How Nurses Can Educate Patients to Make an Informed Decision Regarding Coronary Heart Disease - Essay Example

How can Nurses Educate Patients to Make an Informed Decision Regarding their Health in Coronary Heart Disease Objectives Therefore, the objective would be to conduct an extended literature review of relevant research articles to update knowledge in this area in order to determine the existing current knowledge about coronary artery disease, its relation to lifestyle, and the need and rationale for lifestyle modification to decrease the incidence of this potentially fatal disease. Although modern treatment modalities are available with the enormous advancement of medical technology, no treatment can actually bring the life back to its original scale once the disease is established whatever the management modality may be (Carlsson et al., 1997, 256-259). Since nurses spend considerable time with these patients, and it has been found that educational and supportive intervention during the admission for a critical illness can yield very positive results in terms of patients' compliance or adherence to lifestyle modification measures, it is often prescribed that the nurses deliver patient education and promote healthy lifestyles in patients (Duryee, 1992, 217-225). However, it is always better said than done, since these measures must conform to the patients' beliefs, which always are not congruent. Apart from this, there are other known barriers for the implementation of such strategies, such as, communication barriers between the patients and healthcare personnel and their points of views. Since studies have shown better results with health education in terms of coronary heart disease (CHD), there has been considerable accumulation of literature as a result of consistent research in this area. It is expected that there would be two sides of this problem, the caregiver and the care recipients. Not only the patients' beliefs, the nurses' beliefs also may implicate the situation (Toobert et al., 2002, 574-585). To have a fair and balanced idea about the situation and the scenario, an extended literature review and summation of the resultant themes could present the established facts and identify the gaps in knowledge, so a study can be designed to arrive at a conclusion about the question in what ways the nurses can educate the patients to make an informed decision regarding their health in coronary artery disease. Strategy for Literature Review To build a scientific basis of evidence, a comprehensive literature search was undertaken and then evaluated critically. For the purpose of the review of literature, to support the rationale, need, and continuation of the project, this author conducted a literature search across databases. Those accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, and CINAHL and Cochrane databases were searched to identify relevant literature on prevention of pressure ulcers. HighWire Press was also searched. The key words in the search included "cardiac nursing", "cardiac nurses", "role", "cardiovascular nursing", "intensive care nursing", "critical care nursing", "cardiac intervention nursing", "pacemaker units", "nursing," "clinical trials", "home cardiac nursing", "cardiac surgery nursing", "primary care cardiac nursing", "cardiac imaging nursing," "emergency cardiac nursing", "cardiac nursing education", and "cardiac patient education", "informed decision", lifestyle risk factors", "lifestyle modification", "health education", "patient beliefs", "barriers to communication", "nursing perspectives", "patient perspectives", "preventive cardiology", published in the last 10 years. Moreover, the references cited in the selected articles were also searched for relevant material. Inclusion Criteria Inclusion criteria for each article reviewed were answers to the following questions: 1. Was the article a valid research article 2. Did the article's study include role of cardiac nursing in area of cardiac medicine practice and applied to nursing practice in that area 3. Did the article deal with patient education regarding cardiac health in terms of lifestyle associated factors 4. Did the article deal with nurses' or patients' perspectives in terms of lifestyle-associated risk reduction in coronary heart disease 5. Did the study deal with barriers of communication between the nurses and the patients 6. Was the study based on informed decision making of the patients and role of nurses in providing the information 7. Was the study related to patients' or nurses' beliefs regarding incidence of CHD and importance of lifestyle modification in order to prevent these 8. Was the article published within the past 10 years 9. Did the article have some identification with nursing practice and preventive healthcare delivery related to cardiac care Exclusion Criteria Each article should answer "yes" to all of these four questions, the only exception being question 4, where either patient or nursing perspectives will be acceptable. Based on these criteria, out of about 257 initial articles, only 8 main latest research articles that fit the criteria described above were selected to be critically reviewed to synthesize evidence relevant to nursing practice. It is to note that 4 of these studies were based on patient perspectives, whereas 4 were on nurse perspectives. Those which were review, conversation, editorial, poster presentation, or letters to the editor were excluded. To further narrow the search, a combination of search words were used so specific areas of cardiac nursing are reflected in the research. Although this would miss the literatures that involve combinatorial cardiac nursing roles, this would generate articles that focus on nursing care in specific practice settings. For this assignment, these eight main articles will be critically reviewed, and the findings have been presented in sections below. Chapter I: Literature Review: Nurses Basic Concepts For the purpose of establishing the definitions and a quick review of what is already known on this