The characteristics of cardiac rehabilitation interventions provided by nurses: A scoping review

doi:10.21203/rs.3.rs-2322298/v1

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The characteristics of cardiac rehabilitation interventions provided by nurses: A scoping review

https://doi.org/10.21203/rs.3.rs-2322298/v1

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Background: A cardiac rehabilitation program (CRP) is an interdisciplinary intervention that combines the medical, social, and educational components necessary for cardiac rehabilitation so that people with cardiovascular disease can regain their functional abilities and improve their quality of life.

In CRP, nurses have an essential role in patient care and service coordination. The basic components of a CRP that can be adapted remain unknown, as there are many different CRP. This study aims to identify the key features of a CRP that can inform public policy.

Currently, there is no synthesis of the characteristics of services in CRP that can be adapted in the literature. This study aims to identify the main characteristics of cardiac rehabilitation programs nurses offer when providing cardiac rehabilitation after a myocardial infarction.

Methods: A scoping study was conducted according to Arksey and O'Malley (2005). We systematically searched CINAHL, MEDLINE, Scopus, and Cochrane. Only empirical studies published between 2005 and 2022 with a CRP involving a nurse were included. CRP characteristics were classified, coded, and validated with the research team and categorized for analysis.

Results: Fifteen articles were included in which 15 rehabilitation programs were identified. In total, four programs were offered, individualized nurse follow-up (n = 8), CRP solicitation (n = 2), use of technology (n = 3), and telehealth (n = 1). Overall, the features were categorized into four program types: 1) Interventions promoting early recruitment of participants; 2) Interventions promoting technology use; 3) Interventions based on multiple components; and 4) Interventions based on surveillance and monitoring activities.

Conclusion: With the increase in myocardial infarctions, more and more patients need CRP. Nurse monitoring during CRP can be offered with several components to facilitate follow-up. These different follow-up components allow the nurse to anticipate care issues and obstacles the patient may encounter throughout cardiac rehabilitation. These elements should be promoted for engagement and participation in CR to improve CR provision. Finally, the characteristics of this study will support the conceptualization of a CR program.

cardiac rehabilitation

intervention

Nurse

Myocardial infarction

scoping review

Heart disease is the leading cause of death worldwide[WHO, 20171]. It is defined as a range of diseases affecting the heart including ischaemic heart disease (specifically angina or myocardial infarction), but also arrhythmia, atrial fibrillation, and heart failure[2]. According to WHO [1], 32% of deaths are caused by heart disease.

The therapeutic intervention of choice for ischaemic heart disease is percutaneous transluminal coronary angioplasty (PTCA) [3]. In most situations, this procedure is performed in tertiary centers located in an urban area. Following PTCA, individuals may participate in a cardiac rehabilitation program (CRP). A CR program is an interdisciplinary intervention that combines the medical, social, and educational components necessary for CRP so that people with CHD regain their functional abilities and improve their quality of life [OMS, 2013 4, WHO, 19935].

CRP is an evidence-based intervention that uses physical training, health behavior change, medication adherence, and psychological counseling to improve secondary prevention outcomes in patients with cardiovascular disease[6]. CRP reduce morbidity and mortality rates in adults with ischaemic heart disease, following a coronary intervention, heart failure or cardiac surgery [7]. Several guidelines exist to support CR [8–11]. For the study reported in this article, the policies selected were those of the British Association for Cardiovascular Prevention and Rehabilitation [BACPR] [9], as this follows the advancement of the CRP literature and the nurse’s role is present.

Nurses can take a central role in accordance with their competencies in comprehensive heart disease follow-up care and in relation to the activities offered in CR[12, 13]. The nurse's involvement in the follow-up of heart disease through optimized individualized therapeutic education improves long-term prognosis and morbidity and mortality costs [14, 15].

