Elsevier

Heart & Lung

Volume 33, Issue 3, May–June 2004, Pages 183-190
Heart & Lung

Issues in cardiovascular nursing
Description of a nursing intervention program after an implantable cardioverter defibrillator

https://doi.org/10.1016/j.hrtlng.2004.01.003Get rights and content

Abstract

Background

Although implantable cardioverter defibrillator (ICD) therapy has been found to be effective in preventing and treating life-threatening arrhythmias, adjusting to the ICD and resuming a normal lifestyle are often difficult. There are few intervention trials reported in the literature to aid in adjustment after receiving a primary ICD.

Objective

This article describes the content and structure of a nursing intervention program designed to improve physical functioning and psychologic adjustment after ICD implantation. The nursing intervention program was based on social cognitive theory and the data from a previous investigation covering 7 areas of concern after ICD implantation.

Conclusion

Hospital-based education programs begin the process of recovery after ICD implantation, but they must be supplemented with further interventions to return the patient to baseline physical and psychologic functioning. This is a beginning effort in deriving and testing evidence-based intervention programs for patients with an ICD.

Introduction

The number of individuals who receive an implantable cardioverter defibrillator (ICD) for a life-threatening ventricular arrhythmia has averaged 100,000 per year worldwide during the last few years.1 This number is expected to increase dramatically given the recent findings of the Multicenter Automatic Defibrillator Implantation Trial II,2 indicating that the ICD is an effective therapy for preventing sudden cardiac arrest (SCA) in patients with low ejection fraction and recent myocardial infarction. Although this therapy has been found to be effective in preventing and treating life-threatening arrhythmias, adjusting to the ICD and resuming a normal lifestyle are often difficult. Research findings indicate that 20% to 80% of individuals who receive an ICD have psychologic reactions that include anxiety, anger, depression, and adjustment disorders,3, 4, 5, 6 with a more protracted adjustment reported in those who receive ICD shocks. Few intervention studies have been reported that enhance adjustment to living with an ICD. Given the large number of individuals who will receive the ICD in the succeeding decade, intervention trials that support adjustment after ICD implantation are needed. Therefore, this article describes a nursing intervention program for SCA survivors after ICD implantation.

The 2 types of interventions described in the literature for those who receive an ICD are imparting information (education) and providing psychologic support (support groups and individual counseling). Most of these interventions do not evaluate immediate or long-term effectiveness. Rather than determine the needed interventions from the perspective of the survivors, most programs deliver standard information to everyone. Articles that describe hospital-based teaching programs recommend standard content.7, 8, 9, 10, 11 The content that is believed to be essential for patients receiving an ICD includes information about the disease process, treatments available for other dysrhythmias, implantation procedures and risks, ICD device function, safety precautions, warning signs and symptoms, activity guidelines, and follow-up care.

Several articles describe the use of support groups and individual counseling in aiding adaptation to SCA and ICD implantation.12, 13, 14, 15, 16, 17, 18 Using a Heideggerian hermeneutics research method, Dickerson et al13 described help-seeking experiences of ICD recipients and their support persons attending an ICD support group. They defined 6 related help-seeking themes (hearing and telling stories, encouraging help-seeking by triggers, seeking meaningful information, forming a therapeutic friendship through group camaraderie, gaining assistance from the facilitator, and sharing of a similar view by support persons) and 1 constitutive pattern (coping with the possibility of death). The researchers recommended that storytelling was the central mechanism of interaction in support groups for individuals who have an ICD. Likewise, Teplitz et al16 described the development of a support group for ICD recipients and their families using a 5-phase model: identification of the need for the nursing intervention, implementation of the intervention, structural format used in group meetings, summarization of the group process in relationship to a theoretic framework, and description of common themes present in group meetings. This was a descriptive report that used informal feedback and a brief questionnaire to evaluate effectiveness. Results indicated that participants found the support group to be helpful. Finally, DeBasio and Rodenhausen18 reported that group experience provided a forum in which patients could share problems, fears, concerns, and questions with peers. The anecdotal descriptions provide information that support groups may be an effective strategy for aiding in adaptation after receiving an ICD.

