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Psychological care for patients with symptoms of myocardial infarction: a systematic review

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VOL: 102, ISSUE: 47, PAGE NO: 34-35

Victoria S. Russell, MNursSci, RGN

Medical admissions nurse, Chelsea and Westminster Hospital, London.

Abstract

Russell, V. (2006) Psychological care for patients with symptoms of myocardial infarction: a systematic review. www.nursingtimes.net

Aim: The purpose of this systematic review was to investigate literature on anxiety in patients experiencing symptoms of myocardial infarction (MI) and the provision of psychological care to this group with the aim of improving practice.

Method: A literature search was undertaken to identify articles linking the nurse’s role with MI, the patient?s view with MI and the need for psychological care within acute medicine. Articles were assessed for quality and bias and common themes identified.

Results and discussion: The 23 articles included in the review suggest that patients with symptoms of MI experience some level of anxiety and that they are not always offered psychological interventions to alleviate this anxiety.

Outcome: An anxiety assessment tool was developed to help nurses to assess patients’ level of anxiety and suggest appropriate interventions to offer psychological care to patients with symptoms of MI.

In the UK someone has a heart attack every two minutes (British Heart Foundation, 2003) and over 50,000 people die prematurely of coronary heart disease (CHD) every year in the UK (Cruickshank et al, 2000), the majority as a result of a myocardial infarction (MI). The government has outlined plans for reducing CHD-related death rates in people under the age of 75 years by at least two-fifths by 2010 (Department of Health, 1999). Subsequently, the National Service Framework for CHD (DH, 2000) listed 12 recommendations for improving prevention, diagnosis and treatment.

This article reports on a systematic literature review focusing on improvements that could be made to nursing practice with regard to patients’ psychological needs. It also discusses an anxiety assessment tool developed in response to the review findings.

The review was undertaken after I cared for a patient on a general ward who had high levels of anxiety following an MI (Box 1). A basic literature search highlighted a gap in the research on psychological care, with the general focus being on physiological processes and medical treatment.

Box 1. An anxious patient

Michael Jones*, a patient on a busy medical ward, complained of severe pain across his chest and a feeling of weakness throughout his body. He had a high respiratory and pulse rate and his blood pressure was outside his normal limits. His pain score remained at seven (10 being the highest) even after lying down. An ECG and blood tests were ordered and Mr Jones was prescribed oxygen and a glyceryl trinitrate spray. Regular observations were also undertaken. Mr Jones showed signs of extreme anxiety and repeatedly asked questions such as ‘Am I going to die?’ He stabilised after 10 minutes.

Feelings

Mr Jones’ nursing care appeared to be medically orientated. He was extremely anxious and his respiratory rate and blood pressure were elevated. Whether they were a cause or result of his anxiety, his respiratory rate and blood pressure were likely to exacerbate his medical condition. This emphasises the importance of providing psychological care, which is often lacking within this patient group.

* The patient’s name has been changed

Method

In order to identify current pathways of care for MI patients and explore how psychological factors might contribute to best practice, I conducted a systematic review of the literature.

Each relevant article that met the inclusion criteria was analysed for quality, bias and general structure and content. The review included both empirical (definition) and literature reviews from 1980 to the present day. Inclusion criteria were articles linking nursing practice to MI and/or the patient’s view and the need for psychological care within acute medicine. Box 2 lists search terms.

Box 2. Main search terms

 

Step

 

 

 

 

Search term

 

 

1

 

 

Myocardial Infarction AND Nursing role

 

 

 

 

2

 

 

Myocardial Infarction AND Patient?s experience

 

 

 

 

3

 

 

Nursing AND Psychology

 

 

 

 

4

 

 

Psychological care AND acute medicine

 

 

 

 

5

 

 

Psychological status AND Myocardial Infarction

 

 

 

 

6

 

 

Types of people affected by Myocardial Infarctions

 

 

 

 

7

 

 

Cardiac Psychology

 

 

 

 

The electronic search engines accessed included CINAHL; MEDLINE, EMBASE and PsycInfo. I also used the medical specific worldwide search engine Copernic (http://www.copernic.com).

The quality and bias assessment of the articles was undertaken using existing tools (NHS Centre for Reviews and Dissemination, 2001; Crombie, 1996), and articles were also subjected to a 99-point scoring system, enabling the results to be weighted. The relevant literature was then analysed as a whole using a separate framework for empirical studies (Qualitative Research and Health WorkingGroup, 2002) and literature reviews, case studies and reviews of services (Cochrane Systematic Review, 2002). Common themes were identified.

