Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery Episode 1

This is episode 1 of the series:  Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery

Episode 1: A cardiac rehab nurse discusses her experiences and the challenges in the field. She highlights the crucial role of nurses in patient recovery after cardiac events, the structure of rehab programs, and the importance of nursing expertise in managing medications and comorbidities. The episode also addresses barriers such as limited resources and low reimbursement rates. Despite these obstacles, she finds the work rewarding, especially in seeing patients regain confidence and improve. 

 Episode 2: This discussion covers practical strategies for cardiac rehabilitation, emphasizing both physical recovery, like exercise guidelines, and psychosocial aspects, including managing anxiety, depression, and nutrition. The importance of collaboration with other healthcare professionals and the use of community resources, such as home-based and virtual rehab, is highlighted. The conversation concludes with advice for nurses interested in specializing in cardiac rehab. 

---
Nurses may be able to complete an accredited CE activity featuring content from this podcast and earn CE hours provided from Elite Learning by Colibri Healthcare. For more information, click here

Already an Elite Member? Login here

Learn more about CE Podcasts from Elite Learning by Colibri Healthcare

View Episode Transcript

View this podcast course on Elite Learning

Series:  Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery

Transcript

Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery

Guest: Erin Hill, BSN, RN, CCRP

Erin Hill has practiced as a registered nurse for over 13 years and has been a certified cardiac rehab nurse for over 8 years. She is also a certified personal trainer through the American College of Sports Medicine and enjoys exercise and a healthy lifestyle. She is passionate about cardiology and heart disease prevention. 

Host: Candace Pierce DNP, MSN, RN, CNE 

Dr. Pierce is a nurse leader committed to ensuring nurses are well prepared and offered abundant opportunities and resources to enhance their skills acquisition and confidence at the bedside. With 15 years in nursing, she has worked at the bedside, in management, and in nursing education. She has demonstrated expertise and scholarship in innovation and design thinking in healthcare and education, and collaborative efforts within and outside of healthcare. Scholarship endeavors include funded grants, publications, and presentations. As a leader, Dr. Pierce strives to empower others to create and deploy ideas and embrace their professional roles as leaders, change agents, and problem solvers. In her position as the Sr. Course Development Manager for Elite, she works as a project engineer with subject matter experts to develop evidence-based best practices in continuing education for nurses and other healthcare professionals. 

Episode 1: Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery

Transcript

Candace Pierce: Welcome to our podcast series on cardiac rehabilitation, where we are going to take a closer look at the nurse's integral role in heart recovery. I'm Dr. Candace Pierce with Elite Learning by Colibri Healthcare, and you are listening to our Elite Learning podcast, where we share the most up-to-date education for healthcare professionals. Now, according to the American Heart Association, nearly 800,000 Americans suffer a heart attack each year. And what we do know is that we as nurses play a crucial role in helping these patients get back on their feet. So, in this episode, we're going to focus on the heart of recovery really looking at a nurse's experience and their challenges in this area. And we'll look at what we can do to support patients recovering from cardiac events. So, one of the other things I hope we will be able to highlight is how rewarding this area is and how critical this work is. So, joining me for this insightful and inspiring discussion is Erin Hill. Erin, thank you for taking time to join me for this series.

Erin Hill: Yes, thanks, Candice. I'm so excited for this opportunity.

PIERCE: Absolutely, I really kind of want you to start with your background. How did you get started in cardiac rehabilitation?

HILL: Yes, sure. So honestly, my passion for cardiac, everything related in cardiology started back in high school. I did a lot of reports on heart disease and did a lot of different things with my anatomy classes. Got into nursing actually through studying exercise science. I started with that in college, switched to nursing, and still had this passion for cardiac related things. Ended up working right out of school on medical surgical unit, got into case management after that. And then I was so fortunate and blessed to get hired on as a cardiac rehab nurse, was a part -time position. Honestly, I was just very fortunate to have that. Since then, I've worked in three different rehabs. So, I've worked in a program in Ohio. I've worked in two here where I'm living in Atlanta, and honestly, I'm just, I'm so thankful for this job, for the ability to work in cardiac rehab and the patient population is just amazing to work.

PIERCE: Can you share a little bit about your experience working with the patients who are recovering from these different cardiac events?

HILL: Yes, absolutely. So those who have had some sort of heart event are eligible to participate in cardiac rehab. So, any post MI patients, post PCI, post-CABG, if they've had a valve repair, replacement, heart failure patients, we get a lot of those, unfortunately. And then also too, if they've had a heart transplant, they are eligible to participate in cardiac rehab. Cardiac rehab takes place. It's usually about a three day a week program. So, it's outpatient, we're ambulatory. They're coming to us three days a week, Monday, Wednesday, Friday. And we have several sessions throughout the day where they're coming in. The sessions are about an hour long. And during that hour timeframe, we have them on telemetry, we're checking their blood pressure, if they're diabetic, we're checking their blood sugars. And then they're doing about 30 to 40 minutes aerobic type exercise, so treadmills and bikes and ellipticals and those types of equipment. And then also too, with the facility that I currently work in, we have a lot of resistance training equipment too, that we can utilize with them. So that's kind of the gist of what cardiac rehab is. And we also too, we have a medical director that oversees the programs. We're working closely with him too.

