Suggestions for Nurses and Technologists Working in the Cath Lab Regarding Patients With Psychosocial Concerns
Along with Kawkab Shishani, PhD, Drs Froelicher and Madan published an article in the Journal of Cardiovascular Nursing1 based on their experience caring for patients with coronary artery disease. We talk with them about the psychosocial concerns that can be suffered by these patients, how depression should be assessed in patients with heart disease, and how cath labs can help.
In your Journal of Cardiovascular Nursing article1, you divide the progression of coronary artery disease into acute, chronic and palliative phases.
Erika Sivarajan Froelicher, RN, MA, MPH, PhD, FAAN, FAHA: In many ways, it is an artificial delineation, because heart disease is an ongoing process, and often patients have developed risk factors over many, many years. While trying to explain this topic, one has to categorize, mostly because of how our health care system is laid out. As nurses and clinical consulting psychologists, we usually see patients when they are in the hospital, not in the outpatient setting, even though from the patient experience, heart disease is a continuing process. I have worked in the past in an inpatient and outpatient setting. Simone does outpatient counseling, so we both span the spectrum of when care is delivered to patients. I think it is important to say that for the patient, the disease is a continuing problem, but in terms of having access and opportunity to intervene, we felt dividing the paper into these segments would bring a better delineation.
Simone K. Madan, PhD: This is a broad topic, and the manifestation of psychosocial concerns can be a little different within the chronic, acute, and palliative phases. Some of the needs that the patients have when they come into various settings can be different, alongside how service providers can intervene. A continuum of care is required, with the overall goal of avoiding repeat hospitalizations and improving quality of life.
Cath lab patients could be in any of the three phases.
Erika: I would assume that when nurses make observations in the cath lab, the patient is probably at the peak of their worry and concern, although not necessarily because of worries about the procedure. It is my experience that patients are most worried about what the outcome of the procedure may be. And even if the outcome is not very good, patients won’t be with the cardiac cath nurse who oversees their care for a short time. So, for cath lab professionals, the critical role that I would envision for them would be identifying the patients who have symptoms of depression and making a referral, with follow-up either to an inpatient or an outpatient provider, or in consultation with the primary care physician. I have always found that when nurses make assessments and diagnoses of patients being either very anxious or depressed, or have the impression that there are serious psychological concerns, that it should be taken very seriously. At this point, we should contact the patient’s physician and say, “I have noticed such-and-such, do you have a source of recommendation for where you want this person to be seen?” I do think the cath lab should have resources available of whom to use for a referral. I always advocate that any referral we do means we have visited the place, we know the people, and we can tell them what they can expect, so patients don’t fall between the cracks. I think that would be the critical role for the cath lab staff.
It sounds like staff is on the front lines for psychosocial issues.
Erika: Nurses are in a prime position to make assessments. First of all, they are with the patient 24 hours a day; second, the cardiologist is a highly trained individual, but he or she focuses on the cardiac condition. Not only do nurses have good assessment skills, but they also receive various types of psychological assessment preparation, depending on whether they came from a 2- or 3-year diploma program, or are a clinical nurse specialist. Psychological assessment skills can range widely, and this is, in part, is why we wrote the article. We sought to provide realistic, not-very-long tools that any nurse can administer in order to screen the patient for anxiety, social support, and depression.
Simone and I worked together on a clinical trial called Enhancing Recovery in Coronary Heart Disease (ENRICHD)2, a randomized clinical trial for patients who were either depressed or had inadequate social support. It was a nationwide study. We found nurses tended to have the right intuition in sending us to the bedside of people who they considered eligible candidates for the trial. The one thing that was missing was that while the nurses were correct in their assessment, they may not have taken the next step to refer, so that the patient can be more fully assessed by a mental health professional and be treated. We must implement the necessary step of making a referral. What’s the risk if you are wrong? So, you are being conscientious and there is no harm. But, if you miss someone, they may endure the whole hospital experience, go home, and have prolonged psychological problems that may hinder a full recovery.
Simone: There are three factors we highlighted: social support, depression and anxiety. Each of these factors has undergone consistent empirical examination even through several other psychosocial concerns exist. The literature shows low social support is associated with higher mortality rates, lower life satisfaction, and non-adherence with treatment regimens. Unique social support, like spousal support, is associated with higher levels of response to recovery from surgical procedures. Adequate social support also leads to a higher rate of return to level of functioning soon after the procedure. If there is spousal distress after an acute event, that can interfere with the ability to provide support to the person who has been through the procedure. During the acute phase, spirituality may be an important source of support for some people as they reach out for ways to grapple with what they are experiencing. We don’t go into as much detail about spiritual support, however, since that is not our area of expertise.