Evidence-based interventions designed to assist SCA survivors with adjustment after ICD implantation are few. Table I summarizes evidence-based articles including the intervention format, number of subjects in the study, duration of the study, and findings. Cowan et al19 tested a 3-part intervention consisting of physiologic relaxation with biofeedback training, cognitive behavioral therapy (CBT), and cardiovascular health education provided in 11 individual 90-minute sessions. Follow-up phone calls were made every 6 months for 2 years from the date of randomization. The psychosocial therapy reduced the risk of subsequent cardiovascular death in SCA survivors, but the intervention had no effect on heart rate variability, anxiety, depression, or anger.

Sneed et al14 studied ICD recipients and their significant caregivers who received a 3-part intervention of weekly, postoperative telephone follow-up, evaluation and counseling by a psychiatric liaison nurse, and participation in an ICD support group. Follow-up was limited to 4 months. Results indicated that adaptation to the ICD occurred over time regardless of the intervention. Badger and Morris17 studied 6 patients and their spouses who attended 8 weekly support groups and compared these with a convenience group of 6 patients unable to attend the support group. Common issues of concern among all SCA survivors during support sessions included the following: lifestyle changes, family well-being, family role changes, physical symptoms, shocks from the ICD, uncertainty produced by the arrhythmia and device, fear of shocks with intimate body contact, driving restrictions, body image changes, costs, battery and device failure, and limitations on activity. Group therapy was found to be an effective treatment modality in promoting positive adjustment after ICD implantation, but the study was limited by a small sample size and lack of random assignment. Molchany and Peterson15 tested the effects of a monthly (9 sessions) 1.5-hour support group in ICD recipients several months after implantation. The results indicated no significant reductions in anxiety from participation in the support group intervention.

The effect of CBT in alleviating psychologic somatic distress and decreasing arrhythmic events requiring shocks was studied for a 9-month period.12 CBT was associated with decreased depression, decreased anxiety, and increased adjustment, particularly in those survivors receiving ICD shocks. The study was limited in its short-term follow-up period. The authors concluded that it was difficult to determine if a no “attention-control” group should have been included to determine benefits gained from attention alone or specific components of a CBT program.

Few conclusions can be drawn from these investigations because sample sizes were small (<25 in most instances), nonrandom assignment was used, follow-up was limited to 5 months or less, participants began interventions retrospectively and at varying times after SCA, the intervention varied in length of time and attendance, and standardized measures for assessing outcomes were not used.

We developed and tested a nursing intervention program for SCA survivors who received an ICD during hospitalization. The program was based on social cognitive theory20, 21, 22 and the domains of concern of SCA survivors from a previous study.23 The details of intervention development are outlined elsewhere.24 Briefly, we used the structural elements of social cognitive theory to create the intervention (how to do the intervention) and combined these elements with the disease-specific information and skills derived from the domains of concern (what to do) to formulate the nursing intervention program.

Social cognitive theory, in particular, self-efficacy, is an individual's conviction in one's ability to execute a particular behavior that is required to produce a particular outcome. Behavioral change and maintenance are functions of both expectations about the outcomes that will result from engaging in a behavior and expectations about one's ability to execute the behavior required. Self-efficacy relates to beliefs about capabilities of performing specific behaviors in particular situations, not to a general personality trait overall. Thus, self-efficacy expectations will vary greatly depending on the particular task and the context. Self-efficacy affects emotional reactions such as anxiety, distress, and thought processes.20, 21 This process by which personal and outcome efficacy expectations influence behavior is reflected in Fig 1.

Self-efficacy expectations are increased through 4 mechanisms: (1) performance accomplishments (learning by doing), (2) vicarious experiences (observing others or role models), (3) verbal persuasion from expert sources, and (4) minimizing emotional arousal (reducing anxiety). Successful performance of tasks that afford mastery over a difficult task results in increased self-efficacy and is the most powerful source of efficacy expectations.20, 22 Observing another person demonstrate mastery over situations that are feared or perceived as difficult can enhance one's own efficacy expectations. Effective modeling must demonstrate mastery over difficult situations through determined effort, and the model must be similar to the observer in regard to other characteristics such as age and gender. Verbal persuasion from heath care providers viewed as “experts” have aided individuals in changing their behavior. Finally, high emotional arousal impairs performance of behavior because people are more likely to expect failure when emotionally distressed. High anxiety with accompanying physiologic responses (increased heart rate, trembling, and sweating) may cause individuals to misinterpret performance and extinguish further efforts.20, 21 Outcome expectations are the extent to which one believes that engaging in a given behavior will produce a given outcome. The willingness of an individual to engage in a certain behavior is related to the positive benefits expected if that behavior is performed.22