PIERCE: What do you think sets the cardiac rehab apart as far as nursing?

HILL: Nurses feel like we work in a multidisciplinary team. So, my coworkers are exercise specialists, dieticians, and respiratory therapists. As far as nursing goes, we definitely have more expertise with like the medical side of things, the medications, all their different comorbidities, and managing those things, giving them education on all of those things too. And also, I feel like we're better equipped to communicate with their physicians or their medical providers whenever there's an untoward event or whenever, you know, just any communication updates. And then I believe too, I mean, there's a lot as far as policies, procedures, keeping those things updated. And that's where a lot of the nursing expertise and experience comes in to, I guess, participate in that as well. So that's kind of where the nurse comes in. And there's definitely more like a case management to aspect of it. So, it's not just you're seeing these patients three days a week, but we're connecting with them at home to making sure that they're continuing their exercise or communicating, A lot of our patients to go to dialysis. So, communicating with them and those doctors. There's a lot. We wear a lot of hats in cardiac rehab for sure.

PIERCE: Yes, that's what I was thinking. And while you were kind of describing all of that, what I saw or what I was thinking about was you're really describing this like a relationship. You're building this relationship with your patients. You're really getting to know them more than you would say, in a med surg unit or in those types of roles. So, what do you see are some of the biggest challenges that you have in this role?

HILL: Unfortunately, there's quite a few. A lot of cardiac rehab programs are very small as far as physical space goes. Just, you know, we're not big money makers. We're not the Cath lab or the OR. So unfortunately, a lot of hospital administrators don't value what we do. So, the space is small and that means not as many staff and that unfortunately affects the patient where it takes longer for them to enroll in cardiac rehab after their heart event. We try to get them in within two weeks after their discharge, but sometimes it can take up to two months, unfortunately, just cause the demand for cardiac rehab is so high and there's not many programs. There's not enough space for them. And too, I think most medical professionals have difficulty with time for educating the patients too. That's definitely a challenge as far as educating the patient on their diagnosis. A lot of them don't have any idea. They understand they had a heart attack in the hospital. They don't know quite exactly what that means or all these lifestyle changes that need to take place afterwards. They think it was just a one-time thing and they'll do the rehab and be done with it, but it's something they don't fully understand, it's something they'll have to make these changes every day for the rest of their lives. And also too, another challenge is financial Medicare and all these other insurance companies, they cover cardiac rehab, but unfortunately, they also charge a copay just like you're going to the doctor's office. So that can definitely be a barrier because it's a copay every session that the patient attends. And then to transportation, a lot of the patients rely on so that can be a barrier. Chronic pain, we see that a lot too with patients. And unfortunately, a lot of people will discharge themselves from the program just because they aren't able to exercise with all their pain and not getting quite enough support from the doctors as well. Some doctors are really pro-cardiac rehab. Some of them don't refer their patients to us. So that can be discouraging as well. And then two, the last challenge is a lot of our patients, and I'll touch on this later too. A lot of them struggle with psychosocial needs. Patients are more likely to have anxiety and depression after a heart event. And that can go unaddressed by the doctors. The patients don't really understand what's going on. They know that they feel more anxious or sadder and it's affecting their day-to-day life, but they understand it was probably a result of their heart event. So, they're not getting enough support with that and their attendance with cardiac rehab will suffer.

PIERCE: So, there's a high need but low reimbursement.  I'm assuming maybe in your area there's not a lot of options for patients to go for cardiac rehab.

HILL: Yes, that's correct. Honestly, every single hospital system should have a cardiac rehab, but not all of them do. Cardiac rehab has to be a hospital-based program due to reimbursement. But it's, and especially too, if someone lives in a more rural area than in the city, they're going to live further away from a hospital and they're going to be less likely to participate as a result.

PIERCE: I just wonder why there is such a low reimbursement rate and why it's not utilized as much as it should be, because I know the research is there that shows the need for this type of program and then for physicians not to refer the patients to cardiac rehab that I just have a hard time wrapping my head around that when the research really does show how important it is. What do you think that barrier is as to why some physicians don't necessarily pursue cardiac rehab for their patients?

HILL: Yes, I don't know. It could possibly be because they don't fully understand what we do. And also, they just don't see the value of it. And a lot of times too, they'll have patients who are, we see patients who are younger, 30s, 40s, 50s with heart events. And maybe they were physically active before their event too. So, they will just be like, yes, I've been exercising since my event. I feel fine, all these things. So, the doctor will be like, okay, just keep doing what you're doing. And they won't, we won't get a referral from that. So, it really is dependent. We do have good support from a lot of the doctors, but there are, yes, some it doesn't make sense. Or the patient after maybe they've attended three or four sessions and then they're like, okay, cardiac rehab is, I don't feel like I'm benefiting from it, especially because I'm already doing things at home and they'll tell their doctors and the doctors will be like, yes, that's fine. Just, you don't have to attend if you don't want to. So that's kind of, yes, it's unfortunate really.

PIERCE: How do you manage the emotional toll of working with some of these patients? Because I mean, they're really ill.