topic, evidence from some review literature will be examined, so the reader has a broad overview of the background on which the critical review of literature is based. Studies have revealed that health care providers, specifically nurses in partnership with clients hold the keys to lifestyle-associated risk factor modification of the patients with CHD. The provider's responsibilities range from knowing and using the latest guidelines for lifestyle modification to motivating the client to follow the management plan (Murray, 1989, 686-693). At a minimum, the challenges to a provider include correctly diagnosing the client's condition and assessing the patient's understanding and acceptance of the diagnosis and expectations from being in care. The nurse must discuss the patient's concerns and clarify misunderstandings. Communicating the importance of the lifestyle-associated risk factors is the most significant decisive parameter of atherosclerotic heart disease (Clark, MacIntyre, and Cruickshank, 2007, 513-539). A thorough knowledge about these on the part of the nursing professionals would enable them to provide an effective education, and risk factor management plan can be done by the nurses in congruence with the client's lifestyle and economic situation (Jillings, 2008, 127). In most cases, the client should be offered options to make decisions himself about his altered lifestyle. Furthermore, the nurse can evaluate the results of the therapy and help clients to adjust to any changes that may be necessary (Vale, Jelinek, Best; 2002, 211-215). To achieve these goals, the care provider needs skills in assessment, diagnosis, communication, and behavioral counseling. The nurse has the responsibility of ensuring that the client is educated about his or her condition and the treatment plan (Jackson et al., 2005, 10-14). Some medical and nursing schools include courses in risk factor management and health promotion in their curricula and offer students clinical opportunities to practice the skills required to support clients in effective disease prevention and risk factor management. There remains a need for more research on effective methods to promote behaviour change, because the traditional professional approaches of screening, patient education, and counseling have had little impact on secondary risk factors (Fuster and Gotto, 2000, IV94-IV102). The Transtheoretical Model To answer the question, despite this knowledge why there are gaps in implementation of nurse-administered lifestyle education, research has delineated certain challenges in implementation of these risk-factor information, and these challenges may be responsible for failure on the part of the patients to make a decision about their own healthcare, where the decision involves change in lifestyle with the goal to curb the risks of CHD (Newens et al., 1997, 183-189). As evident from the literature, the challenge for clients in achieving heart health and in minimising risk of heart disease is to modify their lives in ways that support their treatment plan. Making the decision to modify the lifestyle is the critical client factor that precedes lifestyle modification and control of progression of disease in the cardiovascular system (Brennan, 2000, 127-133). Based on their Transtheoretical Model of Behavior Change, Prochaska and DiClemente have developed a set of questions that the health care provider and the nurses alike can use to stage where the client is in the process of making the decision to change lifestyle (Prochaska, DiClemente, Norcross, 1992, 1102-1114). The Transtheoretical Model postulates that people go through a series of stages in the process of changing behaviour. The stages are precontemplation, contemplation, preparation, action, and maintenance. The actual decision to change comes between preparation and action. A relapse can occur at any time and sends the person back to an earlier stage, usually either precontemplation or contemplation (Kviz et al, 1995, 201-212). Use of the questions and the Transtheoretical Model allows clinicians to tailor their interventions to the patient's stage of change-and prevents them from wasting time developing a detailed plan of action for the person who is not yet ready to change (Spencer et al., 2006, 428-443). Dietary Management Current literature with rigors of methodological excellence also suggests that the nurses' knowledge about the risk factors may need to be updated from the evidence from research. Buckland and coworkers recommend better insight into the pathophysiological correlation is necessary on the part of nurses to devise a culture-congruent and belief-accommodative care plan that is state of the art, that is, where evidence from current findings about the CHD risk factors have been incorporated. Traditional educative interventional strategies based on older care provider beliefs may not suffice to be all encompassing since the precise etiology and mechanisms leading to the development of coronary artery disease (CAD) remain incompletely understood although a number of risk factors have been identified over the past several decades (Backlund, Bring, Strender, 2004, 145-152). These include abnormal levels of circulating cholesterol with elevated levels of (Low-density lipoprotein) LDL and reduced levels of high-density lipoprotein (HDL) cholesterol, hypertension, cigarette smoking, diabetes, male gender, postmenopausal state, advancing age, sedentary lifestyle, obesity, and a positive family history of premature vascular disease (Cakir and Pinar, 2006, 190-209). Research reveals that over the past several years, observational and epidemiologic studies have identified a host of new and potential risk factors for atherothrombotic vascular disease (Ovaskainen, Valsta, Lauronen, 1996, 133-36). Of this growing list of new and emerging risk factors, elevated blood levels of homocysteine, fibrinogen, inflammation and infection, atherogenic lipoprotein phenotype associated with small LDL cholesterol particles and elevated triglycerides, elevated levels of