The different components of CRP align with nurses' expertise and scope of practice, as they have the professional latitude to play several key roles, such as in medical risk management, behavior, and health education, psychosocial health, and lifestyle risk management [16]. A recent study suggests that many of the needs of post-PTCA patients could be met by nurses, including educational needs for a lifestyle change, psychosocial health, and risk factor management vie [16]. Nurses are able to make an educational diagnosis, i.e., regarding the patient's needs as well as their psychological and social vulnerability. This aims to lead the patient to develop self-care and coping skills [17]. These elements align with the nurses' field of practice and for which there is scientific evidence of effectiveness and patient safety [15].

At present, it is not well known what different ways nurses can provide follow-up in a CRP are. This study aims to characterize the different key features of a CRP that nurses can offer to people with heart disease. This study will inform the development of a CRP where the nurse plays a central role.

Design

We used a scoping review approach because it allows us to review the literature to identify the characteristics of CRP. The goal is to identify the key modalities that underpin the research area to find the main sources and evidence available [18]. We used the five-step approach developed by Arksey and O'Malley [18].

Step 1: Identify the research question

The research question was determined as a result of nurses' lack of knowledge of the characteristics of CR interventions. The question is: What are the characteristics of cardiac rehabilitation programs that nurses deliver?

Step 2: Identify relevant studies

Search strategy

The search strategy to identify relevant studies was developed with the help of an information specialist (keywords, MESH, databases). The search strategy included three databases: Ebesco (Cinahl and Medline), Cochrane, and Scopus. The selected keywords included three concepts: nursing, cardiac rehabilitation, and myocardial infarction (MI). The authors were interested in MI to have homogeneity in the study population.

For each of the three databases, a search strategy was developed concerning the specificity of the Boreal operators and the MESH (Table 1). The search strategy included publications from January 2005 to April 2022. We restricted ourselves to these years, as the first version of the specialized cardiac rehabilitation conceptual framework used in this study was developed in 2007 [9]. This timeframe also considers technological advances for the management of cardiac rehabilitation.

Step 3: Selection of studies

The selection of studies was made in three stages. The selection aimed to inform the development of a CRP in which the nurse plays a central role. The 1048 articles were imported into the EndNote X9 reference software, and the first author removed duplicates. The first stage of screening of the 762 articles was carried out by JB and consisted of reading the titles and abstracts. Studies deemed to have little content on CRP and addressing the following were excluded: 1) Not on nurses; 2) Not on cardiac rehabilitation program; 3) Medical treatments; 4) Choosing the suitable molecules for drugs; 5) Needs assessment; 6) Surgical interventions; 7) Other chronic diseases; 8) Timeliness of symptom management; 9) Reported errors in cardiovascular disease management; 10) Benefits to cardiac rehabilitation and, 11) Premature mortality of myocardial infarction. From this stage, 28 articles for which we were undecided were reviewed by the second and third authors for co-validation. This exercise resulted in the inclusion of 2 articles and the exclusion of twenty-six articles with 100% agreement. At the end of this second triage, 157 articles were retained to proceed to the third triage. The first and third authors reviewed the 48 rejected systematic review articles based on the first stage criteria and 100% agreement to reject them was maintained.

For the second screening stage, the first author read titles and abstracts with the following inclusion criteria: 1) cardiac rehabilitation, and 2) nursing. Exclusion criteria were: 1) case reports; 2) editorials; 3) outcome poverty; and 4) nursing certifications.

For the third stage, the 54 articles were read in full by the first author and the coding was validated by the second and third authors. From this step, 15 articles were selected for data extraction. See Fig. 1 for the flow chart.

Step 4: Data mapping

Data extraction

The selected articles were imported into the NVivo 12 software. The research team generated a coding tree for data extraction. The extracted data included details such as author name, country, and type of region (e.g., urban, remote, rural). The design, population, and setting (myocardial infarction, percutaneous transluminal coronary angioplasty). Presence of a referral framework, type of intervention, elements of the intervention, and patient outcomes. The first and third authors held coding and validation meetings to develop the summary table and extracted data. In line with the recommended authors, we did not assess the methodological quality or risk of bias of the included articles, which is consistent with guidance on conducting scoping reviews [19].

