Recognition and referral of depression in patients with heart disease

Enhancement of Preoperative Mental Health Assessment Through Clinical Nurse Specialist Project Leadership

PURPOSE/OBJECTIVES

The aim of the project was to discern whether a collaborative, consultative-rich, clinical nurse specialist-led project could increase completion rates of a patient health questionnaire for depression and a generalized anxiety disorder questionnaire with appropriate referrals in adult patients in the ambulatory and hospital settings of a robust cardiovascular surgery practice before cardiovascular surgery.

DESCRIPTION OF PROJECT

The Define, Measure, Analyze, Improve, Control implementation methodology guided this quality improvement project. The workflow was analyzed in collaboration with stakeholders, and barriers to and facilitators of questionnaire completion were identified. Interpreter services partnerships were enhanced and used for patients with a preferred language other than English. Weekly data analysis assessed ongoing questionnaire completion rates.

OUTCOME

Documented completion rates of questionnaires improved across ambulatory and hospital settings by 15%. Patients with a preferred language other than English had an 80-percentage-point increase in documented questionnaire completion.

CONCLUSION

Clinical nurse specialists are poised to lead projects because of their use of the collaborative and consultative core competencies. A formal electronic health record report was established for monitoring outcomes. Embedding questionnaire administration within the standard workflow of ambulatory and hospital staff makes administering questionnaires preoperatively a sustainable practice in both settings.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy

BACKGROUND

Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption.

METHODS

We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.

RESULTS

We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.

CONCLUSIONS

We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Relationship between physical capacity and depression in heart failure patients undergoing hybrid comprehensive telerehabilitation vs. usual care: subanalysis from the TELEREH-HF Randomized Clinical Trial

AIMS

The hybrid comprehensive telerehabilitation (HCTR) consisting of telecare (with psychological telesupport), telerehabilitation, and remote monitoring of cardiovascular implantable electronic devices might be an option to improve both physical capacity and depressive symptoms. The aim of the study was to investigate the influence of HCTR on depressive symptoms and physical capacity in heart failure (HF) patients in comparison with usual care (UC).

METHODS AND RESULTS

The present analysis formed part of a multicentre, randomized trial that enrolled 850 HF patients (New York Heart Association I-III, left ventricular ejection fraction ≤ 40%). Patients were randomized 1:1 to HCTR or UC. Patients underwent an HCTR programme (1 week in hospital and 8 weeks at home; exercise training 5 times weekly) or UC with observation. The Beck Depression Inventory II (BDI-II) score (cut point for depression ≥ 14) was used to assess depression and the physical capacity was measured by peak oxygen consumption (peak VO2; mL/kg/min). Measurements were made before and after 9-week intervention/observation (HCTR/UC group). Both groups were comparable in terms of demographic and clinical characteristics. In HCTR group, at entry, 23% of the sample obtained BDI-II scores ≥14 vs. 27.5% in UC group. There were no significant differences between groups regarding ΔBDI-II score (P = 0.992) after 9-week HCTR/UC. There was a significant improvement in physical capacity only in the HCTR group in both patients with (P = 0.033) and without (P < 0.001) depression.

CONCLUSIONS

In HF patients, HCTR provided similar reduction of depressive symptoms as UC. HCTR resulted in a significant improvement in physical capacity in patients with and without depression.

Exploring the experiences of nurses caring for patients with COVID-19: a qualitative study in Iran

BACKGROUND

The coronavirus disease (COVID-19) is now a major public health emergency in the world. Nurses as key members of the COVID-19 patient care team are exposed to most challenges caused by the disease. As exploring the experiences of nurses as patient supporters and caregivers can play an important role in improving the quality of care for patients with COVID-19 disease, the present study explored the experiences of nurses caring for patients with COVID-19.

METHODS

The study employed a qualitative design. This study employed purposive sampling to select 10 nurses with bachelors and master's degrees in nursing who were taking care of patients with COVID-19 in ICUs or inpatient wards in southern Iran. Data were collected through semi-structured interviews. The collected data were analyzed using the qualitative content analysis procedure proposed by Graneheim and Lundman.