lipoprotein(a) (Lpa), insulin resistance syndrome, psychosocial factors and a number of genetic polymorphisms are of particular interest (Chair, 2003, 79). The guidelines of administering an educative intervention from the nurses must incorporate these new factors since it has been found that many patients, as many as 30-50% with established CAD lack these traditional risk factors (Jensen et al., 2008, 3062-3069). Client Education Methodologically sound literature has also indicated the prospective roles of the nurses in the measures of deployment of cardioprotective lifestyle interventions that modify risk. The nurse shares the responsibility for client teaching with other members of the care team. In individual situations, it may be either the nurse or health educator who assumes responsibility for ensuring that the client does learn about his or her condition and potential risks (Jensen et al., 2008, 3069). Some of the barriers to successful client education are low literacy, lack of understanding of the importance of treating a condition without apparent symptoms, language differences, and great variability in health beliefs, perceptions, and priorities. CHD is usually associated with one or more characteristics known as risk factors. A risk factor is "an aspect of personal behavior or lifestyle, an environmental exposure or an inborn or inherited characteristic, which on the basis of epidemiologic evidence is known to be associated with" the occurrence of disease (Hobbs and Erhardt, 2002, 596-604). Several aspects of the association between a potential risk factors and the disease are evaluated before an association is considered causal. These include the strength or magnitude of the association, the consistency or repeatability of the association, temporality, dose response, the biologic and epidemiologic plausibility of the association, coherence of the potential cause with what is known about the disease, a decrease in the incidence of disease when the potential cause is eliminated, and experimental evidence. Although few potential risk factors meet all of these criteria, the goal of epidemiologic investigations is to establish these characteristics (Sol et al., 2005, 20-24). Smoking Cessation Gies et al. in their 2008 study investigated the effects of nurse directed smoking cessation program. This research was conducted through a quasiexperimental, prospective, longitudinal design with provision for biochemical validation of self-reported tobacco abstinence on a randomized group of 68 inpatients. The authors have established the rationale of undertaking this research through an exhaustive literature review from which the reader can easily understand the need for this research (Gies et al., 2008, 6-21). Some important findings from this literature review can be mentioned here since they bear strong relevance to the topic of this study. Cigarette smoking is perhaps the most preventable known cause of CHD today, leading to more deaths from CHD than from either lung cancer or chronic obstructive pulmonary disease (Johnson et al., 1999, 55-64). CHD risk increases with number of cigarettes smoked, longer duration of smoking, and younger age at initiation of smoking. The CHD risk of male cigarette smokers is 2-3 times that of nonsmokers, as opposed to women who are current smokers having up to four times the risk of first myocardial infarction of those who have never smoked. Cigarette smoking was associated with a fivefold increase in the risk for fatal CHD and nonfatal myocardial infarction (MI), and tripled the risk of angina (Smith and Leggat, 2007, 165-181). This elevation in risk of MI and CHD death is sustained from youth into advanced age for men and women. Smoking cessation confers benefit regardless of sex, age, or presence of CHD. Men and women of all ages with documented CHD who quit smoking have half the risk of mortality compared with those who continue to smoke (Miller et al., 1997, 409-415). For women who quit smoking, MI risk is indistinguishable from that of nonsmokers within 3 to 5 years of smoking cessation. There are many successful approaches to smoking cessation, and these interventions are less costly than many other preventive interventions. The simple advice from health care providers to smokers to quit smoking increases smoking cessation rates by 30%. Therefore smoking cessation should be encouraged regardless of age, sex, or the presence of established disease (Gies et al., 2008, 6-21). There is evidence from other studies that if the time of administering the education is chosen wisely, educative intervention in terms of smoking cessation by nurses produce positive results in a very high percentage of patients (Hajek, Taylor, and Mills, 2002, 87-89). However, most of these studies were done in large hospital settings, and the authors have examined the effects of similar intervention in a small hospital. The study by Bolman and coworkers is unique in the sense that it incorporated in its design a biochemical method of evaluation and validation of the strategy. The patients' self-reported tobacco abstinence was validated by biochemical tests. The nursing interventions usually involve nurse counseling and post discharge followup. The primary purpose of these studies inclusive of this under review is to evaluate the effects of a structured nurse-directed smoking cessation education for hospitalized adult smokers. This study reveals that nurse-directed tobacco cessation interventions are more effective than traditional care in reducing or eliminating tobacco use in adult patients after discharge from larger inpatient settings (Bolman, de Vries, and van Breukelen, 2002, 99-116). Physical Activity Regular physical exercise has favorable effects on many CHD risk factors, including hypertension, plasma lipid, insulin and glucose levels, and coagulation and fibrinolysis. The level of regular physical activity or fitness is inversely related to risk for development of hypertension, and in people at high risk for hypertension, a program of regular exercise decreases that risk (Peterson et al., 2005, 93-110). In people with established hypertension, starting a program of low to moderate regular endurance exercise lowers the blood pressure 5% to 10%. High-density lipoprotein is increased, whereas LDL, very-low-density lipoprotein, and triglyceride levels are decreased by regular exercise (Astrup and Rossner, 2000, 17-19). This response appears to be related to the intensity, duration, and frequency of exercise. Insulin levels are reduced, and insulin resistance and glucose intolerance are improved by regular exercise (Lakka and Salonen, 1992, 466-472). Exercise also promotes favourable effects on coagulation by decreasing platelet aggregatability, lowering plasma fibrinogen concentration, and enhancing tissue plasminogen activator activity. Even a moderate level of regular exercise is an important adjunct to weight reduction in obesity, which is an important risk factor for CHD (Barnett-Damewood and Carlson-Catalano, 2000, 24-31). Chapter II: Literature Review: Patients Risk Intervention on Physical Activity Smith et al. in their study involving the examination of effect of a randomised multifactor risk intervention on prevention of ischaemic heart disease, specially concentrated on physical activity over a 36-month period, found upon comparing the effects of low-intensity intervention and low-intensity intervention that males indeed benefit from the physical activity intervention (Smith et al., 2008, 380). Peterson and co-workers studied the effects of physical activity interventions in women through a 12-week intervention programme (Peterson et al., 2005, 93-110). Allison and Keller determined the self-efficacy intervention designed to improve self-efficacy and physical activity in older adults who sustained a cardiac event. This is an important study due to the fact that most studies involving nursing interventions usually involve people who are less than 65 years of age. However, the older adults also need to undertake physical activity, and nurses have important roles to implement the education and extend support to maintain a behaviour change in this population when they are on their own in the community (Allison and Keller, 2004, 31-48). The theoretical framework draws upon the social cognitive theory that has been identified to serves as the basis for successful educative intervention strategies leading to sustained changes in health behaviour. It has also been suggested that increased physical activity leads to significant increase in self-efficacy. Thus, as a measure of educative intervention in risk reduction of CHD, promotion of self-efficacy can be a novel venture, which can motivate people to indulge in physical activities more. Self-efficacy has significant lasting and dynamic effects on physical activity behaviours. This study was done on a three-series design was used to examine the effects of a self-efficacy coaching intervention on self-efficacy and physical activity of older adults at 6 weeks and 12 weeks postcardiac events on the basis of random assignment. An important aspect of nursing intervention has been indicated in the design. In this study, the intervention nurse was carefully selected on CHD knowledge and communication skills, and she was trained so that the interventions were implemented as planned to control intervener bias. This nursing intervention based on social cognitive theory in this study revealed that there exists an indirect effect of interaction on increased distance walked related to treatment conditions and the subjects' self-efficacy for physical activity over the 12-week period (Allison and Keller, 2004, 31-48). Dietary Modofication Bemelmans et al. had studied the effects of different types of education regarding dietary modifications on the population. They performed a quasiexperimental study for exploring the effects of a nutritional educational programme. It was eventually found that a nutritional educational programme directed to CHD risk reduction would more effectively change the risk dietary behaviour on a long term basis if it is administered through group sessions. To design this study, the authors have performed extensive research and literature review. Many interesting facts about population behaviour and its implications have been revealed. Dietary factors are important determinants of cardiac risks since they determine the lipid levels and consequent effects on atherosclerosis; weight and obesity, which are considered independent risk factors for many other risk factors of and for CHD (Holmes, 1989, 9-11). Moreover dietary regulation can control diabetes which is a very frequent association of CHD, the prognosis of which is determined by associated diabetes and vice versa. During weight loss treatment, the strongest determinant of the rate and amount of weight loss that will occur is the extent of the negative energy balance. An important component of dietary therapy is addressing both fat and caloric restriction. Studies have evaluated the restriction of either one alone and have demonstrated less weight loss, especially when fat is restricted in the absence of caloric limitations (Lau-Walker, 2004, 216-225). Programs using the lifestyle approach include nutritional education. Elevated serum total cholesterol and LDL cholesterol are associated with an increased risk of CHD in men and women of all ages. At any given level of LDL, higher levels of HDL confer protection against CHD. Diabetes mellitus is associated with an increase in the incidence of CHD in men and women across the life span (Mensink et al., 2003, 377-384). Diabetes doubles the rate of MI in men and increases the rate of MI in women four- to six-fold. Diabetes, hyperinsulinemia, and insulin resistance are associated with higher relative weight; higher systolic and diastolic blood pressure; lower levels of HDL; and higher total cholesterol, HDL, and triglyceride levels. Since other CHD risk factors cluster in people with diabetes, attention should focus on altering those risk factors where change is known to make a difference in CHD