HILL: I know, yes, that is, and that can be challenging too. It's hard, because when they first come to us, we do like an initial assessment, like an initial orientation-type day with them where we talk about every aspect of their health. And of course we address psychosocial. We use a screening tool called the PHQ -9 Patient Health Questionnaire. It's got nine questions on it. That's what we use to screen for depression. There are several other tools out there. But we address that with them, and we talk through their history as far as anxiety and depression goes. We talk about their current stress levels. How has work been, how do they sleep at night? We're addressing all those things. And it can definitely be challenging too. Because sometimes you get people who they've really opened up to you, especially on that first day, you build that trust with them and, that it can be challenging because you're like, for the nurse, it's like, I can put myself in their shoes, try my best to do that and really try to value them, listen to them. But it's really just, I guess, giving them that encouragement that first day that things will get better. And what's nice to see is when we do that initial screening for depression. We reassess them usually about after the first 30 days in the rehab program. We will almost always, I would say 90 % of the patients, 95% will see an improvement in that depression screening. And then definitely by the end, by the time they've done 24 or 36 sessions with us, we almost always will see an improvement in that score. And that's just so amazing to see. And we go over that with them and we're like, look at how much you've improved in this area. And we ask them, how are you feeling? How has this affected your day-to-day activities? How has it affected your sleep? So, I think it's just, that's a very rewarding piece of the cardiac rehab work that I do as well, seeing that with patients improve. But honestly too, handling those patients and working with them, it's taking care of yourself too, as the nurse, making sure you're prioritizing your own health and sleep and nutrition, exercise those things.

PIERCE: How often do you get patients that come in or who you can tell they just don't believe this is going to work for them?

HILL: We actually, I would say not quite half, but maybe 30%, 40% of patients, they're very skeptical. They'll come in and like I mentioned earlier, it's mostly the patients who are already making lifestyle changes. They've changed a lot of their eating habits after their hospital, after their cardiac event, and they've improved their stress, they're starting to exercise again, or maybe they were already exercising too before their event. So, they're just like, I'm not sure how cardiac rehab is going to really change things or really help me too. And honestly, that can be challenging because it's like, yes, that may be true. And I may not be able to convince them of the benefits, but I can definitely still educate them on the research and all the benefits and, let them make that decision on their own too and give them the tools they need maybe to just continue at home, at least giving them some guidance as far as exercise and intensity and things so that they continue at home.

PIERCE: Is there a role for family members in cardiac rehab?

HILL: Absolutely, yes. A lot of times the patients will bring their family members at least to that initial assessment that we do with them. And I think too, just a lot of the patients will struggle with making all these changes as well with their exercise and their eating. So, educating them is helpful when the family is there too, going over all that information with them, because then the family members can see, maybe I can make some changes with myself too, to support my loved one who had this event. So also, to the family members on occasion, we'll attend the session with the patient. They can't do any exercise with the patient, but they can at least be present in the room and see what their loved one is doing and how they're feeling how much improvement they're making too. So that can help with the family members as well too, I guess, spur them on to supporting the patient and change.

PIERCE: So, I don't have experience in cardiac rehab, but I started my nursing journey on a cardiac floor, sending them to have open heart surgery and then taking care of them when they were done. I have experience of working with them prior to them coming to see you. But as I'm listening to you, kind of what I, and this I want you to correct me if I'm wrong, but part of what I'm understanding is, it's really bringing them in to continue that education that was started in the hospital, but to also work towards helping them create healthy routines to continue to improve their health and maintain their health.

HILL: Yes, absolutely. And honestly, I think the best things that on the inpatient side that the nurse can do would be to discuss, exercise, exercise, even walking at home is perfectly safe after a heart event. So, giving the patient that sort of education. And there are so many different medications and things that these patients are started on that they're not used to, that they have no idea how to take and I see that a lot, unfortunately, when the patients come to us, they're on two or three different new blood pressure medications. They're on a statin, they're on blood thinners. So, educating them on the importance of those medications, taking them, that's honestly the best way that they can be supported from the inpatient side. I was just going to say, I think I just giving them that education about home walking on discharge, giving them education about quitting smoking and that sort of support as well. Because we see, we see that a lot too. That's yes, the best way to support.

PIERCE: So, it sounds like they're with you for a while. So, when do you really start to see that the education and the routine is really starting to take hold for that patient?

HILL: That's a great question. I would say honestly after the first at least 12 sessions, you can just see the patient feels so much better, so much more confident with their exercise too. And they know what a normal blood pressure range is now. If they're diabetic, they know what a normal blood sugar range is. But yes, we do have them up to 36 sessions. That's what Medicare will pay for. So, it's so cool to develop that relationship with them and see them over time, rebuilding their confidence with their exercise and giving them that education too. It's just, it's so rewarding, but yes, I would say overall that first at least 12 sessions you can tell that just the emotional and the, yes, even their physical abilities to being able to see them progress in their exercise. And they're just, it's just amazing to see. And usually too, we are in group sessions. So, there's five, six, seven other patients in the session with them too. And a lot of them too will build relationships with other patients. It's really neat to see that as well.

