (Dennis et al.1997). Hence, this situation in practice was delivered by simple psychological therapy through CR nurses and OTs to patients like Maggie and others through the means of stress relieving exercises, group support, re-assessing Maggie's HADS, Beck Depression Inventory (BID) scale, Killip Class, Diagnostic Interview Schedule (DIS), Center for Epidemiological Studies Depression scale (CES-D) and evaluation of number of Premature ventricular contractions (PVCs) and as Health Related Quality of Life (HRQOL) . However, the CR team’s understanding of this discipline is limited, and the time for this professional group to offer such support to Maggie is reduced owing to their own clinical responsibilities.

It may be plausible to infer that the inclusion of a counsellor may improve the overall effectiveness of the multidisciplinary CR team (Wade et al. 2005). Since the counsellor works on a part time period, and not always present there; hence, this weakens the CR programme. Support and information given to nurses from this specialist practitioner clearly will back up the overall care strategy, and enabling nurses to offer more sensitive care targeting patients particularly like Maggie. From Maggie's medical rehabilitation history she needed all the help to stand back on her feet, make her feel secure and drive her away from the sense of isolation and loneliness. Maggie's core beliefs, assumptions and thinking pattern would have been more effectively addressed with approaches that could have helped to identify her dysfunctional thoughts, and the beliefs underling them. In practice, the omission of the multidisciplinary team formation was due more to a lack of resources rather than an oversight by the CR management. In practice nurses often stated that they required more time with some patients, but due to the constraints on their time and staffing levels this made it difficult for them to accomplish more towards patients like Maggie. Limited resources are the most common problem across many of the CR programmes that were surveyed (Clark et al 2004). Hence, this provides little time to meet the individualised needs of patients in practice and hindering the successful execution of nursing care.

In a critical review in the deliverance of individualised care to post-MI patients among different gender, it is been recognised that men and women approach a crisis differently (Arnold 1997). Characteristically, men prefer action and solutions as the first line of defence against their anxiety; whereas woman tends to talk about what it means. One is an instrumental way of coping, and the other is a relational means of coping (Ogden, 2004). It may be pertinent that different approaches to a crisis by patients could influence the type of format needed for effective rehabilitation, rather than all patients following the same standardised programme as the patient in practice has done. Once again, one could argue that CR programmes would increase the benefit to patients if they were more individualised in meeting their needs. Additionally, more focus could be given to interpersonal support, group discussions, and having a place for patients to ask questions in order to really understand the lifestyle changes.

In order to provide more effective nursing care, it is important for nurses to realise that for Maggie, and many other patients, is the need to have a place for conversing with others along with participation in routine exercises, because the CR weekly meetings are not enough, for Maggie and others, who suffered from same psychological symptoms of post MI; they need persistent reassurance that their fears will subside. However, the weekly CR meetings should be more often than once a week with a nurse to encourage more open discussions, especially for Maggie, to open up and talk more about what she and others really fear. Is it only fears, for Maggie, of getting another MI attack, or because of the lonely life she is living without any partner where she could share her sorrows or happiness times with him/her? Maggie stated that talking to other patients was of great benefit to her. She explained that the group came to serve as a major factor in increasing her confidence, motivation and fitness. It is considerable that camaraderie grew amongst exercise groups, as each member was in the same boat with regards to difficulties facing and circumstances (Clark et al 2004). To highlight once again on completion of the programme, Maggie became concerned that she would lose that motivation and once again feared isolation. The psychological stress heightens a physiological response, and the protective factors in the environment (i.e. social support of friends, healthcare resources) can act as moderating variables in lessening the stressful impact of this physiological disruption (Ogden 2004). Once the process of short term recovery is complete, the emphasis of CR will shifts to long term maintenance of physical activity and lifestyle change, along with appropriate drug therapy. Upon the CR programmes completion, Maggie was encouraged by CR nurses to continue exercising at a local leisure centre. With the exception of telephone contact if needed, their nursing care was now limited due to time restrictions and their need to focus on the next programme group.

Therefore, one may consider that social support in the form of a social group would be a great addition to the CR programme and an extension of the nursing care provided. This is supported by guidelines which recommend that CR programmes should extend longer than the current 7-week norm, including more liaisons among several parties: Maggie, the Counsellor, GP (Wade et al. 2005), and the community based services, and have greater primary involvement in the provision of care (DoH, 2000; SIGN, 2002). Moreover, there is a growing evidence of the effectiveness of nurse-led secondary prevention interventions for patients with CHD, particularly in primary care settings [(McAlisster et al, 2001), AppendixVII].

In conclusion, this paper has critically analysed the nursing care received by Maggie in a cardiac rehabilitation setting. It focussed predominantly upon the psychological symptoms manifested by Maggie. The paper also highlighted that Maggie's post-MI psychological effects are often fearful and vulnerable of making articulation and her circumstances are difficult for the nurse to interpret. However, by establishing a therapeutic relationship with Maggie, and using the best available assessment tools, most up-to-date, evidence and relevant multidisciplinary input of holistic approaches can help the nurse on to focus on providing appropriate care for Maggie.

Pivotal to the success of cardiac rehabilitation the multidisciplinary approach will ensure good communication and education, and a great deal of CHD patients will benefit from the nursing input following their seven week CR programme, such as support groups and nurse-led clinics, which should be considered in order that patient's care is more effectively managed. Therefore, further research needs to be done surrounding the economics of cardiac nurse-led clinics to identify their cost-effectiveness. Problems highlighted in nursing care stemmed mainly from a scarcity of resources resulting in the inability to meet patients' specific needs and fostering longer waiting times to begin a programme, which is viewed as poorly tailored to meet users' needs along with a need to improve nursing care strategies of being more effective. In this paper, the surrounding gaps in individualised nursing care points out to a lack of resources rather than a lack in effort or performance by the multidisciplinary team in practice where many researchers suggested that the current healthcare system fails to reward high quality patient-centred care, and reinforces financial standardised care (Talerico 2003). Thus, there is a necessity for the revision of policies and work practices, as well as organisational, individual and the staff factors. Hence, inadequate staff numbers and constraints on time and costs have been identified as barriers in some areas to the successful implementation of effective nursing care (Cambell et al 1996). Finally, in order to care properly for patients, nurses must have the appropriate knowledge and skills for professional nursing care, able to maintain an ethical relationship, create good relationships with patients, initiate and participate in health promotion and preventative work, such as cardiac rehabilitation programmes, which is considered of utmost importance.









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