Step 5: Extract and organize the data

Characteristics of included studies

Table 2 presents the characteristics of the 15 selected articles on 14 CRP. The table lists the authors and year of publication, the type of population and country, the types of interventions, the nurses’ roles, and the studies’ results. The rehabilitation programs were categorized into intervention types and the elements described for the interventions. Table 2 presents all included articles, their main characteristics, and results. All studies were published in English.

To make the key components of CR interventions more explicit, the first and third authors discussed and extracted intervention characteristics. Different clinical roles and activities of nurses emerged. The interventions were then categorized into four mutually exclusive groups: 1) recruitment and adherence interventions, 2) information technology interventions, 3) multicomponent interventions, and 4) nursing supervision interventions. In addition, to highlight the clinical role and activities of the nurse, role and activity mapping were added in this scoping study.

Of the 15 studies included, all presented results on the effectiveness of CRP. Thirteen studies were based on randomized controlled trials [20–33], one study was a systematic review of the literature [34], two studies were retrospective [35, 36], and one study was based on a prospective cohort [26].

Conceptual frameworks

Only four studies[20, 26, 27, 32] reported using a conceptual framework to guide their CRP. For example, Cossette et al. [20] used Leventhal's self-regulation theory to focus on changing perceptions of illness, i.e., improving perceived control and encouraging a positive attitude towards rehabilitation. Harbman [26] based her study on the conceptual framework developed by Sidani and Irvine to identify the structure, process, and outcome variables most relevant to the evolution of nurse practitioners' contribution to secondary prevention. Houle et al. [24] used Bandura's social cognitive theory for the clinical nurse specialist intervention which suggests health promoting interactions and four sources of efficacy expectations. Finally, Mittag et al. [32] used Prochaska and DiClemente's cognitive-behavioural and health psychology for counseling interventions.

1) Characteristics favoring early recruitment of participants

Two studies investigated early intervention strategies for recruiting patients to promote better participation in the CRP [20, 22]. In the CRP evaluated by Cossette et al. (2012), the nurse scheduled three meetings after the PTCA. The first meeting took place in person with the nurse before discharge. In this first meeting, the nurse discussed symptom management, physical activity, patient concerns, and worries. The second meeting was a telephone follow-up by the nurse, which took place three days after discharge. Items discussed included the ability to manage the disease after hospital discharge, concerns, and modification of risk factors. Finally, the third meeting occurred in person or by telephone ten days after hospital discharge. The nurse discussed clinical problems and treatments, risk factors, lifestyle modification, and CRP enrolment. These early activities resulted in a better rate of CRP enrolment, 45% for the intervention group versus 24% (p < .001) for the control group.

Grossman et al. [22] used four types of recruitment strategies with activities performed by nurses: 1) an initial patient-nurse interview, consultation, and treatment; 2) a letter mailed to the patient's physician; 3) a personal phone call from one of the CR nurses; and 4) a personalized letter from a CRP nurse with a coronary stenting education package. These four types of intervention aimed to improve adherence to the CRP. They then compared the four types of interventions to determine their effectiveness. The first intervention was a discussion and treatment, a 250-foot nurse-assisted walk during hospitalization. A 30-minute face-to-face consultation took place 24–48 hours after the intervention with a cardiac information handout. The 250-foot assisted walk had to be prescribed by the doctor, i.e., permission to take a 250-foot supervised walk with the nurse. This resulted in an enrolment rate of 81.2%. The second intervention was a letter sent to the treating physician three weeks after the hospitalization so they could ask the patient to enroll in the ambulatory CRP. This intervention had a 33.3% enrolment rate. The third intervention was a telephone call to the patient three weeks after discharge by a CRP nurse with a CR entry interview. For this intervention, only 3.1% of participants enrolled. The fourth intervention consisted of a letter from the CRP sent to the patient three weeks after discharge that encouraged enrolment in the CRP via an entry interview. In addition, an educational handout was sent with the letter one week after hospital discharge. Only 20% of participants enrolled in the intervention. Finally, regardless of the intervention, patients who received a face-to-face interview with the nurse were more likely to enrol in CRP χ2(1) = 86.80, p < .001.