A total of 5,268 articles were identified in the initial search but only 23 matched the inclusion criteria.

Results

Four subject categories, each with its own sub-category, emerged from the literature (Table 1).

Table 1. Subject categories emerging from the literature

 

Category

 

 

Sub-category

 

 

1. What is the recommended role for a nurse caring for a patient presenting with symptoms of an MI?

 

 

How do nurses perceive their role in caring for these patients?

 

 

2. Do patients presenting with symptoms of MI need psychological care?

 

 

How do patients react in this situation?

 

 

3. What psychological needs were highlighted by these patients?

 

 

Do different types of patients/at-risk groups require different psychological interventions?

 

 

4. What psychological care is suggested for these patients?

 

 

What interventions should be used?

 

 

What should the nurse’s goal be?

 

 

Category 1. The nurse’s role

Most research on the nurse’s role in caring for patients with MI focuses on practical skills. For example, Edwards (2002) discussed the importance of nurses understanding the physiological processes of MI and suggested their role should be developed to include administering thrombolytic therapy. However, while nurses must understand the physiological processes of an illness they also have a duty to provide holistic care. The only article which included details on anxiety management achieved a low score. Kelly (2004) used a holistic assessment strategy to assess MI patients’ physical, psychological and social well-being and the views and observations of family members. Psychological care was found to be best in the cardiac care unit but patients often present with MI in the emergency department or on general wards.

There is a lack of evidence of nurses’ responsibilities in providing psychological care to patients presenting with symptoms of a MI.

Nurses’ perceptions of their role

Newens et al (1996) found that nurses had poor knowledge of symptoms associated with MI. However, they did not include psychological symptoms in their study so nurses’ understanding of these is unclear. Ford (1990) investigated nurses’ narratives of caring for a cardiac patient, which suggested being able to sense the patient’s feelings of vulnerability and be attentively present was part of their role .

Svedlund et al (1999) reported that CCU nurses described their relationship with MI patients as caring, which they defined as being able to read the patient and being sensitive to body language and facial expressions. The study suggests that it requires a particular type of person to be a nurse, someone who can sense other people’s feelings and feel comfortable building close relationships.

There is a lack of nursing knowledge of psychological reactions to a MI and the evidence suggests that the psychological care is not universally provided.

Category 2. Do patients need psychological care?

There is a strong link between physiological and psychological symptoms. Three studies stated that the anxiety felt by MI patients can put further pressure on the heart - through a rapid pulse rate, increased blood pressure, increased respiration and peripheral vasoconstriction - increasing the cardiac damage.

Kinzinger (1992) found that 80% of participants reported discomfort, tension, fear and anxiety, while Bolwerk (1990) suggested that health professionals should regard all MI patients as anxious because they may be masking their anxiety. Strandmark (2004) warned that repressed feelings can transform into bodily symptoms. Psychological care should therefore become standard for all seriously ill and injured people (Nichols, 1985).

How do patients react?

Clark (2003) used qualitative interviews to explore patients? perceptions of their MI experience; these included ‘panic’, ‘worry’, ‘fright’, ‘sweats’ and ‘anger’. Cornock (1996) stated that the most common reactions to MI are ‘anxiety, fear, anger, along with feelings of hopelessness, helplessness and worthlessness’. He argued that these reactions can be linked to factors such as behavioural type, effect on Maslow’s hierarchy of needs model, the health beliefs model and cognitive dissonance. For example, Maslow’s hierarchy of needs model identifies levels of human need. Once one level of need is met, the individual moves up to the next. The first level is based on the need to feel safe - during an MI this need is not met.

The health beliefs model is concerned with health beliefs that may influence patients? reaction to illness. The main example given is individuals? locus of control, which can be internal or external. People with an internal locus of control believe they can influence the features that affect life, while those with an external locus believe they are subject to fate and destiny and are not in control of their own lives. Those with an external locus are more likely to have reactions such as hopelessness and helplessness than those with an internal locus who might use problem-solving coping strategies.

Cognitive dissonance involves the individual holding two inconsistent beliefs or opinions, such as the need for treatment and knowledge that treatment provided has failed. Such a cognitive dissonance might be common in MI patients who had to be resuscitated - they have positive view of treatment but it has failed because they needed to be resuscitated. In this case, the individual would experience dissonance and therefore a negative state.

