What constitutes the ‘Minimal Care’ interventions of the nurse, physiotherapist, dietician and psychologist in Cardiovascular Rehabilitation and secondary prevention: A position paper from the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology

Abstract

Background

In cardiovascular prevention and rehabilitation, care activities are carried out by different professionals in coordination, each with their own specific competence. This GICR–IACPR position paper has analysed the interventions performed by the nurse, physiotherapist, dietician and psychologist in order to identify what constitutes minimal care, and it lists the activities that are fundamental and indispensable for each team member to perform in clinical practice.

Results

In analysing each type of intervention, the following dimensions were considered: the level of clinical care complexity, determined both by the disease and by environmental factors; the ‘area’ complexity, i.e. the specific level of competence required of the professional in each professional section; organisational factors, i.e. whether the care is performed in an inpatient or outpatient setting; duration of the rehabilitation intervention. The specific contents of minimal care have been identified for each professional area together with the specific goals, the assessment tools and the main essential interventions. For the assessments, only a few validated tools have been indicated, leaving the choice of which instrument to use to the individual professional based on experience and usual practice.

Conclusion

For the interventions, attention has been focused on conditions of major complexity requiring special care, taking into account the different care settings, the clinical conditions secondary to the disease event, and the distinct tasks of each area according to the operator's specific role. The final report performed by each professional has also been included.

Introduction

The care activities that represent the cultural, organisational and scientific core of cardiovascular prevention and rehabilitation are carried out by different professionals, each contributing their own specific expertise. The national and European cardiovascular prevention and rehabilitation guidelines^1–3 recommend the need for interdisciplinary and multiprofessional interventions, but no documents exist that provide a detailed coordinated picture of how each single team member performs the interventions that constitute the core of cardiac rehabilitation (CR). Moreover, the current treatment modes for acute cardiac disease have also widened the clinical spectrum of the patients who access CR and secondary prevention programmes: from young, uncomplicated patients to highly complex patients, to those with comorbidities, and elderly frail patients.^4,5

The different care settings also have an impact on the CR services that are delivered and hence on the contents of intervention by each professional: the ISYDE.13 survey² listed different structures as active in Italy: from inpatient facilities for post-acute/instable patients to outpatient centres for stable/chronic patients. Cardiovascular team-based care is a paradigm for practice that can transform care and help meet the demands of the future. One strategic goal is a new cultural awareness required in order establish what the most appropriate choices are so that ‘the right things are done at the right time for the right patient’ with an adequate allocation of the available resources and giving due value and recognition to the role played by each health professional within the care process.

Scientific societies play a crucial role in helping members successfully transition their clinical practices to the future, with all its complexity, challenges, and opportunity: to this end, the Italian Group of Cardiac Rehabilitation and Prevention–Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (GICR–IACPR) set up a multidisciplinary working group to develop a position paper on Minimal Care (MC) pathways. MC does not intend to provide a framework of all CR activities, but rather aims to provide guidance on what, in the opinion of the scientific society, should be the reference point concerning what it is essential to implement in clinical practice. Our aim was to identify the components of assessment and intervention that must be guaranteed by each professional working in CR.

This position paper expresses the views of the GICR–IACPR and represents its official position.

Methods

The IACPR, a scientific society of cardiologists, includes among its members professionals working in CR services. Four professional sections were created (called ‘areas’) to which nurses, physiotherapists, dieticians and psychologists refer. Each area has been invited to designate its representatives in a multidisciplinary working group to develop a preliminary document⁶ on ‘MC pathways’ with the essential contents of nursing, physiotherapy, dietary and psychological care. These MC documents were developed after a review of the current national and international guidelines and operative instructions of a wide range of national healthcare structures different for patients’ clinical spectrum and setting, and following a rigorous technical-scientific approach featuring modulability and appropriateness. The preliminary document has been submitted to all the members of each area. Subsequently, feedback and suggestions were collected by way of the internet in order to ensure that the contents of assessment and intervention outlined in the document enjoyed as wide a consensus as possible and were sustainable in the working reality of each care facility. This document is the result of processing and review by non-medical professionals and cardiologists.

Structure of MC

Each pathway was elaborated considering both clinical factors specific to the disease and environmental factors related to the patient, such as the family/economic situation and accessibility to care, as well as the dynamic interactions between them and the clinical factors and intrinsic factors to the specific professional area, in order to identify the different levels of care complexity pertaining. We thus differentiated between: (a) a ‘clinical care complexity’ signifying the need for integrated poly-specialist and multiprofessional and interprofessional interventions, in that a patient is termed ‘complex’ based on a set of factors that include consequences of the disease, co-existing morbid conditions, the presence of complications, direct and side effects of the treatments carried out, cognitive deficits and disadvantaged social status,⁶ often combined with an added burden of organ/systemic functional decline due to aging (Table 1); and (b) an ‘area complexity’, which in this context can rightly be defined as the condition in which a patient has a particular need for care in a specific professional area, regardless of whether or not the patient carries a high ‘clinical complexity’ (Table 2).