PIERCE: Throughout this, I've heard you say often, it's so rewarding. So, if you had a nurse that was listening to this and thinking, I've really been thinking about pursuing cardiac rehab. What is this? So, what would you list, like, the most rewarding aspects of being a nurse in cardiac rehab? What would that list look like for you?

HILL: Yes, well, like I mentioned, definitely seeing that long -term relationship with them and it's not even just focusing on their health too but getting to know them as an individual and as a person and valuing them, asking them, I like to ask people, did you do anything fun over the weekend or how's your family doing? Did you grow up around this area? Those sorts of questions to help build relationships. But and like I mentioned to just seeing rebuild their confidence after their event and being able to, to just sit one-on-one, and with the inpatient side, it's hard to, I guess, have that time to sit one-on-one with a patient and really talk with them. So that's another thing that's so rewarding with them too, and actually having that ability to give them education. With my role as well, we have a couple different governing bodies. So, the American College of Sports Medicine gives us lot of our regulations and things. And we also have the American Association of Cardiovascular and Pulmonary Rehabilitation. So those two organizations hold state conferences, national conferences as well. So that can be rewarding too, to be able to attend those and to collaborate with other professionals in the field who live all across the country. That's really neat as well and I get different ideas on how they operate their rehab programs. And also, to the American Association for Cardiovascular and Pulmonary Rehabilitation, they do a program certification, which is very rigorous. There's a lot of statistics on patient performance measures that need to be gathered and making sure policies and procedures are up to date, doing emergency and services and continuing education. So, working on that as well and accomplishing that is so rewarding, so fulfilling to say that my rehab program is a certified program. And then too, we get to work with cardiologists in all different specialties, heart failure cardiologists, structural, interventional, and transplant. So that's really neat to be able to work with that multidisciplinary team as well and just continuing to learn for myself as a nurse is very rewarding.

PIERCE: So, can you share like maybe a memorable success story? 

HILL: Absolutely. Yes. and it's actually neat. This particular patient had a heart transplant, and he was just so inspiring. I had the privilege of doing his initial assessment, and he would just tell me all the time how just so thankful he was to have a heart transplant. Those people are very sick, obviously with heart failure before that takes place, and I remember after post-op after his transplant, he was telling me he'd get up and walk the hallways around the nurse's station. He would even go into other patients' rooms and try to get them up and walking and get them out of bed. It was just so neat. And he stayed with us the full 36 sessions and just being able to see him progress in his exercise. And our communications department actually did a story on him too on his progress and his surgery and post-op everything. Honestly, I'm just so proud of that, even to be able to talk about that.

PIERCE: He sounds like maybe he's a volunteer now at your cardiac rehab. Like he's still coming around and trying to help others.

HILL: Yes, exactly. He is. Because where I work, my facility, we are connected to it. We call it the Wellness Center, but it's a gym where patients can come to as well. And anybody honestly from the community can participate. So, he will come in, and say hi to us every time. It's just, it's so neat even to see him now. I mean, it's been over a year since he was with us. So, it's so cool to see him.

PIERCE: Well now I want to know if you have another success story. That's a fun story.

HILL: I know, I know. It's yes, honestly, it's because we're a part of the wellness center, our rehabs right next door. I see patients all the time after they're done in our program. And it's just so cool to see them still active and still being a part of their exercise program. It's so neat to see.

PIERCE: It sounds like a lot of them when they're done with their time with you, they still come to the gym. So, you still get to kind of maintain that relationship with them. So, get to check on them, answer any questions that they have.

HILL: Yes, absolutely. Because sometimes they do. And even after their discharge, I give them our business card, put my email on it and tell them, feel free to reach out anytime with questions, email me, call me. So it is, yes, we're still definitely very much involved with them after their discharge from us. 

PIERCE: That's really good to see the familiar faces. You've created that trust with them. They know where they can go if they have questions. So, I love how even though they transition out, they still have access to somebody and you're probably easier to get to than their nurse at their physician's office, honestly.

HILL: Yes, yes. It’s so true. Some people have difficulty reaching their doctor's office, and they'll come to us and ask whatever questions. 

PIERCE: That's really good. Well, we are out of time for this first episode. Erin, thank you so much for taking time to really just share your insight into cardiac rehab and what it really looks like. And just it's amazing to hear firsthand accounts and challenges that you have with patients and how you can work through those and just how rewarding this area is, because it's not a highly talked about area of nursing. Is it hard to find an opening in cardiac rehab?

HILL: Sometimes, sometimes they can be. There's a lot of programs that are always looking for nurses. it just depends. Definitely full -time positions are difficult, but PRN, part-time, yes. For sure. 

PIERCE: Absolutely. To our listeners, I hope you found these stories and insights as inspiring as I did. Erin, you're amazing. I love hearing your passion for your patients. So yes, our next episode, we're going to focus on effective patient care strategies and best practices.

HILL: Thank you, Candace.

Episode 2: Cardiac Rehabilitation: The Nurses' Integral Role in Heart Recovery

Transcript

PIERCE: Welcome back to Cardiac Rehabilitation, the nurse's integral role in heart recovery. I'm your host, Dr. Candace Pierce, and I'm excited to continue this discussion with Erin Hill. Thank you for continuing this discussion with me, Erin.