2) Technology-based interventions

Three interventions presented in four studies relied on technologies to support the clinical activities of the CRP [21, 24, 27, 30]. These technologies were varied. Interventions were carried out through different uses of technologies.

Gonzalez et al. [21] used a mobile application to support adherence to lifestyle advice and self-monitoring of risk factors to complement CRP. A tablet or smartphone was provided to patients to record information on lifestyle (e.g., pulse, blood pressure), symptoms and medications. The software offered positive feedback on values through graphs against target values. The data was reviewed by the nurse twice a week and was accessible to the physician and physiotherapist of the CRP. The system prioritizes the patient when they enter heart pain and non-use of medication in the patient interface.

The intervention by Houle et al. (2011, 2012) used a pedometer to support walking activities. Clinical CRP nurses assessed the patient at the time of hospitalization, and if the patient was suitable for the program, a pedometer and a journal were provided. Information about the cardiac procedure was taught. Patients were given a recommended daily exercise goal and asked to record their number of steps per day in the journal. Follow-ups with the CRP clinical nurse specialist included a telephone call within two weeks of hospital discharge and five face-to-face meetings at six weeks and at three, six, nine, and 12 months after the myocardial infarction.

Lear et al. [30] used a home heart rate monitor and blood pressure monitor linked to a patient computer portal. A 30-minute training session was provided for patients with the heart rate monitor and blood pressure monitor, and completion of the online form. The webpage was used for weekly scheduled education sessions with the program's nurse case manager, a physical activity specialist and a dietitian - three sessions with each professional over the 12 weeks. The webpage displayed the tasks to be completed each week, and patients were asked to upload their exercise data twice a week (e.g., weight, blood pressure before and after physical activity, and random blood glucose for diabetics). Thereafter, these data were entered once a week and then once a month unless otherwise specified by the nurse. Patients had discussion sessions with the program's nurse case manager and a physical activity specialist to discuss changes and needs. From the included articles, two interventions provided a 30 minutes training and information material to patients before intervention about the technology they will be asked to use [24, 27, 30]. However, the authors did not specify who provided the training.

3) Interventions based on multiple monitoring modalities

With regard to interventions based on multiple components, in the coding that was not mutually exclusive, the studies presented different strategies, which allowed us to categorize them into four broad categories. We observed that interventions could be delivered through multiple components of patient follow-up.

Seven included studies reported using various strategies in their CRP intervention [24–29, 33, 35, 36].

For example, Bowler and Blake [35] presented an intervention using a book as a teaching tool to support the nurse's information for the patient's health education at discharge. CRP nurses offered bedside visits to assess patients' ability to participate in CRP with a support book or to receive follow-up at home without the support book [35]. Just as Jolly et al. [29] used a heart book to support the information given to patients by the nurse, they followed up with a cohort of patients in a CRP center and at home.

Harbman [26], introduced five types of sessions combining pre-discharge visits, in-person home visits, and phone calls: 1) in-person pre-discharge, 2) phone call two weeks post-hospitalization, and then; 3) in-person two weeks post-hospitalization; 4) in-person at six weeks post-discharge and 5) in-person three months post-discharge. The face-to-face encounters lasted 30 to 60 minutes and were conducted in an outpatient clinic. Houle et al. [24, 27] preferred telephone and face-to-face follow-ups at the CRP centre, with the only visit during hospitalization being to recruit patients for the research project. Hunger et al. [25] conducted telephone follow-ups and home visits. First, the first meeting took place in the hospital before discharge and lasted one hour. The information given orally to the patient was related to the disease, co-morbidities, and medication, and then a heart book was given to them for reference at home. Thereafter, four home visits were scheduled with telephone calls every three months. Kirchberger et al. [28] provided home visits by the nurse, but also telephone follow-ups as well as face-to-face meetings with the nurse were offered before the start of the CRP and at the day seven follow-ups after PTCA up to six months. In addition to structured visits, other authors have used an educational book to support the patient at home [25, 29, 35]. Ögmundsdottir Michelsen et al. [36] reported home visits by the nurse to follow up after hospital discharge on disease risk factors and offer support with their CRP intervention. Face-to-face meetings were offered with the nurse prior to starting the CRP and at follow-ups. They used written communication to explain the CRP follow-ups with the nurse and the need to see a cardiologist.