In assessing patients, there are instruments that can be helpful, or even very simple questions. Try to assess for the person’s structural support. Who helps them with day-to-day things if they need some help? If they need some functional support, car rides, for example, what happens when they go home? Who is going to pick them up from the hospital? Certainly the cath lab team could ask the patient these questions to assess for social and emotional support. While using formally constructed instruments is worthwhile, cath labs could even use very simple ways to evaluate concerns during the normal day-to-day discourse with patients.
Depressive symptoms can be present in many patients. Depression and anxiety often go hand-in-hand. Coronary artery disease patients suffer in high numbers; perhaps 20-30 % of the patients can have depressive symptoms. Actual clinical depression is different, and can be present in almost 22% of coronary artery disease patients. We also know women have higher rates of depression and anxiety, particularly if they have less education and if they have less social support. Depression and particularly anxiety are associated with increased cardiac events. People don’t engage in behaviors like exercise and tend to be more avoidant if they are anxious. Older patients are more prone to anxiety, because of cognitive changes and also, their physical frailty can make them more nervous when they find themselves away from settings that are familiar to them. To assess depression, our article details a patient health questionnaire with only two items: 1) Does the patient have interest or pleasure in doing things?; 2) Are they feeling down, depressed, or hopeless? This and/or other suggested instruments or scales can be administered to patients, or nurses can simply evaluate as they engage with patients in the cath lab.
Erika: Nurses have assignments where the same patient is cared for the same nurse as much as feasible within the staffing schedule, so they have continuity of care. It is the nurse in particular that has such intimate contact with the patient through all of their physical care, as well as all the access. By developing a trusting relationship with patients and their families, when one identifies a patient who is either anxious, depressed, nurses can address these concerns it from a unique standpoint. By asking the patient to identify the extent to which they have been suffering and been uncomfortable because of their symptoms, patients can feel very relieved. Patients who are depressed often don’t acknowledge that fact to the cardiologist or to the nurse, because they feel they are there because of their heart problem, and how they feel, their emotion, is not part of that treatment. It can be a wonderful opportunity, for example, when one says, “You look very sad. How long have you been feeling this way?” By opening the conversation, and focusing on the observed signs and symptoms, patients very often open up and they start to cry at that time or truly open up and discuss how much they have been bothered.
In essence, this gives patients the opportunity to discuss what we consider a co-morbidity. If a patient came into a hospital with a heart attack or acute coronary syndrome and had diabetes, we wouldn’t ignore the diabetes . Well, similarly, we shouldn’t be ignoring any of the psychological diagnoses. Nurses do tend to be the ones who elicit responses. I personally have found that patients are very open and appreciative of being asked about their feelings, both in the past and in the present.
Simone: I just saw a patient who came into the outpatient clinic. He was referred for high blood pressure and came in for biofeedback. He didn’t say, “I’m an overthinker” or “I am too anxious.” He was a 63-year-old African-American man with a family history of heart disease. He had been to the emergency department several times for chest pain. I started by asking, “When do these symptoms happen?” It turned out he began worrying as soon as he got up in the morning and took his medication. We were able to come to the idea that while he has a blood pressure issue needing to be resolved — he’s not responding well to the medications — there may also be an over-thinking, anxiety component feeding into the blood pressure issue.
How should referrals be handled?
Erika: Unlike places like Britain or Australia where there is so much more of a continuum of care with the general practitioner, people in the U.S. have what I call episodic encounters with specialists. So, for this reason, the key message is that not only should one make referrals for patients, but we should always put the patient in charge of their referrals. I say, “I’m concerned about you and I want you to call me back or send me a message to let me know when your appointment is and that you have followed through.” That way, you enhance their own self-efficacy and their own self-confidence. You teach them how to use resources, not by just saying “Make an appointment,” but actually encouraging them to plan ahead, indicate when they think they can do it and to respond back to let you know whether the appointment occurred.
Simone: It’s very easy for these patients to fall through the cracks.