Stewart et al’s (2000) empirical study received a high score and reported similar findings to those of Cornock (1996) on the effect of the locus of control, as 86% of participants associated the emotional impact of the situation as a stressor. The emotional impact is described as denial and confusion at the onset of symptoms, leading to fear and uncertainty which appeared to emerge from a perceived loss of control. This aspect of control appears to affect patients’ reactions to the situation. The study recognised three coping strategies used by patients during their reaction to the situation: emotion-focused; problem-focused; and relationship-focused. Through the emotion-focused strategy, the patient shows signs of emotional suffering. When a problem-focused strategy is used, the patient may seek information and, when the relationship-focused strategy is used, they may show signs of wanting to communicate. The latter strategy has the potential to be effective.

Strandmark (2004) described the essence of illness as powerlessness, which means reactions are the result of a self-image of worthlessness, a feeling of being imprisoned by the situation and a sense of emotional suffering. Subsequently, illness results in an overall threat to an individual’s autonomy. When patients feel imprisoned by the situation, this is believed to have an oscillating effect between the reactions of hope and despair. Strandmark described patients’ emotional suffering as dissatisfaction with themselves. This article is not specific to MI, but raises interesting issues to help nurses to understand patients’ reactions to illness. It received an average research score, so the issues have still been considered. It suggests that, to improve ill health, powerlessness must be prevented by empowerment.

Kristofferzon et al (2003) conducted a literature review on differences in gender coping mechanisms and social support during MI and found that women minimised the impact of the MI, tended to delay in seeking treatment and did not want to bother others with their health problems, while men were more likely to seek social support. The review received a high research score, so great emphasis is placed on these gender differences when discussing suggestions for care provision. Martin et al’s (2004) empirical study, which also received a high score, supported this gender difference theory, finding that women are less likely than men to attribute initial MI symptoms to cardiac causes, and also that when women seek medical advice they are less likely to be told their symptoms are cardiac related. Martin et al (2004) therefore suggested this is due to a stereotypical perception that MI is a male problem.

This category not only shows that anxiety is a common psychological symptom in MI patients but also highlights the risk that this anxious state will increase the strain and damage to the heart. The category therefore identifies the need for intervention to prevent illness and emphasises the link between physiological and psychological aspects of health which influence each other strongly.

Category 3. What psychological needs were highlighted?

Cronin and Harrison’s (1988) empirical study investigating how MI patients perceived nurses? behaviour suggests that patients want their basic medical needs to be satisfied before their more complex psychological needs, which the authors explain using Maslow’s hierarchy of needs. This is an important issue for professionals - while research that shows that thrombolytic therapy is more effective the sooner it is administered (Conway and Capewell, 2000), this study seems to suggest that patients’ complex needs are not being met after their basic ones have been attended to.

The need for information was a common theme. Zinzinger (1992) suggested that anxiety is often compounded by lack of information. Moller et al’s (2004) empirical study found that patients’ knowledge of their illness after admission for an MI is poor; 48% of participants could not explain what an MI was. This statistic comes from a high-scoring study and suggests that physicians need to provide more information to these patients.

Kristofferzon et al (2003) discovered that women receive less information than men. However, they stated that previous research in this area suggested male patients have a higher need for information. Shaw (1999) also highlighted that different coping strategies require different amounts of information, concluding that ‘people who use active, information-seeking strategies and have internal locus of control are more likely to want detailed information than those who prefer an avoidant approach’. Although this article received a low research score, it raised interesting issues regarding the adaptation of information to suit individual patients’ needs.

Do different patients need different psychological intervention?

The findings on MI patients’ information needs suggest that psychological interventions should be adapted for the specific patient group. This became apparent throughout the literature, which also suggested three factors affect information needs - gender, cultural group and whether the information is for patients or relatives.

Kristofferzon et al (2003) found that women use more coping strategies than men but these do not appear to be more effective - the women tended to use passive strategies such as depressive reactions, denial and blame. This suggests women may need assistance in choosing the most beneficial coping mechanism. It may be argued that these findings reveal a need for separate psychological intervention tools but the nature of the environment in which MI patients present mean an easy, universal tool would be more appropriate. However, it is important for nurses to be aware of the differences in reactions.