risk, including hypertension, hypercholesterolemia, and smoking (Bemelmans et al., 2004, 240-246). Diabetic Health Care In this context, the study by Cooper and colleagues provides important insight into the client perspectives in response to diabetes health care education. The relevance of diabetes as an important correlative and independent risk factor of CHD has been mentioned. Very important significant points are revealed in this study (Cooper, Booth and Gill, 2003, 191-206). The aim of health education is to develop competencies in patients that allow them to assume greater control over the management of their disease. Effective management of these diseases needs a range of generic strategies to implement health education. While health education is aimed at active involvement of patients in their own decision making process. It has been argued in other studies that there is always a power relationship between patients and nurses, and a more active involvement of the clients making them more resourceful enough may disturb this power equation, and the nurses may find that their perspectives would not agree with those of the clients (Wells, 1993, 47-58). As a result, empowering the clients through education enables them to question a medical decision. The key notes that emerge from this study make valid points about such interventions, and any framework designed to intervene risk factors through health education must consider the learning of the clients and their behaviour in relation to health protection. As evident, these would guide variables to be used to direct practice, to determine intervention goals, and to explain the outcomes of intervention. These variables from different studies can be classified as cognitive factors such as attitudes and self-related beliefs including perceptions about self-efficacy. A successful programme would include the theories of personal models of illness, and it should also consider social-environmental variables such as social norms, influence of friends, family, and healthcare providers (Hildingh, Fridlund, and Segesten, 1995, 921-928). Supportive proof of such a strategy is available from other studies where it has been argued that such illness perceptions become more important as the emphasis on healthcare points towards prevention that depends on people's adherence to management programmes for risk factor modification (Cooper, Booth and Gill, 2003, 191-206). Although not directly related to nurse-administered education interventions, the article by Erhardt is relevant since it hints to the problem of practice related to educative interventions for cardiovascular risk reduction and its inability beget lifestyle changes to a great extent. There are evident gaps in the guidelines, where professionals have insufficient time and underestimation of patients' cardiovascular risk. Moreover, the patients' perception about their own risks are often inadequate leading to lack of adherence to lifestyle modification and lack of awareness about cardiovascular risk. Even though professionals think that they implement guidelines successfully, the patients remain undertreated, and their perceptions do not tally with those of the care professionals. The author highlights the importance of risk factor modification and control, and literature also suggests so. The recent joint European guidelines on cardiovascular disease prevention prescribes that the practitioners assess overall cardiovascular risk in the context of primary prevention. There are certain barriers that have been identified that hinder the patients' response to educative interventions. These are lack of awareness, limited access to care, low level of compliance, reluctance to persist on a non-pharmacological regimen leading to lack of adherence to lifestyle modifications. It is very evident that there is gross discrepancy between reality and perception about heart disease in the population. One major problem that has been identified is that despite current increase in knowledge in the population, it does not ensure bringing about changes in health-related behaviour or lifestyle through conscious effort. To make matters worse further, the information giving procedure by the healthcare professionals are often inadequate, inconsistent, and inaccurate, making room for further improvement, and hence further research in this area (Erhardt, 2005, L11-L15). Conclusion Patient education is increasingly being recognised as an important function in nursing practice. It forms an integral component of healthcare. It is a process of assisting individuals to change behaviour. Nurses provide patients with information about health, and are encouraged to become partners in their care. As nurses spend a considerable amount of time in direct patient care, several opportunities for patient education arise. Nursing staff utilise a variety of teaching aids to provide this information, including videos and booklets and providing individual teaching to patients. Approaches to teaching can vary. So too can level and content. Meanwhile, outstanding progress has been made in our understanding of CHD risk factors and their management. The evidence against cigarette smoking, elevated serum cholesterol, and high blood pressure is strong, and sustained campaigns are underway to prevent and appropriately manage them. The importance of adequate physical activity and weight control is acknowledged; however, unstructured education programme, lack of a systematic and individualised approach to teaching, failure to identify a patient's individual learning needs, inappropriate timing of information delivery and inappropriate teaching strategies further contributed to lack of success. Therefore, further research is indicated as to how the nursing profession can best execute a patient education programme that can be effective in reducing patient CHD risks. Reference List Allison, MJ. and Keller, C., (2004). Self-Efficacy Intervention Effect on Physical Activity in Older Adults. 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