Erika: For many years, I was responsible for cardiac rehabilitation care. In some cities, the cardiac rehabilitation nurses come to the hospital, meet the patient, set an appointment with them and their families, to then come to the outpatient rehabilitation setting. That is ideal. But when that isn’t the case, it is important that the report be forwarded with recommendations and a request for follow through. So much goes on when patients are discharged from the hospital. They get back home, are concerned about family responsibility and work, and continuity of care can easily not happen. Setting up mechanisms for continuity is critical. Similar to when we begin a smoking cessation program in the hospital, we need to make sure that patients continue with some support or further intervention when they go home.
How should cath labs seek to implement this aspect of care?
Erika: More and more hospitals, as part of the Magnet hospital requirements, are identifying system approaches for care that are incorporated into the entire nursing plan. There could be a checklist as to whether these assessments have been made, whether these referrals have occurred as part of a discharge plan, and then, the piece that needs to be added is some kind of feedback loop showing continuity of care after patients go home, in whatever setting (an outpatient setting, a private consultation, or in a rehabilitation setting). The reality is that the largest number of people we encounter in hospitals today are heart failure patients. They may also be seen in the cardiac cath lab to evaluate whether there has been progression of their disease, whether there may be options for a transplant, and so on. These are the areas where systematic planning through the leadership of the nursing staff in the hospital can implement such changes.
Simone: In some ways, semantics becomes an issue also. Sadness, grief, and/or fear might be a normal reaction to an acute event. But depression, not so. Depression has a different meaning than just those reactions. Depression means not having any interest, feeling hopeless and self-critical. Often there are regrets about “what did I not do?” Those kinds of things we would call depression. Certainly fear is a normal reaction when you have an acute event. But, at the same time, if the patient is starting to engage in anxious behaviors, which might mean pressing the call button frequently, checking in, making frequent phone calls – what’s happening with my heart? – and being agitated and worried, these manifestations would be considered not normal. These are behaviors and can be treated well. There are some good treatments, particularly cognitive behavioral treatments, to address those kinds of anxiety disorders.
Erika: For depression, there is a DSM V category, and so there is an official diagnosis, which means health care providers can receive reimbursement. Cost is an important matter, and we need to educate patients to look into their insurance plan and see whether they have coverage for diagnosis.. If depression is diagnosed, then there is reimbursement for the treatment, while the global catch-all phrase, “stress” — I don’t see good diagnostic categories for that to receive treatment.
Patients should have the option of a counseling intervention as well as pharmacologic intervention. It is important that the counseling option is there. Very often, physicians tend to prefer the medication approach. In the past, there was concern about the cardiotoxic effects of psych medications, but in the last 10-15 years, some very effective pharmacological treatments have arisen that are free of cardiotoxic effects. The general guidelines for depression state that pharmacologic as well as psychological intervention and counseling are equally effective, if carried out appropriately by an appropriately trained mental health professional. The key is that the two of them together result in fewer relapses of depression. People who have had one episode of depression are at much higher risk of having a second or third if they don’t have complete treatment.
You argue that depression can be a co-morbidity.
Erika: Right now, the American Heart Association does not list depression as a risk factor for heart disease like it lists physical inactivity, obesity, cholesterol, hypertension and smoking. Right now, all the American Heart association lists is a 15-year-old document by Dr. Blumenthal and his group that identifies stress with heart disease patients, but it is not elevated to the level of a risk factor.
Simone: I work in an outpatient clinic, which is a general medicine clinic. I am one of the psychologists working with the referrals that come through. I hear a lot of the discussions between residents and the physicians during training, and much of what they talk about are psychosocial factors. Obviously medical care is discussed, but often what they are addressing with these patients is depression and/or anxiety. If depression becomes elevated to a risk factor, cardiology practices and general medicine practices can have psychologists on staff to help patients.
Erika: I first came to UCSF in 1991, and had a colleague who was a psych mental health nurse with a marriage and counseling license. She was very active in seeing patients in the hospital who had, in addition to their medical diagnosis, what the nurses observed as psychological problem(s). She would come and assess these patients, and she was the psych liaison for many years. We lost that position in the early 1990’s due to a cutback of clinical nurse specialists. But I thought it was an ideal model, and I could envision a psychologist being incorporated into this kind of a role.