HILL: Yes, thanks Candace. I'm so happy for this opportunity.

PIERCE: Absolutely, I can hear your passion for like just sharing this area that you just love and the patients that you work with. So, I can just see it in you. If you joined us for our last episode, you heard some incredible stories and insights about the challenges and rewards of working with cardiac patients. So, for this episode, we're going to shift our gears a little bit and we're going to focus on some practical strategies and best practices in patient care. So, our goal is that when you walk away from this podcast, you're going to have some valuable tips on how to support your patients physically and emotionally. And we'll also talk about how to effectively communicate and collaborate with other healthcare professionals and overcoming some common barriers and rehabilitation. You ready to dive in, Erin?

HILL: Yes, I'm super excited.

PIERCE: Awesome. Okay, so in your experience, what are the most important aspects of physical recovery for patients after a heart related event?

HILL: Well, definitely with cardiac rehab, obviously we're focusing mostly on the physical aspects. So, the exercise, the current guidelines that the American College of Sports Medicine recommends are at least five days a week, 30 minutes of exercise. So, patients, most of the time they're coming to us three days a week, 30 minutes exercise during our hour-long sessions. So, we encourage them on the days that they're not attending, maybe on a Tuesday, a Thursday, or over the weekend, get out and walk, 15, 20 minutes, start off with that. But eventually we would like to see them work up to that full 30 minutes. A lot of them too are interested even before they're done with us, they're interested in joining like a gym or doing something else outside of their home. So, we give them a lot of those resources as well too. So, in addition to the physical side though, their psychosocial, their anxiety, their depression, helping them recover from that. And also too, we focus on their nutrition and especially if they have diabetes too, how to manage their blood sugars and just right food choices. Some programs are very blessed to have a dietician on staff. We do not, but we do have inpatient dieticians who come to our department once a month and they teach like a nutrition classes for our patients. And it's free, we don't bill for that at all. But also too, if the patient does have diabetes, their insurance would cover for them to do like a one on one with a dietician as well. So, we can refer them to that. But those are the main ways that we help support them when they're recovery for sure.

PIERCE: So, in episode one and just now you've really mentioned the anxiety and the depression that these patients usually come to you with after a cardiac event. So how do you effectively address the emotional and mental well -being of these patients?

HILL: Yes, absolutely. I know, and I mentioned before in the first episode as well, just how prevalent it is after a heart event. The patient may have never struggled before with anxiety or depression and all of a sudden, they're having these, experiencing these new emotions. So, we use that screening tool, the patient health questionnaire. It's a nine-question screening that we use. And if they score moderate, moderate severe, severe depression, we refer to their, usually their primary care doctor and just let them know. and we go over with the patient too, their score and what they're doing at home to manage those emotions. We discuss relaxation techniques. So, things like deep breathing and meditation. A lot of people have those sorts of practices already in place. Some of them don't, but even two things like yoga or listening to music, walking their dog during the day, that can definitely help as well. And also too, we can discuss with them, you know, attending talk therapy, like with a psychologist or, you know, a mental health professional as well. We can also refer to our pastoral services in our hospital and the patient. They usually have other resources too that they can give to the patient. And then also too, I frequently see when patients come to us, some of them may have prescribed an SSRI and another depression medication, but they are scared to take it. So, giving them that education on that particular medication as well. 

PIERCE: What is usually their reason for being scared to take it? 

HILL: I think they're worried that there may be some addictive properties or a lot of them just don't like how they feel when they take those medications. They usually have a lot of side effects too. So, I'm discussing that with them and discussing there's different dosages that the doctor can use. So, we definitely encourage them to discuss with their doctor if they're experiencing any side effects while taking these medications. That's usually the concerns with those.

PIERCE: Yes, I totally understand those. So, what are some strategies that you use to ensure patients are really understanding, especially the new medications that they come to you with and all of these lifestyle changes? There's a lot of lifestyle changes that really need to happen with cardiac events typically tip for a typical patient.

HILL: Yes, absolutely. So, when they come to us for their initial assessment, we always go through their medication list with them. My particular facility uses Epic. So, we do medication reconciliation in Epic too. And it's nice because with the system, we can print off like written materials and handouts and things for their medication education. And also too, the good old teach-back that we do all the time with our patients too and discussing that with them and seeing how well they know their new medications and understand those. But yes, as far as like lifestyle changes and things, education is huge for that.

PIERCE: How long does it usually take for them to really start to put those lifestyle changes into play?

HILL: I think usually by the time they're done with us, we have them, two to three months, 36 sessions. I think by that time they're really feeling a lot better about the changes that they're making and more confident.

PIERCE: Yes, because I mean for some patients that's a complete overhaul of everything they've eaten, the way that they have lived. So, I mean, they're going to come completely.

HILL: Yes. It can be very overwhelming for them, but just the fact that they're coming to us consistently and we're doing education with them every session. It's not just like a one-time thing and we're done with it, but constantly educating them on watching their weight at home. And especially if they have heart failure monitoring that and, yes, their nutrition, their salt intake and teaching them how to check their blood pressure at home too, especially if they're taking blood pressure medication and monitoring all those numbers or blood sugars, all those things too, just constantly educating.