RESULTS

The analysis of the data revealed four main themes and ten sub-themes: A) physical, psychological, and social burden of care (excessive workload; fear, anxiety, worry; unpleasant social experiences; compassion fatigue) B) unmet needs (personal needs and professional needs) C) positive experiences (pleasant social experiences and inner satisfaction), and D) strategies (problem-solving strategies and stress symptom mitigation strategies).

CONCLUSIONS

An analysis of the themes and subthemes extracted in this study suggested that the nurses who participated in this study faced many personal and professional challenges. Therefore, health officials and specialists need to pay special attention to nurses' challenges and needs.

Understanding and managing depression in older people

Clinicians do not always recognise depression in older people as they attribute symptoms to the ageing process and the effects of failing health. Similarly, older people do not always appreciate that their symptoms relate to their mood. Understanding how depression affects older people can improve access to support, thereby improving overall health and quality of life. To ensure these outcomes we need a workforce with excellent communication skills that supports therapeutic relationships, promotes recognition of symptoms, and enhances assessment, diagnosis, treatment and management.

Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study

BACKGROUND

Depressive symptoms and/or depression are commonly experienced by older people. Both are underdiagnosed, undertreated and regularly overlooked by healthcare professionals. Healthcare facilities for people aged ≥75 years have been in place in Sweden since 2015. The aim of these care centres, which are managed by registered nurses (RNs), is to offer care adjusted to cater to the complex needs and health problems of older people. Although the mental health of older people is prioritised in these centres, research into the experience of RNs of depressive symptoms and/or depression in older people in this setting is limited. Therefore, this study aimed to illuminate RNs, working at care centres for older people, experience of identifying and intervening in cases of depressive symptoms.

METHODS

The data for this qualitative descriptive study were collected through interviews (n = 10) with RNs working at 10 care centres for older people in southern Sweden. The transcribed texts were analysed using inductive content analysis.

RESULTS

The participants' experiences could be understood from four predominant themes: (1) challenging to identify, (2) described interventions, (3) prerequisites for identification, and (4) contextual influences. Key findings were that it was difficult to identify depression as it often manifested as physical symptoms; evidence-based nursing interventions were generally not the first-line treatment used; trust, continuity and the ability of RNs to think laterally; and the context influenced the ability of RNs to manage older people's depressive symptoms and/or depression.

CONCLUSIONS

The process of identifying depressive symptoms and performing an appropriate intervention was found to be complex, especially as older people were reluctant to present at the centres and provided obscure reasons for doing so. A nurse-patient relationship that was built on trust and was characterised by continuity of care was identified as a necessary prerequisite. Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression. Further research is also needed into efficacious nursing interventions targeting depressive symptoms and/or depression.

Competências do enfermeiro na promoção da saúde de indivíduos com cardiopatias crônicas

RESUMO Objetivo: identificar as competências do enfermeiro relacionadas à promoção da saúde de indivíduos com cardiopatas crônicas, à luz do Consenso de Galway. Método: revisão integrativa da literatura, com busca de artigos publicados entre os anos de 2010 e 2014, nas bases de dados LILACS, BDENF, IBECS; e no portal PubMed, em fevereiro de 2015. Os 21 artigos selecionados foram analisados de acordo com os oito domínios de competências: Catalisar mudanças, Liderança, Avaliação das necessidades, Planejamento, Implementação, Avaliação do impacto, Defesa de direitos e Parcerias. Resultados: todos os domínios de competências foram contemplados nas intervenções do enfermeiro na promoção da saúde de cardiopatas crônicos, sendo o Planejamento e a Avaliação os mais evidenciados. Conclusão: os resultados desta pesquisa destacaram o enfermeiro como agente capaz de operar a gestão do cuidado, com vistas a melhorar articulação deste último com o trabalho e educação e, desta maneira, a assistência à saúde da população.