Clark et al (1998) identified that cultural factors can heavily influence patients’ perspectives of health and illness, while Fishel (1998) stated that cross-cultural studies have revealed substantial differences in the symptoms of anxiety presented in different cultural groups. Both studies highlighted the lack of research into cultural and minority groups within this area of healthcare.

Albaugh’s (2003) empirical study received the highest research score. This highlighted effect of religion on psychological requirements. The importance of spirituality to religious patients in terms of coping with life-threatening illness suggests patients’ spiritual needs must be attended to, highlighting the importance of effective communication between nurse and patient.

Svedlund et al (1999) placed great importance on the relationship between nurses and patients’ relatives, suggesting the first encounter between the two groups is important in building trusting relationships. They conclude that the relationship between nurse and family has a knock-on effect to the nurse-patient relationship, and advocate involving relatives and ensuring they are offered information and the chance to communicate.

Category 4: What psychological care?

This review has highlighted the importance of psychological care for this patient group. Moller et al (2004) suggested patient counsellors could be used to improve patients’ understanding of their condition and recommended that physicians caring for these patients receive training in communication skills. This study received a high research scoring, implying that this suggestion is evidenced based. However, while it suggests that physicians need more training, the present research suggests nurses also require more psychological education. While Moller et al’s suggestion that a counsellor be used to provide information and possible psychological care implies that this is not within the nurse’s remit, the study was conducted in Germany, where the nurses’ role differs from that in the UK.

Fishel (1998) used an anxiety assessment tool which assesses stated characteristics signs and levels of anxiety against suggested interventions such as medication, empowerment, music therapy, breathing exercises and touch therapy. The author suggested the tool should be implemented in the emergency department and general wards. While it has the potential to improve care most significantly in these areas, given the lack of psychological care provided currently (Newens et al, 1996), the tool is relatively complex and time-consuming and would not be practical for these busy areas. Fishel’s (1998) research received a low score its references list Spear (1996), who recommended use of a visual scale for anxiety assessment. This article was not identified within the main search and therefore has not been given a research score, but a visual scale would be a practical form of assessment for use within emergency departments and general wards.

Some of the articles suggested interventions that may be effective in reducing anxiety. While empowerment and good communication have been recommended, Fishel (1998) also suggested music therapy, breathing exercises and touch therapy. Bolwerk (1990) also explored the idea of using music to reduce stress and, while it may be difficult to offer in some areas, it is an interesting concept. Breathing exercises aim to increase oxygen intake and produce a calming effect through deep breathing, while touch therapy is intended to reduce anxiety through the laying on of hands. Fishel (1998) and Spear (1996) also recommended pharmaceutical interventions such as benzodiazepines. These types of drugs have a fast onset with few side-effects but should be used as a final intervention.

What should the nurse’s goal be?

Many authors identified the nursing goal as the provision of care (Kelly, 2004; Cronin and Harrison, 1988; Ford, 1990). This philosophy of care should be considered the goal of every nursing intervention. Kelly (2004) argued that the nurse’s goal when caring for MI patients should incorporate a human perspective that considers their physical needs in association with their psychological and sociocultural needs, reinforcing the humanistic approach to caring for this patient group.

The synthesis of these findings has created a new evidence base that has identified the need for changes in practice. The first category has highlighted the lack of psychological care being provided to patients presenting with symptoms of MI (Edwards, 2002). However, the second category clearly suggests these patients need psychological care due to the damaging effect of anxiety on the already compromised heart (Cronin and Harrison, 1988). The third category revealed that patients’ main psychological requirement is information from health professionals (Moller et al, 2004; Stewart et al, 2000), while the final category suggests interventions to reduce anxiety, proposes a tool be used to assess anxiety levels - suggesting a visual analogue scale may be appropriate for nurses to use in emergency departments and general wards - and offers appropriate interventions. This research highlights the use of empowerment as a humanistic approach to psychological care of these patients. Empowering patients can help them to gain an internal locus of control and move up the hierarchy of needs, thereby reducing anxiety and improving health.

Assessment tool

In Gibb’s (Rolfe et al, 2001) framework for reflection the action plan asks: ‘If it arose again what would you do?’ The rationale for this systematic review was based on a reflection I experienced with a patient who experienced the onset symptoms of MI and appeared anxious, yet was given no psychological care. The review has revealed that the patient?s care could have been improved by offering psychological care, and that the use of the anxiety assessment and intervention scale may have ensured this aspect of care was provided.