PIERCE: That's it. You said it can be overwhelming. So how do you help them overcome the sense of just being overwhelmed with everything?

HILL: Yes, a lot of that honestly is education and just trying to I guess get a better understanding of their knowledge of their condition too and assessing that and whatever barriers or whatever lack of knowledge that they may have addressing those things as well. And then too, with their attendance, there's so many barriers that can come up like I mentioned in the first episode transportation needs financial and then to it, what if they're very depressed, that can be a barrier as well if they're still smoking, that can be a barrier, so addressing those types of things with them too. When we're doing these assessments and all these things on their needs, come up with a plan for their risk factor modification. So, if they have high blood pressure, most of them do we're talking about, you are checking it at home every day, coming up with a goal for the patient. And it doesn't have to be anything drastic, even let's say they weren't checking their blood pressure at all, even just that goal of I'm going to check it at least once a day in the morning before I take my medication, something like that. So, coming up with a goal for each risk factor. So, they're smoking, and their nutrition, and their diabetes and those sorts of things too. And we use a lot of those motivational interviewing techniques too in our rehab program and I can discuss that as well. 

PIERCE: Yes, absolutely. And I know you're talking about goals. So, when I teach my patients, it's usually we're going to start with some smaller goals and then we're going to use these smaller goals as jumping off points for the goals that are going to completely change your life. Pretty much is what would happen in cardiac rehab. But to kind of limit that feeling of overwhelm of being overwhelmed and to limit the feeling that you're going to fail.

HILL: Yes, it's yes just giving them that support and that confidence and like I said, every day discussing that with them and assessing, how are you feeling today and making that observation with them? And maybe they'll be like, yes, I'm not feeling great today and reflecting that back to them, “It seems like you're feeling down today,” and just normalizing their behavior to a lot of them feel like they're alone on this island but just reassuring them, maybe I, as a nurse could say, I've heard a lot of my patients say that they're struggling with depression symptoms or they're struggling with all these lifestyle changes after their hospital admission and validating how they're feeling that and asking them, how they're managing those things. 

PIERCE: So, looking at collaboration because I know in episode one, you really kind of listed off a lot of those healthcare professionals that you would get to work with. What does it look like to collaborate with the physical therapist? Do you have social workers too? Because I know you mentioned case management.

HILL: Yes, most rehab programs don't have social workers on staff, but we can definitely refer, either through their primary care doctor's office or even reaching out to the inpatient case management department as well. But nurses, most cardiac rehab programs have a nurse on staff. Most of them also have exercise specialists on staff who focus mostly just on the exercise aspects of the patients and the disease process and those sorts of things. We also have respiratory therapists who are available too, because unfortunately a lot of our heart disease patients also have COPD and other pulmonary comorbidities as well. So, collaborating with them and teaching the patients how to use their inhalers and things like that. With physical therapy, they are definitely very helpful if the patient is still very deconditioned after their hospital admission. Sometimes they may not be ready to participate in cardiac rehab quite yet. So, we can refer them to physical therapy, like an outpatient physical therapy. And also too, a lot of our post-op patients, there's all those sternal precautions and things after their CABG or after their valve that we have to abide by. So, collaborating with PT with those sorts of things too, and just staying up to date with those, that can really help a lot. But yes, sometimes too, we also can utilize the outpatient pharmacy, as well with like medication education too, which is nice. Sometimes they'll teach education classes with the patients too. And like I mentioned with the dieticians, we can collaborate with them. Sometimes they'll do like cooking classes as well, the patients can attend. 

PIERCE: That sounds fun. I want to come to some of those. 

HILL: They are such a good time. The patients love them. 

PIERCE: What are some other valuable community resources that are around to support patients during this recovery journey?

HILL: Yes, absolutely. So, we can refer them to, like I mentioned earlier, some local gyms. A lot of patients will be interested in that, even exercising outside of the rehab. We encourage that for sure. But also too, if they're elderly, which most of our patients are, they're in the 60 to 80 age range. A lot of like the different area agencies on aging can also offer support, maybe if the patient still needs assistance at home, like with a home health aide or transportation, like I mentioned, is a big barrier. So those types of agencies can really help. And obviously the independent transportation companies using them. And then too with other community, like support groups, Mended Hearts is, I believe, it's through the American Heart Association. There's a lot of different local chapters and it's all support for patients that have experienced a heart event or who have heart disease, and I know with my local chapter, the meetings are held through Zoom. So, it's not even like the patient has to be able to organize transportation. And so, the patient can attend through Zoom. Their family members can attend as well. And then also too, I mean, the American Heart Association, they're a great organization as far as support and even just online with their recipes and their exercise guidance and those sorts of things too. We can refer patients to all those.

PIERCE: That's a lot of resources that are around that to look into. So, I want to go back to where you were talking about motivational techniques, motivational interviewing techniques. Can you break down some of those to how you use them to encourage your patients?