Only one author, Minneboo et al. [33], used nurse follow-up for a referral to three types of community-based programs, Weight Watchers, Philips DirectLife and Luchtsignaal which already exist, and adherence was according to patient need.

4) Interventions based on surveillance and monitoring activities - education

In the 14 studies included, the nurse had a pivotal role in monitoring risk factors, lifestyle changes, and health education [20, 22–29, 31–33, 35, 36]. We observed that this monitoring activity was carried out in different ways and with varying monitoring modalities. We observed that interventions could be carried out through different surveillance and monitoring activities.

Five studies reported that nurses conducted home visits to perform lifestyle and risk factor monitoring activities [25, 28, 29, 35, 36]. Seven studies offered telephone monitoring by nurses to track progress in cardiac risk, CRP and improvement in patient quality of life [20, 24, 26–28, 32, 35]. Six studies used personalized visits to the clinic [20, 22, 24, 26, 27, 31, 33].

Two studies used web-based applications with a patient and professional interface for nurse monitoring of patients [21, 30]. The nurses had access to the patient's data and provided feedback through text messages or messages on the web platform. Priority was given to follow-up if the patient experienced chest pain [21]. These platforms also provided patients' blood results [30].

This scoping study aimed to identify different characteristics of nursing interventions in CRP models. From this scoping review, the authors identified 15 articles. The synthesized information on the characteristics of nursing interventions may provide valuable input to facilitate the design and implementation of nursing interventions when developing a CRP. However, no study has provided a comprehensive description of the role of nurses in follow-up in CRP.

This scoping study identified multiple components of nursing roles in a CRP. Based on the results presented, we found that: 1) enrolment is an essential component of cardiac rehabilitation programs; 2) use of technology appears to be necessary to support the patient in CRP; 3) many interventions are based on multiple follow-up activities: e.g., book, phone call, home visits, etc. to adapt to the needs of the patients; and 4) monitoring by nurses appears to be an essential component. These results lead to the following observations. Nurses can perform several follow-up activities in a CRP linked to characteristics. These features allow patients to have individualized follow-ups and a health professional, the nurse, dedicated to their needs. The use of technology is a complementary tool for home follow-up in order to offer CRP to a larger number of patients, and the follow-ups offered have shown positive effects.

1.) Enrolment is an essential component of cardiac rehabilitation programs

Early enrolment in CRP is an essential characteristic of participation in CRP. However, this characteristic seems to be under-researched. Only two out of 14 studies investigated the concept of early CRP enrolment [20, 22]. Despite the paucity of studies describing this feature of a CRP, it appears essential that early enrolment strategies be included in CRP. Some studies show positive outcomes when CRP is offered at the time of the patient's hospitalization [20, 22]. In addition, non-referral early on to a CRP is one of the most important reasons for patients to drop out [37]. Specific populations are less likely to be referred to a CRP, including women, the elderly, and people with MI without coronary revascularisation, who have a much lower benefit than those referred to a CRP [37]. Several international practice guidelines in CRP propose a recruitment process that should be coordinated to identify eligible people within 24 hours of hospital discharge [9]. For people with planned outpatient coronary revascularisation, CRP standards report that identification should be made for recruitment within 72 hours of their hospital admission [9].

According to BACPR [9], patients screened before hospital discharge have better enrolment outcomes for CRP participation. Also, according to BACPR, a re-entry process for CR should be initiated if patients initially declined to participate in a CRP the first time [BACPR, 20179].

2.) The use of technology to support activities

The use of technology is a modality that nurses can use in their clinical activities during CRP. However, it is still infrequent in CRP. Technologies have shown potential for success in supporting individuals, involving them in changes and knowledge of their medical outcomes to have a personalized follow-up and close contact with the nurse during CRP.