I have had informal discussions with cardiology colleagues who have said well, surely cardiologists can’t make all these referrals, and what about false positives? The best argument again and again, was that if you had a patient with diabetes, would you ignore it because they are in the hospital for a heart condition? Of course not! It would be considered medical malpractice. Similarly, through medical education programs via the American College of Cardiology and American Heart Association, there would be the need to educate physicians. Time is always the barrier that is put up by some people for new concepts. I would reassure these physicians that they would not necessarily need to take the time out to make those assessments, but would need to be open to the fact that the nurses are doing so, and that the nurses would inform them of the findings and discuss with them suitable referrals. Referrals become very touchy. I always use the approach of saying, “We have some people in our lists that are very responsible consultants for this kind of a problem. Would you be comfortable with me making that referral, or would you prefer to refer your patient to someone you had had success with?” Invariably, 9 out of 10 say go ahead and make the referral, although some will indicate that in their practice there is a psychiatrist or psychologist right down the hall and the physician will refer the patient to them. Nurses need to be comfortable about recommending referrals. The above suggestion might be a way to make it happen without usurping the cardiologist’s purview, because after all, patients choose a cardiologist, they don’t choose a nurse. Nurses come with the hospital.
How does gender influence any predisposition to psychosocial concerns?
Erika: My observations have always been that when the cardiac patient is a man and suffer heart disease diagnosis and they need rehabilitation, they tend to go home and relax, and someone takes care of them. However, when women have a heart attack, their role, in addition to returning to the workplace if they work, may include being the provider and the support to the family. So very often, women cannot sit back and keep off from what has been their pride and joy of providing for the family. This is particularly important when people come from cultures where home responsibilities are not shared equally between men and women. In our San Francisco area, over 37 different nationalities use our hospital. While being sensitive to the cultural issues, and the fact that there are still many people where the women’s work is in the home, it is next to impossible for these women patients to return to their home in order to recuperate there. Some encouragement, not only to the patient who is a women, but to the patient’s partner and family members, reinforcing that they need to care for her for a given number of weeks until she has recuperated, is so essential. It is here that we need to provide the social support to women.
In Europe, there are some countries like Germany, where they are very active with rehabilitation, putting patients in serene places in the countryside, often located long distances away from their homes. I tend to have a major bias about that, because I feel it is artificial and patients are not able to learn the behavioral skills that they need in their usual environment. There was a Swedish study where they enrolled very young professional women. These patients were brought to a rehabilitation center for several weeks, and spouses were invited to join them. The study showed how important it was to teach the rest of the family members that the woman needs to be freed up to recuperate, and not feel guilty or be uncomfortable about not being able to fully meet her household responsibilities that she takes pride in, including child care as well as with the care of the home.
Nursing education in the U.S. emphasizes the autonomy of the patient, but we must remember that there are individual variations. In one of our studies, we asked one of the Filipino leaders, what’s important for patients in the Filipino population? While there is no generalization with any group, they made the point that invariably the senior patron is the one who helps make the decisions. Some patients do want to defer all the questions to someone else, because that person may have a higher level of education, and the patient feels that person can get more in-depth information and understand it. Also, in the cath lab, where patients can be in a state of high anxiety, the opportunity for understanding and being able to remember and be effective, probably is next to nil, other than being directly responsive to the expressed signs and symptoms.
Simone: The main idea that we would want to convey to the cath lab team is that as long as the team is collaborative, respectful, shows a genuine interest in the patient and their family perspective, and has a positive tone, much can be done. One question can even be, how much does the patient want to know? Some people may not want to know so much, while some may be more comforted by having more information. The team should follow that lead with the patient.
We know women especially like to tell their story about the acute event. If it is not too close to the procedure, then it might be a good idea if the patient is really bubbling to tell the story, to let them tell their story and give accurate reassurance, without sounding patronizing. It may be that the cath lab team tells the patient, “This could be a chance to make changes, to make a difference to your health.” This can be a way that nurses and the cath team can help. Also, I would recommend asking the patient how much contact they want with their family while they are waiting for the procedure, and do they want the family to be there soon after the procedure. That can help to assess psychosocial status as well. Particularly if there is family discord, patients may actually prefer not to have family around.
Mood-enhancing or distraction strategies are also positive, including relaxation strategies that would bring down physiological arousal.
Simone K. Madan can be contacted at email@example.com. Erika Sivarajan Froelicher can be contacted at firstname.lastname@example.org.
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- Mendes de Leon CF, Czajkowski SM, Freedland KE, et al. The effect of a psychosocial intervention and quality of life after acute myocardial infarction: the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial. J Cardiopulm Rehabil 2006;26(1):9Y13.
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