HILL: Yes, absolutely. So, our big priority with cardiac rehab is behavior change and that's long -term behavior change, not just while they're in our rehab program. So, like I mentioned, assessing their current knowledge, and figuring out which of their health, you know, needs are their biggest priority and discussing them with them what the modifiable risk factors are for maybe their high cholesterol or their high blood pressure, discussing those things with them. Trying to gain an understanding, what does the patient know about the connection between their behavior and the risk factor? And then assessing what does a patient value about that particular behavior? We get a lot of patients maybe with their religious or their cultural beliefs, it can affect their eating habits and different things like that. So, trying to really understand that and gain that knowledge about the patient. And then obviously asking the patient, do you feel like you're ready to make this change? I like to ask on a scale of one to 10, are how ready are you to make this change? And what would it take? Like if the patient answered, maybe they'll say a six out of 10 for, let's give an example of quitting smoking. How can I make six move to like a seven or eight, what would it take for that to take place? Do they feel confident to make that change on a scale of one to 10? And maybe they'll say that it's a four for quitting smoking. How can I make that patient move that four to a five or a six? And then asking them what their biggest barriers are to this particular behavior change. So, with the quitting smoking, maybe they're having a stressful time at work, or they're going through a lot of life changes with their family as well. So going through those barriers and then coming up with cardiac rehab, we're big into, I don't know if you've heard of the acronym smart for smart goals. So specific and measurable, achievable, realistic, and then time oriented. So even with that, just, we come up with like a big overall smart goal for our program but we're also looking for each individual risk factor to setting a small achievable goal that they can accomplish even before their next session with us too. So maybe if they're having a lot of anxiety, depression, you know, just encouraging them, maybe before your next session, just say hi to three people, three strangers, three people that you don't know, or reach out to an old friend and see how that affects your depression and the way that you're feeling. So, goal setting is just so imperative in our field. And honestly, in nursing as a whole, really is huge. So, the last thing I'll mention is how are they going to measure their behavior change? So, with their quitting smoking, we actually have a screening tool that we use for that. And I'm just using smoking as an example because it's easy. One of the questions on that screening tool is how long does it take you when you wake up first thing in the morning to the time where you smoke your first cigarette? And for most patients who are very addicted, it's within the first hour. So, discussing with them, maybe if you can wait maybe to midday before you smoke your first cigarette of the day, that's something that they can measure over the long term too. And that will help them to be more successful with that. And then obviously, people are simple. We love rewards. So, rewarding, coming up with different, and these don't have to be big, even just, I'm going to go out and buy myself a new pair of like running shoes or something along those lines, rewarding your progress when you accomplish those things.

PIERCE: Yes, because I know like a lot of times when people are on diets, they look forward to their cheat day. Like that is their reward. If I can make it 10 days eating healthy, then I can eat a piece of pizza on day 11.

HILL: Yes, absolutely. So yes, it keeps them motivated to just having those small rewards in the back of their head.

PIERCE: Absolutely. So, when you're talking about some of these barriers that you see, what are some strategies for helping them overcome barriers that kind of keep them from adhering to their medication regimens and their lifestyle modifications? I know we were talking about motivational interviewing, and you mentioned, like rewards, but as far as the nurse in cardiac rehab, what are some of those strategies that you use?

HILL: Yes, like I mentioned before, just assessing initially their current knowledge, their needs, even their home environment too, and how that's going to affect their ability to make all of these lifestyle and behavior changes and their family support too. Is their family, are they on board with all these things.

PIERCE:  I was just thinking family, because I feel like family sometimes makes it harder for people who have to make these huge lifestyle and behavioral changes. So that seems like a really big win. So especially with family support or lack of family support, how do you overcome that type of barrier?

HILL: Yes, just trying to get the family involved as much as possible and encouraging the patient to bring their family. It’s so nice when the patient does bring their family to the sessions, because when we're doing education with them, they're able to also receive that education. They're able to see what the patient is doing while they're with us as well. But yes, the other barriers are just encouraging that objective measurement of monitoring their progress towards their goals, either like with workout logs. A lot of times too, the patient will have a smartwatch, Apple watches are becoming so prevalent nowadays too. And the Fitbits, yes. So, we definitely love to encourage that and self-monitoring of those things. Behavior changes are a collaborative process involving the family and loved ones. 

PIERCE: Have you seen success with patients whose families just refuse to be a part of their journey?

HILL: Yes, on occasion, and that can be definitely challenging. And especially if the patients score higher with the depression screening, there isn't a whole lot, unfortunately, that we can refer to. Usually just their doctors, some people, that's their only support. It's hard to see that.  I shouldn't say a lot, but some patients are very socially isolated, and they may not have any family members nearby. Sometimes they have a close friend who's their contact or their support person. But yes, that is challenging. I wish I had a better answer, honestly, to address those concerns. Doing the best that we can as nurses too to support that patient with their journey and their health recovery and giving them, when they're done with us, giving them the resources to continue.

PIERCE: So, we know depression and anxiety, as we've said, you usually see those with patients who've had cardiac events. And you've already done your screening, and maybe later on when they're working with you, you start to see some of those early signs of depression and anxiety that we would look for from someone recovering from a cardiac event. 

