Wednesday, 19 December 2018

Patients' experiences with patient participation in the clinical pathway of heart attack

Our study by Bårdsgjerde et al. (2018), Patients’ narratives of their patient participation in the myocardial infarction pathway, is the first study to explore patient participation in all phases of the heart attack pathway. Every year cardiovascular disease causes 7.4 million deaths (WHO 2017). Over the last decades, the treatment has been improved, and today the hospital stay is short, approximately 2-4 days. Heart attack is often treated with percutaneous coronary intervention (PCI), and in many countries with sparse population this treatment is centralized to a few hospitals (Chew et al. 2013, Clune et al. 2014, Hagen et al. 2015, Tanguay et al. 2015). In Norway, this centralization results in many patients being transferred over long geographical distances (often more than 300km) to receive PCI treatment. After a heart attack, secondary prevention with lifelong medication and lifestyle changes is crucial to prevent new cardiac events (Piepoli et al. 2016). Short hospital stays and transfers between different hospitals can reduce the opportunity for information and patient participation regarding further medication and lifestyle changes. In our study, we have investigated how ten patients living in areas without local PCI facilities experienced to participate in their own treatment in different phases of the pathway.

We found that patient participation changed during the pathway, from a low level of involvement in the acute phase to shared decision-making in the rehabilitation phase. In the acute phase, a highly qualified medical team that took control over the situation met the patients. The patients were passive participants and received little verbal information at this time, but felt that they were in safe hands. Later in the pathway, some challenges emerged. The patients revealed that they received a varying amount of information about medication, lifestyle changes and further follow-up. The long journey from the PCI hospital back to their home often posed practical challenges for the patients as it often included several bus lines, planes and ferries, and they lacked personal belongings, e.g. clothes, money, credit cards etc. Not until they started at a cardiac rehabilitation program, they took an active role in their own treatment and became motivated to initiate lifestyle changes.

We argue that there is a need for individual plans for information and patient participation to improve patient involvement in an earlier stage of the pathway. While still in hospital, patients need specific guidance regarding secondary prevention, which should be structured and standardized, and implemented in clinical and educational guidelines. The problems related to the discharge process and the homeward journey reveals a need for improvement. Further research from a healthcare professional perspective can be valuable to understand more about this topic and the challenges that might exist in the clinical pathway.



Bårdsgjerde, E.K., Kvangarsnes, M., Landstad, B., Nylenna, M. & Hole, T. (2018) Patient's narratives of their patient participation in the myocardial infarction pathway. Journal of Advanced nursing Article accepted on 12th November, 2018. Doi: 10.111/jan.13931

Chew, D.P., French, J., Briffa, T.G., Hammett, C.J., Ellis, C.J., Ranasinghe, I., Aliprandi-Costa, B.J., Astley, C.M., Turnbull, F.M. & Lefkovits, J. (2013) Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. The Medical Journal of Australia, 199(3), 185-191.

Clune, S.J., Blackford, J. & Murphy, M. (2014) Management of the acute cardiac patient in the Australian rural setting: A 12 month retrospective study. Australian Critical Care, 27(1), 11-16.

Hagen, T.P., Häkkinen, U., Belicza, E., Fatore, G. & Goude, F. (2015) Acute myocardial infarction, use of percutaneous coronary intervention, and mortality: a comparative effectiveness analysis covering seven European countries. Health economics, 24(S2), 88-101.

Piepoli, M.F., Corrà, U., Dendale, P., Frederix, I., Prescott, E., Schmid, J.P., Cupples, M., Deaton, C., Doherty, P. & Giannuzzi, P. (2016) Challenges in secondary prevention after acute myocardial infarction: A call for action. European journal of preventive cardiology, 23(18), 1994-2006.

Tanguay, A., Dallaire, R., Hébert, D., Bégin, F. & Fleet, R. (2015) Rural patient access to primary percutaneous coronary intervention centers is improved by a novel integrated telemedicine prehospital system. The Journal of emergency medicine, 49(5), 657-664.

WHO (2017) Cardiovascular diseases (CVDs).

Sunday, 9 December 2018

Graduate nurses adaptation to individual ward culture

Roger Watson, Editor-in-Chief

In a time when nursing shortages are acute and many leave their jobs or leave nursing altogether, there is increasing attention on the experience of newly qualified nurses. The aim of the present study from Australia by Feltrin et al (2018) and published in JAN was to: 'increase understanding of strategies graduate nurses use on a day‐to‐day basis to integrate themselves into pre‐existing social frameworks.'

A small sample of nurses was interviewed who were at least four months into their first year of clinical practice. The strategies used by new nurses included: self‐embodiment and self‐consciousness, navigating the social constructs and raising consciousness. Self‐embodiment and self‐consciousness was exemplified by a comment from one of the nurses: 'Being vocal about what you don't know and being confident with what you do know.' In terms of navigating the social constructs, one students said: 'Learning from the senior staff. I guess they've been there the longest. They know what they are talking about.' And, as the authors explained: 'Raising consciousness involved the adaptation processes through reflectivity. Being aware of the differences between fitting in
not fitting in was integral to the (graduate nurses') eventual successful navigation of the social constructs.'

The authors concluded that newly qualified nurses: 'require preparation and to be adequately supported in their adaptation to ward culture'  and if they: 'are not supported in this process, the individual, their colleagues and the patient are probably affected.'

You can listen to this as a podcast


Feltrin C, Newton JM, Willetts G. How graduate nurses adapt to individual ward culture: A grounded theory studyJ Adv Nurs2018;