The nursing intervention program consisted of 3 parts: (1) Structural Informational (SI) booklet, (2) Nursing Telephone Support (NTS) protocol, and (3) Nurse Pager. Each part of the nursing intervention program was designed to target 1 or more of the 4 components of self-efficacy enhancement.

The SI booklet, “Sudden Cardiac Arrest: A Survivor's Experience,” contains 2 components: (1) a descriptive component including individual verbatim statements about experiences of others during the first year of recovery and (2) a management component outlining successful strategies (skills) used by other SCA survivors in dealing with issues in recovery. The SI booklet's purpose was to describe the experiences one can expect to encounter during recovery and to offer suggestions for behavioral strategies to deal with these issues.

The NTS protocol was a telephone intervention delivered by an expert cardiovascular nurse during 8 weeks subsequent to ICD implantation. The purposes of the NTS intervention were to: (1) teach specific knowledge and behavioral skills needed to manage recovery, (2) enhance self-confidence (self-efficacy) in one's ability to deal with illness demands, and (3) reduce emotional arousal and anxiety. Telephone calls were designed to last approximately 15 to 20 minutes. Each call was carefully scripted and included check-in, assessment in the area of concern, discussion of strategies for dealing with the concern, provision of positive feedback, anxiety reduction statements, practice of new behaviors, determination of goals for the upcoming week, collaboration on a learning assignment, and summarization. Each telephone call concluded with setting an appointment for the next call and reminding the patient of the availability of the Nurse Pager. A complete set of handouts related to each content area was developed and provided for reference during the telephone calls. The content of the NTS is outlined in Table II.

For example, “Dealing With ICD Shocks” encompassed the concerns of the sensation of receiving an ICD shock, knowing what to do after receiving an ICD shock and how to access the 911 system, handling an ICD shock in a public place, and reviewing electrical safety precautions with the ICD. Information reviewed on this topic included specific concerns about being shocked, experiences of others who have been shocked, and upper and lower heart rate cutoffs of the ICD. Verbally persuasive statements to allay anxiety and stress were included. Specific skills learned during this call included checking one's pulse rate, keeping a diary of ICD shocks (date, time, activity before being shocked, symptoms before being shocked, how they felt after the shock, and loss of consciousness), and implementing the ICD Shock Plan (Table III). Family members were encouraged to go to cardiopulmonary resuscitation (CPR) training. A list of CPR class locations in the area was provided. Assignments for this call consisted of sharing and practicing the ICD Shock Plan with family members, talking to family members about taking a CPR class, and learning to check one's heart rate to safely exercise without receiving an ICD shock.

Individuals were given access to a nurse expert 24 hours per day, 7 days per week with a nationwide paging system for the entire year of study participation. Questions related to medical care were referred to the participant's physician. Each after-hours page was answered by one of the nurses trained in the nursing intervention.

After the intervention program was concluded, we asked participants about the most helpful and useful aspects of the nursing intervention. Most (97%) found the SI booklet to be extremely helpful in mapping expectations of ICD recovery during the year. From the NTS protocol, survivors conveyed that specific information in living with an ICD, psychologic support, and the structure of the intervention were the most valuable. Twenty-three percent of participants used the Nurse pager during the study, with 75% of the nurse pages being related to a specific ICD concern. Although most participants did not use the Nurse pager, it was an important aspect in the initial decision to participate in the study.

Specific lessons learned during our study focus on timing, content, and modality when implementing evidence-based nursing interventions for SCA survivors who receive an ICD.