Gallagher et al. [38] reported that 77% of patients were in favor of receiving technological support during the CRP, whether via a web app, online videos, personalized emails ,or their mobile phone. In the context of supervised physical activity, patients reported being in favour of virtual monitoring by a coach or computer games [38]. The use of mobile technology is reported to increase adherence to CRP as well as participation in monitored sessions, and CRP completion is more significant in patients using this technology [39]. Mixed monitoring with a face-to-face encounter in a centre and a remote electrocardiographic monitoring device at home was found to be as effective as the usual program in improving functional capacity in moderate-risk patients [40]. Participants indicated choosing the telerehabilitation platform due to better accessibility and flexibility. Having feedback, individualized follow-up, monitoring to real-time coaching by specialists facilitated confidence, motivation to adhere to the prescribed intensity and reassured activity in the post-acute period [41]. Patients report that the use of a mobile application leads to positive effects during their CRP, i.e., allowing for better motivation. The application allows for reminders to stay active and provides personal feedback to each patient [42]. Telerehabilitation as well as a combination of methods when offering CRP would allow for better monitoring of patients at a distance when they face barriers or limitations to following a CRP in a CRP centre. This combination is done by means of remote monitoring of telecoaching as well as the use of online support via social media which helps patients in their motivation and interest to take part in CRP [43].

3) Interventions based on multiple monitoring modalities

Offering CRP with different modalities for clinical follow-up would facilitate access for patients who face barriers and limitations to participation in CRP in a specialised centre [43]. Post-exercise telecoaching allows patients' needs to be met through video or telephone communication. In addition, telecoaching makes tools available to patients, medical and scientific information, which increases their health-related knowledge and increases adherence to treatment [43]. The use of multiple ways of communicating with patients, such as emails, text messages and phone calls, has been shown to increase patients' confidence, skills and knowledge about managing cardiac risk factors during telecoaching [21]. The studies illustrated that multiple components were offered during the CRP intervention for risk factor follow-ups for the MI patient (e.g., telephone follow-up, home visit, face-to-face meeting, educational materials, etc.). In addition, the multiple ways of communicating between patients and health professionals (e.g., text messages, video and phone calls, emails) allowed to rapidly focus on adjusting exercise modalities and characteristics. But also, the verification of the occurrence of adverse events and possible barriers that the patient may encounter to participation in CRP [44].

On the other hand, in CRP with a multidisciplinary team and follow-up with professionals through different ways of follow-up in the hospital, teleconsultation, email or text messaging, the ability of patients to engage in their care was increased. As a result, patients' health literacy levels increased, and patients demonstrated a greater ability to engage with healthcare professionals [45].

The creation of a peer support group in the hospital in addition to individualised face-to-face meetings with the nurse to discuss health advice helped to share the participants' progress towards achieving the goals and encouraged the participants to share their experiences and concerns to reinforce behavioural changes. Their results show that self-efficacy and health-related quality of life improved among patients [46].

To allow for a better participation rate in a CRP, a combination of follow-up methods was used for the patients. Home visits by the nurse to make a structured assessment of the patients' clinical and mental status were followed by regular telephone calls by the nurse to follow up on any problems. The creation of a peer discussion group to share their experiences of physical activity proved to be positive in changing lifestyle habits and risk factors [47].

4.) Interventions based on surveillance and monitoring activities - education

Nurse monitoring is an intentional clinical assessment process throughout the care episode. It may be done continuously or at a set interval. The actions to be undertaken include the collection, analysis, and careful synthesis of clinical parameters and the physical and mental state of the patient [48]. This allows anticipating and recognizing changes in a critical condition, the transmission of results, and clinical decision making [48]. Nurses' ability to detect deterioration in patients with risky clinical conditions through vigilant and attentive clinical monitoring remains a priority goal for reducing adverse events in nursing [49].