HILL: Yes, definitely. A lot of times I'll hear from people, they're not sleeping good at night. They're sleeping an excessive amount of time, or their sleep is disrupted, and they may have concurrent insomnia, something along those lines. That's definitely a warning sign. But also too, we like to ask the patients, what hobbies or activities you enjoy at home. And a lot of them will give us a list of different things. And we asked them too, like how those things have been affected because of their heart event. And if they're not feeling like doing those things that they used to enjoy, that's definitely a big sign that they may be experiencing some depression too. They may have an inability to focus on just small things like reading a book or watching TV. They may feel really distracted. They may feel like they've let down their friends or their family. So those are kind of the warning signs and especially, it may be that they only experience those feelings once or twice a week, but if they're experiencing those things every day, that's something that needs to definitely be addressed by their primary care provider.

PIERCE: Absolutely. Do you typically refer them? Do you contact their provider?

HILL: Well, either we can contact them directly through our EMR or sometimes if they're not in the same network, we will send them a fax, or we'll call their office directly and just tell them the patient screened high on this and they're experiencing these different symptoms as a result of that. And also too, especially the last question on the screening that we do ask if they've ever had thoughts of self-harm. And if they answer positively to that, I mean, there's definitely more that we delve into with that, and we refer them, and especially if they have a current plan, I mean, obviously that's an emergency situation, but, yes, for sure. And it's very nice. Sometimes they already have like a psychiatrist that they've been referred to. So that's also helpful if that's already happened.

PIERCE: Absolutely. So, what are some of the emerging trends or developments in cardiac rehab and patient support?

HILL: Yes, I'm so excited about this. Currently, the American Association for Cardiovascular and Pulmonary Rehabilitation, they are working on legislative approval for home-based and virtual cardiac rehab. So that was something that was more prevalent during COVID and the shutdown and everything like that. And it was actually being reimbursed during that time. But since the health emergency has ended, that reimbursement is no longer taking place. And a lot of those patients, unfortunately, can't participate anymore. And also too, if patients live in a more rural area, that distance to participate. So, working on approval for that home-based and virtual cardiac rehab, and also too, I mentioned in the first episode, cardiac rehab programs are required to be hospital-based programs if they want to get full reimbursement. So, there's also working on legislation to approve doctor's office or other outpatient building rehabilitation settings and making sure that the reimbursement is equal for that. And also too, there's this mentality that the patients need to constantly be on telemetry and that we always have to monitor the heart rate and rhythm. And I think that's great for the first few sessions, but a lot of rehabs are moving their patients off of continuous telemetry and onto more of just monitoring their heart rate through like a wristwatch or yes, some sort of heart rate monitor. So that's also something that's up and coming as well. We're moving off of that continuous monitoring. And also too, there are actually some rehab programs that are looking at like art therapy and mental performance and those sorts of things too, to also help patients in their recovery and just how that can help with our mental health. So, it's so neat to see that, that holistic approach to rehab.

PIERCE: So, I had a podcast that was done not long ago, and it was about music. It was about using music as therapy. And so, when you were mentioning the art therapy, it had a lot of really good research to show even just how music can be beneficial.

HILL: Yes, absolutely. And even just bring in like some coloring pages into the rehab setting for patients to use maybe right before or after their session too. It's just, that sort of thing. It's just amazing. It may seem insignificant, but it really can make a difference over time for the patients.

PIERCE: Absolutely. So, what advice do you have for nurses who maybe want to specialize in supporting patients who have had heart related events?

HILL: Yes, definitely. If someone really is looking into becoming like a cardiac rehab nurse, definitely some acute care experience is required. Preferably like telemetry experience in the inpatient setting. Like I mentioned, educating those patients on their medications, and even starting a home walking program right after discharge. Nurses who are further interested, case management experience is helpful to nurses who may want to start in cardiac rehab. And then joining, like I mentioned, our governing bodies, American College of Sports Medicine, and the American Association of Cardiovascular Pulmonary Rehabilitation. They hold conferences, they have memberships through their website and hold a lot of continuing education on their own too. So, getting involved with that and just learning more about that field. And even too, I'm sure a lot of the nurse managers and nurse leaders would be very open to having someone interested shadow in the department as well and seeing what cardiac rehab all is about. 

PIERCE: Those are some great ideas for people who are interested in cardiac rehab. So that wraps up our series on cardiac rehabilitation. Over these last two episodes, Erin has really walked us through some experiences and challenges that nurses face in cardiac rehabilitation, sharing some inspiring stories of our patients and really discuss some practical strategies for patient care and support. So, Erin, thank you so much for taking time with us today.

HILL: Yes, thanks, Candace.

PIERCE: We know that heart disease is the leading cause of death for both men and women in the United States, accounting for one in about every four deaths. So, the work that nurses do like Erin in cardiac rehabilitation is critical because it's not just about recovery. It's about giving patients a new lease on their life. To our listeners, thank you for joining Erin and I today. I hope that you're walking away with some valuable insights and practical tools to really enhance your practice to really keep inspiring and keep caring and keep leading the way in heart health. Don't forget to subscribe for more episodes on topics that matter to nurses. And if you have not already, I really encourage you to explore many of the courses that we have available on elitelearning.com that will help you grow in your career and earn CEs.