The timing of nursing interventions after ICD implantation needs to be targeted within the first 3 months and initiated within 2 weeks of hospital discharge. This is a time when patients are struggling with the management of physical symptoms and activity, and anxiety is somewhat lower than during hospitalization. With hospital stays of 24 hours or less for ICD implantation, delivering information and psychologic support is needed after returning home. Patients and partners do not retain or are unable to retrieve much of the information provided in the hospital before and immediately after ICD implantation. During the first 3 months, individuals are the most distressed by the experience and most often need additional support. Early intervention during a critical time period of recovery can assist individuals with effecting a positive recovery that is sustained during a 1-year period. Follow-up information and support would be helpful later on during the first year or after the person receives an ICD shock.

The content of the SI booklet and the NTS protocol has been validated with previous research and was directly applicable to the experiences of participants. Study participants rated learning new information about the ICD, learning what to expect as a normal part of recovery, and having an opportunity to ask questions and have them immediately answered as the most important aspects of the intervention. Supplementing the telephone intervention with written material that was sent before the initiation of the NTS protocol gave individuals an opportunity to review the material before the calls and use the material as a resource between calls and after the intervention was completed. Essential content that should be delivered during a post-hospitalization protocol should include elements outlined in Table II. As ICD implantation procedures change, content relevant to patient safety and management should be updated.

Partners are key players in the patient's recovery process. They often have higher anxiety than the patients25 and need information and support. Partners were included in the intervention if they were available. Future research should focus on the development of specific interventions targeted to partners of SCA survivors who receive an ICD.

A telephone intervention is an effective modality for delivering a nursing intervention for those with driving restrictions and those living in rural areas who cannot travel long distances. The telephone also provided participants with a valuable sense of connection with the expert nurse and assisted participants in feeling supported and cared for when receiving the NTS calls. This type of information and support from an expert nurse were significantly different from the information and support they could receive from family and friends. Our dropout rate was 6% during the first 3 months and 8.6% at 12 months, which supports the premise that an effective and therapeutic connection can be made by telephone with individuals who are seriously ill.

Delivering a nursing intervention to individuals who are not able to drive, who often live long distances from tertiary medical centers, and who are seriously ill is a challenge. Participants related that an accompanying videotape with the written materials may have enhanced their understanding of the material. More than 75% of individuals in our study had a VCR readily available in their home. Only 51% of the participants in our study had Internet access easily available to them at home. Although the Internet is not readily available to everyone, it holds promise for expanding the delivery of nursing interventions in the future.

Future research needs to focus on testing this nursing intervention program in other populations of ICD recipients, perhaps in some who are now receiving an ICD for prevention of SCA. Wider testing of the intervention in populations with greater ethnic and income backgrounds is needed. We often noted greater receptivity to the intervention for those with out-of-hospital ventricular fibrillation cardiac arrest with loss of consciousness or those with very limited social support. Our interventions were designed primarily for those who receive an ICD for the first time; however, some elements of the intervention program may be helpful to those who need a review when they receive an ICD replacement.

Further studies are needed to examine the cost-benefit ratio of providing this type of intervention on a wider scale. We are interested in reducing the number of nursing intervention phone calls while still providing key information to reduce the costs of the intervention. Individuals participating in the nursing intervention reported slightly more clinic visits than those not participating in the intervention. This was often the result of the identification of high-risk symptoms during the NTS calls by the nurse, who then counseled patients to contact their health care provider. This suggests that additional follow-up care is needed after ICD implantation during the first 3 months. Some individuals who were taking several cardiovascular medications and had low ejection fractions could have benefited from closer post-ICD implantation follow-up care.

Other research opportunities exist in determining the best training methods for experienced cardiovascular nurses to learn skills in delivering the nursing intervention program. Nurse training is required before using the NTS protocol before it is adopted into standard clinical nursing practice. We believe a protocol-driven nursing intervention will assist in the development of evidence-based nursing practice in the future.

Section snippets

Conclusion

Hospital-based education programs help begin the process of recovery after ICD implantation, but this must be supplemented by further interventions to improve psychologic adjustment and enhance return to normal physical functioning after ICD implantation. With the possibility of many more people receiving ICDs in the future, further development and testing of interventions to reduce physical symptoms and improve adjustment are warranted.

References (25)

  • C Higgins

    The AICDa teaching plan for patients and families

    Crit Care Nurse

    (1990)
  • E White

    Patients with implantable cardioverter defibrillatorstransition to home

    J Cardiovasc Nurse

    (2000)
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