In both cases, the distinction into ‘high and low complexity’ was inevitably schematic, and did not comprehend an ‘intermediate zone’. In order to facilitate the description of the model, only two alternatives were presented, but we leave it up to one's clinical judgement eventually to adjust the level of complexity for patients whose classification into either of the two alternatives is not adequate.

The term ‘complexity’ refers to uncertainty, dynamicity, unpredictability and risk. Complex patients require individualised treatment, based on suitable clinical judgement and adequate decisions at the highest levels of knowledge of the context. The way in which healthcare is delivered has evolved in response to the changing needs of patients. In order to provide safe and effective care for patients with complex health needs, success depends on collegiate working through effective interdisciplinary team-based care characterised by shared goals, clear roles, mutual trust, effective communication and measurable processes and outcomes, with the patients and family at the centre of care. As the goal of MC was defining the minimum essential skills that every professional must guarantee, it was developed with an artificial separation of the paths that are consequently illustrated in parallel. As a result, to ensure a smoother exposure, the document is not structured as an interdisciplinary model, in which the group of people with specialised knowledge and skills work together to provide coordinated assistance through an agreed treatment plan.⁷

We also identified organisational factors, in the sense of both the care setting as well as the duration of the CR intervention better specified as follows: (c) care setting, diversified into: inpatient facilities capable of managing situations of ‘high clinical care complexity’, predominantly for post-surgical outcomes or the more severe conditions of disability, whether premorbid or post-index event; inpatient facilities suited for patients in a phase of stabilisation mainly regardless of complexity; outpatient facilities that receive subacute patients for intensive CR who are increasingly complicated by conditions of high clinical complexity, without the need for 24-hour surveillance; outpatient facilities for long-term treatments dedicated to low clinical complexity. (d) Duration of CR programme. The care setting influences in part also the time that is allotted for the treatment: obviously, a longer period of treatment will favour a more complete achievement of the CR and prevention goals. During the inhospital stay, instead, the patients’ clinical conditions are what determine the length of stay, on account of the need to address and resolve the unstable clinical state. Also, for the duration of the CR intervention, an arbitrary cut-off was defined which represents the average treatment thresholds established by the health authorities: programmes involving up to 15 days of hospitalisation or up to 12 accesses for outpatients was defined as ‘short term’, up to 30 days or more of hospitalisation or up to 36 accesses or more for outpatients was defined as ‘long term’.

To describe each condition of intervention, we considered the interrelations between the main dimensions – clinical-environmental complexity, complexity for the professional area, care setting, duration of the programme – and analysed the treatment goals, specific assessments and the interventions indicated.

In relation to assessment tools selected, only a few validated tools, among the many in use, have been recommended, leaving it to the experience and usual practice of each individual what instrument to choose (Figure 1).

Activities common to different areas (‘transversal’) have not been presented separately for each area, nor have all the actions that each operator habitually performs as part of their duties been described as these are assumed to be an integral part of theoretical-technical knowledge and expertise exercised in that profession.

Information and training interventions are performed by all professionals and include group meetings and individual counselling sessions. Family members, or another caregiver, are key partners in patient care and must receive the necessary support to have a positive influence on self-management behaviour. The caregiver should be supported by a specific standardised educational training, which combines the knowledge and skills, to optimise the preventive efforts.⁸ These actions are not analysed separately because the contents of these interventions, even if specific and selected by each professional, have common matrixes.

The transmission of information to other members of the interdisciplinary team is an integral part of teamwork; a common language and information shared among all team members, both medical and non-medical, is always crucial.

A paragraph is dedicated to the principles of the final assessment, as a common act of verification carried out by each professional, and to the practice of good medical reporting, understood as an indicator of the care process in CR.

Results

In the description of the specific contents of MC, the goals, assessment tools and interventions were analysed for each area. As this is a very complex reality, we have not presented different clinical conditions but, in accordance with the stated aims, we have illustrated the essential and indispensable interventions that each professional should perform, with specific focus on the more complex conditions requiring special care or a different approach in the different care settings.

MC: nurses

The nurse is generally the first healthcare operator who meets the patient and has contact with the family members. In the care path, the assessment phase includes the use of validated and sensitive scales; reassessment with the appropriate tools makes it possible to verify if the goals have been achieved, and the medical report represents the completion of the path. The specific tasks of the nurse in CR are to identify cardiovascular risk factors and intervene in them, to intervene in the particular disabilities, and to promote adherence to pharmacological and non-pharmacological therapy.⁷ A standardised nursing language, covering the vast majority of needs that may arise, is provided by the international nursing diagnosis classification (NANDA international) taxonomy. To describe and ensure cost-effective, high quality appropriate outcomes of nursing care delivered across settings and sites, standardised terms and definitions are required. With regard to the evaluation of nursing classifications, the literature findings support the use because only the NANDA contain allocated sign/symptoms and aetiologies.⁹

Hence, when investigating the level of cognitive disability and functional disability, the nurse should refer to the NANDA functional models (part one) and, when identifying educational needs, to the functional models related to health/wellbeing promotion (NANDA part four), with the aim of delineating the socioeconomic and cultural aspects, social and family network and housing/economic situation, and identifying the risk factors.

