By Dawn Siek, BSN, RN,CV-BC

One center's journey to providing mindful meditations to patients.

720,000 Americans are expected to experience a new acute cardiac event this year.¹ Cardiac rehabilitation (CR) is an important part of the recovery process, with an estimated 250,000 Americans participating each year.^2,3.

Stress management interventions are not often offered as part of the menu of treatment options included in CR, possibly due to the lack of consensus about the most effective approach and stress quantifications.⁴ In addition, there are inconsistencies in the literature describing the association between stress and conditions associated with coronary artery disease (CAD).⁵ Screening, using the Patient Health Questionnaire-9 (PHQ-9) upon entry to a CR program, is recommended since depression is often associated with adverse events, increased mortality, and worse prognosis in cardiac patients.⁶ CR programs must be innovative and take initiative in order to provide effective stress management techniques that contribute to comprehensive care and, ideally, improve function and overall well-being.⁷ Data demonstrating improvement of patients’ PHQ-9 scores are reported yearly to AACVPR, which requires that all accredited centers produce evidence that demonstrates progress in decreasing patients’ symptoms of depression, as measured by the PHQ-9.

Purpose

As part of its Evidence-Based Scholars program, a nurse at Chilton Medical Center in northern New Jersey aspired to create an innovative approach to decrease self-reported anxiety and experiences of depression in patients who utilize CR. The PHQ-9 (Kroenke, Spitzer & Williams, 1999) was leveraged; this measurement tool is used to screen, diagnose, monitor, and measure the severity of self-reports of depression and is routinely administered to CR participants. A brief nine-question instrument that assigns a weight to the degree to which depression problems have affected the patient’s level of functioning, the PHQ-9 can be administered repeatedly in order to measure improvement or worsening of depression in response to treatment.

The nurse led her team to explore whether patients enrolled in cardiac rehabilitation, given access and the ability to use stress management resources, improved their quality of life and self-reported depression scores.

An extensive literature search yielded several main themes from the reviewed articles:

• CR staff have limited resources and time and must be creative to help their patients reduce stress.
• There is no definitive way to reduce stress in the CR population.
• There is sufficient evidence to support the creation of techniques for stress reduction in patients who utilize CR, as a means by which recovery from a cardiac event may be optimized.

The Experience at Chilton Cardiac Rehabilitation

CR staff, which include cardiac nurses and exercise physiologist clinicians, previously administered PHQ-9 at the point of initial assessment and again at discharge. If the patient scored greater than 10 on PHQ-9, the referring cardiologist was notified. Patients were then educated about deep breathing techniques and asked about the presence/absence of stress symptoms, encouraged to verbalize their stress, and educated about publicly available electronic meditation apps.

However, the evidence supported a change in practice to support creativity and to leverage innovation in this area.

Discussion/Implications/Next Steps:

In collaboration with Chilton’s Concern (Employee Assistance Program) and Behavioral Health Community Services departments, 12 mindful sessions, 5-10 minutes in length and accessible by QR code, were created, along with the Grow Your Mental Health booklet. The title was chosen so that the booklet was not specific to Chilton's CR and could be used for others. Current practice is to provide the Grow Your Mental Health guidebook to every patient upon entry to the to the CR program. Patient pre- and post- scores derived from the PHQ-9 are used to measure improvement for individuals as well as in the aggregate.

Outcomes

• Patients’ scores derived from the PHQ-9 were analyzed to measure the effectiveness of the practice change. (See Table 1, below)
• Since the program’s inception in March 2023, an increase in the mean score has been achieved.

Summary

In conclusion, the elements contained within the Grow Your Mental Health booklet successfully assisted patients who were participants in the Chilton CR to achieve greater self-reported mental well-being. The staff were educated about the booklet, which is provided to all patients upon their initial interview. Creativity, innovation, and patients’ demonstrated need for new techniques about stress management drove the mission to create the Grow Your Mental Health booklet for all our cardiac rehab patients.

Feel free to use it in your own program!

Grow Your Mental Health QR code:

Dawn Siek, BSN, RN,CV-BC, has been a nurse for 36 years — 24 of them within the discipline of cardiac rehabilitation. She currently is Assistant Nurse Manager for Chilton Medical Center, Atlantic Health System, in the specialty of cardiac rehabilitation in Pompton Plains, New Jersey, for the last 6 years. Dawn also was a poster presenter at the 39^th AACVPR Annual Meeting, where she was recognized for her entry detailing the “Growing Your Mental Health” booklet.

REFERENCES

¹ Benjamine, EJ, et al. heart disease and Stroke Statistics-2019 Update: A Report from the American Heart Association. Circulation 2019: e56-e528.

² Ritchey MD, Maresh S, McNeely J, et al. Tracking cardiac rehabilitation participation and completion among Medicare beneficiaries to inform the efforts of a national initiative. Circ Cardiovasc Qual Outcomes 2020;13(1): e005902-e005902.

³ Thomas RJ. Cardiac rehabilitation/secondary prevention programs: a raft for the rapids: why have we missed the boat? Circulation 2007; 116:1644-1646.

⁴ Blumenthal JA, Sherwood A, Smith PJ, Watkins L, Mabe S, Kraus WE, et al. Enhancing Cardiac Rehabilitation with Stress Management Training. Circulation. 2016; 133: 1341–1350.

⁵ Shi,Y,Lan, J. (2021) Effect of Stress Management Training in Cardiac Rehabilitation Among Coronary Artery Disease: A Systemic Review and Meta-Analysis

Rev. Cardiovasc. Med. 2021, 22(4), 1491–1501; https://doi.org/10.31083/j.rcm2204153

⁶ Human Kinetis (2021) Guidelines for Cardiac Rehabilitation Programs 6^th ed.,137, 140-141.

⁷ Dang D, & Dearholt S.L., & Bissett K, & Ascenzi J, & Whalen M(Eds.), Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model and Guidelines, 2022,4e. Sigma Theta Tau International Honor Society of Nursing. https://apn.mhmedical.com/content.aspx?bookid=3144&sectionid=264685441