Factors affecting nurses' intent to assess for depression in heart failure patients

The association between depression and cardiovascular disease has been well established and has been shown to decrease patients' quality of life and increase the risk of mortality, frequency and duration of hospitalization, and health care costs. The inpatient setting provides a potentially valuable opportunity to assess and treat depression among patients with acute cardiac illness, allowing for daily monitoring of treatment side effects. Although systematic depression screening appears to be feasible, efficient, and well accepted on inpatient cardiac units, the current lack of consistent inpatient assessment for depression in heart failure patients suggests the presence of barriers influencing the effective diagnosis and treatment of depression among inpatients with heart failure. The theory of planned behavior describes the cognitive mechanism by which behavioral intent is formed, giving some insight into how nurses' attitudes and beliefs affect their performance of routine depression screening. In addition, application of this cognitive theory suggests that nurses may be influenced to adopt more positive attitudes and beliefs about depression through educational intervention, leading to greater likelihood of routine assessment for depression, ultimately leading to more timely diagnosis and treatment and improved patient outcomes.

Improving health professionals' self-efficacy to support cardiac patients' emotional recovery: the 'Cardiac Blues Project'

BACKGROUND

Many patients experience the 'cardiac blues' at the time of an acute cardiac event, and one in five go on to develop severe depression. These emotional responses often go undetected and unacknowledged. We initiated the 'Cardiac Blues Project' in order to help support patients' emotional recovery. As part of the project, we developed online training in order to support health professionals in the identification and management of the cardiac blues and depression. The aim of this study was to assess the acceptability of the training and its impacts on health professionals' self-efficacy.

METHOD

In July 2014, a 'cardiac blues' pack of patient resources, including access to health professional online training, was mailed to 606 centres across Australia. In the first 3 months after distribution, 140 health professionals registered to undertake the online training and participated in the present study. Participants provided information via a six-item pre- and post-training self-efficacy scale and on 10 post-training acceptability items.

RESULTS

Health professionals' self-efficacy improved significantly after undertaking the online training across the six domains assessed and for the total score. Acceptability of the training was high across all 10 items assessed. Ratings of usefulness of the training in clinical practice were particularly favourable amongst those who worked directly with cardiac patients.

CONCLUSIONS

The health professional training significantly improves health professionals' confidence in identifying and managing the 'cardiac blues' and depression. Monitoring of uptake is ongoing and future studies will investigate patient outcomes.

A qualitative study of nurses' clinical experience in recognising low mood and depression in older patients with multiple long-term conditions

AIMS AND OBJECTIVES

To explore how nurses' recognise depression in older patients with multiple long-term conditions and the strategies they use to support the patient.

BACKGROUND

Depression decreases an older person's quality of life and sense of wellness, and increases functional impairment. The positive role of nurses working with patients with long-term conditions is now being recognised internationally; however, there is a gap in the research about how nurses recognise depression in older patients and how this impacts on their practice.

DESIGN

This is a qualitative study informed by a constructivist grounded theory approach.

METHODS

In-depth telephone interviews were conducted with 40 nurses working in geographically diverse areas in New Zealand.

RESULTS

Having the conversation with older patients about their low moods, or specifically about depression was not something that all the nurses had, or felt they could have. While some nurses knew they could provide specific advice to patients, others believed this was not their responsibility, or within the scope of their role.

CONCLUSION

Faced with an increasing number of older people with long-term conditions, one of which maybe depression itself or as a result of living with other long-term conditions, ongoing monitoring and support pathways are necessary to prevent further decline in the older person's quality of life and well-being.

RELEVANCE TO CLINICAL PRACTICE

Nurses in primary health care can build on current knowledge and skills to increase their capability to promote 'ageing well' with older people who have long-term conditions and depression.

The Effect of Educational Intervention on Nurses' Attitudes and Beliefs about Depression in Heart Failure Patients

Systematic depression screening is feasible, efficient, and well accepted; however the lack of consistent assessment in heart failure inpatients suggests barriers preventing its effective diagnosis and treatment. This pilot study assessed the impact of an educational intervention on nurses' beliefs about depression and their likelihood of routinely screening heart failure patients. Registered nurses (n = 35) from adult medical-surgical units were surveyed before and after an educational intervention to assess their beliefs about depression prevalence and screening in heart failure patients. There was no significant influence on nurses' beliefs about depression, but the results suggested an increased likelihood that nurses would routinely screen for depression. The moderately significant correlation between beliefs and intent to screen for depression indicates that educational intervention could ultimately have a positive influence on patient outcomes through early detection and treatment of depression in patients with cardiovascular disease; however the observed increase in the intent to screen without a corresponding change in beliefs indicates other influences affecting nurses' intent to screen heart failure patients for depression.