The general elements that make up the nurse's assessment and interventions are listed in Table 3.

MC: physiotherapists

The physiotherapist's goal is to achieve the maximum possible recovery of functional capacity and autonomy within the time available. The initial assessment phase is critical for the selection of the treatment that is most appropriate with respect to the patient's functional needs and the care setting, while the final assessment phase is fundamental both for verifying the results achieved and planning an appropriate maintenance programme The selected assessment scales highlight the fact that knowledge of the level of autonomy, stability and perceived fatigue is necessary to be able to identify the subjective problems of the more complex patients, just as identifying what is the appropriate intensity to use is indispensable for ensuring an effective and safe outcome of the intervention. In situations in which the complexities and clinical complications are less significant and patients are less severely impaired, the indications for the assessment and treatment are less complex and easier to put into effect.^10–12

The general elements comprising the physiotherapist's assessment and intervention are presented in Table 4.

MC: dieticians

Nutritional interventions are focused on modifying unhealthy eating habits and on the treatment of obesity, dyslipidaemia, hypertension and diabetes mellitus. It is necessary to give all cardiac patients nutritional information based on the evidence in favor of use of the Mediterranean diet.¹³ Multimorbidity, whether or not associated with frailty in elderly patients, is often correlated to nutritional problems which can be an additional factor on top of those due to metabolic disorders. Impaired oral health has been associated with mastication and nutritional problems, especially among elderly people who live alone. Patients with high complexity in the inpatient hospital setting are more frequently dependent on external support for some of their vital functions and substantial changes in the food intake may be necessary. The dietician should adopt the nutrition care process methodology for the assessment, nutritional diagnosis, intervention, monitoring and re-assessment, and should use the international dietetics and nutrition terminology language and the evidence-based dietetics practice indications in order to ensure that the patient receives safe, effective and high-quality nutritional care.¹⁴

The general elements that make up the dietician's assessment and intervention are listed in Table 5.

MC: psychologists

The specific objectives of the care path are the identification and correction of psychosocial and/or behavioural risk factors, assessment or further investigation of the cognitive deficits detected, optimisation of the patient's awareness and acceptance of the disease, provision of psychological support to the patient and their caregiver, promotion of medium and long-term treatment adherence and of disease management, activation of positive affectivity and of personal/sociofamilial resources, assessment of occupational problems and reduction in occupational distress, family and social reintegration.^15,16 Psychosocial risk factors are both psychological factors (depression, vital exhaustion, anxiety, hostility and post-traumatic stress disorder) as well as social factors related to a low social status (problems with finances, housing, work), a lack of social support and loneliness.

The general elements that constitute the evaluation and intervention of the psychologist are listed in Table 6.

MC in conditions of high complexity

The conditions of highest complexity pertain essentially to the inpatient hospital setting where one finds the clinically more unstable patients, those with post-surgical outcomes unresolved or with premorbid conditions, comorbidities, or consequences of the index event affecting their recovery. However, not all complex situations are necessarily determined by the disease event itself – sometimes complex situations can arise – in both the inpatient and outpatient setting – that call for a special, dedicated care approach in one particular professional area. The activities of the different operators in relation to high clinical complexity and high area complexity are reported, respectively, in Tables 7 and 8.

Final assessment and report

All professionals must ensure that the patient and/or caregiver has access to the information in order to guarantee homogeneity and usability of what has been done through the various interventions.¹⁷ The report must state clearly the goals pursued and the results achieved, the individual or environmental resources/barriers identified, and any problems still unresolved or for which special attention is required. In addition to the letter of discharge/termination of the treatment cycle, the patient should also be given any medication/treatment charts and reminders, which can help to consolidate the benefits of rehabilitation and implement effective prevention.¹⁸

Table 9 summarises the contents of the report in relation to each professional area.

Limitations of this document

As a result of the need to perform an analytical description of the different care paths, the set of interventions described in this document do not always appear to be coordinated and integrated with one another: the next goal will be to produce a diagnostic-therapeutic care pathway specific for CR, which will explicitly state the requirements for ensuring an effective functioning of the interprofessional team as a whole. Only through an integrated type of approach, in fact, can we address the biological complexity of the disease through the creation of ever more accurate models and, on the other hand, take into account the determinants linked to comorbidities and to socioeconomic and psychological factors.

Author contribution

FF contributed to the conception of the work and drafted the manuscript; OB contributed to the conception, acquisition and interpretation of data for the work; EA contributed to the interpretation of data and drafted the manuscript; LdV, MF, AP and DT contributed to the acquisition and interpretation of data for the work; SA, MA, BB, SBo, SBr, PF, MI, BM, MLM, AM, RP and MS contributed to the acquisition of data for the work; SBa, RG and MP critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work ensuring integrity and accuracy.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References