The findings generated from the research led to the design of an anxiety assessment and intervention tool (Fig 2), the aim of which is to reduce the anxiety felt by patients with the onset of MI symptoms. The review suggests that anxiety is the most common reaction to MI and that empowerment is the most effective intervention for this.

Since nurses have the most contact with this patient group, they are the appropriate professionals to implement this tool, which will help them to select a psychological intervention for individual patients. Nurses using the tool will need education on why this aspect of care is necessary and advice on how to offer psychological interventions. It can be used on all patients presenting with MI since this study demonstrates they all experience some level of anxiety (Bolwerk, 1990; Nichols, 1985).

Integrating the tool within the observations charts used to record vital signs would remind nurses that these patients need psychological care and that their anxiety levels should be assessed regularly. Involving patients’ relatives in aspects of information provision will offer them psychological support (Svedlund et al, 1999). Nurses should also ask patients whether any spiritual care would help reduce their anxiety and improve their ability to cope (Albaugh, 2003) - in such cases it may be necessary to involve others such as a hospital chaplain or other appropriate religious practitioner.

The anxiety assessment and intervention scale involves asking patients to rate their anxiety on a scale of 1-4, in which 1 is slight anxiety and 4 is severe anxiety. The score of 1 is classed as a level of anxiety since Stewart et al (2000) stated that all MI patients should be treated as anxious.

 

Scale of anxiety

 

 

Description of anxiety

 

 

 

 

Intervention recommended

 

 

1

 

 

Slight anxiety

 

 

Provide information

 

 

2

 

 

Mild anxiety

 

 

Provide information

 

 

Sensory therapy

 

 

3

 

 

Moderate anxiety

 

 

Provide information

 

 

Sensory therapy

 

 

Breathing exercises

 

 

4

 

 

Severe anxiety

 

 

Provide information

 

 

Sensory therapy

 

 

Breathing exercises

 

 

Pharmaceutical Intervention

 

 

Each of these scores has a recommendation for a nursing intervention attached to them. These interventions are created from the findings in this research and use a relationship-focused coping strategy which has been shown to be most effective (Stewart et al, 2000). This focuses on the relationship between nurse and patient and emphasises the importance of communication.

Interventions

The provision of information has been identified as being an important psychological need of this patient group (Clark, 2003; Kristofferzon et al, 2003; Shaw, 1999; Zinzinger, 1992), so the tool recommends patients on all levels of the scale be given information as this offers them control. This information should be provided in lay terminology (Clark, 2003) and should cover all equipment, procedures, diagnosis and prognosis. The literature suggested increased information and openness for both gender groups (Kristofferzon et al, 2003). Therefore this tool recommends that equal amounts of information should be provided to both sexes.

The provision of sensory therapy involves the reduction of noise which has been shown to increase stress (Zinzinger, 1992; Bolwerk, 1990). The use of touch therapy has been shown to improve communication between nurse and patient (Fishel, 1998), while environmental awareness during interactions, such as pulling the curtain or sitting close to the patient, demonstrate the nurse is giving the patient full attention, which can reduce anxiety (Ford, 1990).

Breathing exercises are only used in patients with moderate or severe anxiety. This is because they are time-consuming and are used to control breathing patterns found in people with high levels of anxiety.

Pharmaceutical interventions are only recommended in cases of severe anxiety, to prevent the already compromised heart sustaining further damage. Fishel (1998) recommends benzodiazepines for situational-induced anxiety such as that experienced during the onset of MI symptoms. These drugs, which include diazepam and lorazepam, have a fast-acting effect and few side-effects. This study suggests that for efficiency one type of benzodiazepine should be prescribed on the ’as required? section of the drug chart, for every patient presenting with symptoms of MI. This would allow the nurse to administer the drug immediately if the patient scored 4 on the scale.

Conclusion

This systematic review was inspired by reflection which identified a gap in care provision that compromised the quality of care a patient received. It was conducted using a review model and a reflective framework to offer structure. Synthesis of the findings from the review has confirmed the gap I discovered and generated recommendations to address this. This study has explored patients with onset symptoms of MI and their need for psychological care, which was found wanting. Recommendations for improvements have been made and an anxiety assessment and intervention scale has been developed. The scale is only a prototype for which an empirical study needs to be conducted to assess its efectiveness in reducing anxiety.

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