In most studies, nurses performed clinical monitoring of patients [21, 23–33, 35, 36]. The nurse's interventions focused on patient monitoring can be done in several ways, at home, by telephone, by WEB application, in person. Monitoring is a mental task that includes assessment and analysis functions by nurses [50]; a cognitive and behavioral process that demonstrates early recognition and identification of early indicators of patient change [51]. Positive consequences of monitoring include preventing patient harm, decreasing adverse events, optimizing health outcomes and increasing positive outcomes [50, 52–54]. The analysis of the nurse's role through CRP interventions clarifies how the nurse becomes the reference person for patients in different ways. Nurse monitoring can also take place during home visits and is important in identifying the care and services that the patient needs [55].

In the context of CRP, we found that this monitoring can be expressed in different ways. For example, telephone monitoring by a nurse as a safety net for patients awaiting CRP increases adherence to the CRP, allows monitoring of their condition and responding to adverse events between hospital discharge and the start of the CRP [56]. This telephone-based ambulatory monitoring system allows the patient to be followed, as a baseline risk after their cardiac hospitalisation during their recovery. A period of vulnerability that is present between their hospitalisation and the start of the CRP which is monitored by the nurse [56]. Nursing monitoring through educational intervention, of parameters, medical risk factors and patient habits within one month after coronary intervention has also been shown to improve the health and life of patients [57]. When CRP is nurse-led, monitoring of behavioural, physiological and biochemical parameters as well as motivational interviewing leads to better adherence to treatment, but also to improvement in lifestyle and medical risk factors [58]. The support of technology for nursing monitoring allows for easier follow-up with the professional, but also personalised monitoring from home [38, 42, 43].

Strengths and limitations

A major strength of this scoping review is the co-validation of included and excluded articles in the study by all authors in a three-step process.

In our included studies, the severity of the patient's MI and the type of cardiac procedure were not indicated in order to know the cardiac risk stratification of undergoing CRP outside a specialised CRP centre. Although CRP guidelines recommend enrolment in CRP from hospitalization [8–10], only two studies in the set of reviewed studies addressed early enrolment and these were in a specialized CRP centre [20, 22].

Follow-up with patients by the nurse of the different modalities is under-explained, which does not allow us to be exhaustive in our synthesis. These follow-ups were often poorly described in the articles, so we may have missed important details.

Mapping the data was a considerable amount of work, as it was poorly explained in the text. We therefore agreed with the first and third authors to get together and map all the key features of CRP interventions in the 15 studies. A pragmatic decision had to be made to report the key clinical activities of nurses and their roles to enhance the results of this scoping review.

A limitation is the lack of data on the documentation supporting patient health education provided to patients. It was reported in only five out of 15 studies[22, 24, 25, 27, 28, 35]. Considering the retention of patient information, it is difficult to conceive that the nurse did not use and provide educational materials to patients during the encounters. Furthermore, we limited ourselves to studies published in French and English. It is not known whether studies in languages other than French and English have similar results. We also excluded opinions and editorials that might discuss barriers and facilitators in CRP.

This scoping study was motivated by the need to identify the key characteristics of the interventions offered by nurses in a CRP. The contribution of this work lies in the synthesis of the types of interventions that can be used to develop a CRP intervention. This scoping study is a starting point to assist decision makers and professionals in designing a CRP. As a recommendation from this scoping study, we suggest that the documentation offered, as well as the pedagogical and educational materials used, be explained in studies. Furthermore, it would be interesting to know which CRP guidelines were used in the delivery of CRP. Finally, we recommend that the clinical activities and the role of the nurse during CRP follow-ups be further explained.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Funding

This research was done in the course of the first author’s doctoral studies.

Authors' contributions

JB analyzed and interpreted the data. MEP and MB did a co-validation of the undecided articles.

JB and MEP was validated the 54 articles included for this review.

Data coding was done by JB, MB, and MEP.

review. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

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Table 1. Search Strategy
Ebesco	TI "nurs" OR AB "nurs" OR SU "nurs" AND "cardiac rehab" OR "post myocardial infarction program" OR "post-myocardial infarction program" OR "cardiovascular rehab" OR (MH "Rehabilitation, Cardiac") OR "Cardiovascular disease" AND (MH "Myocardial Infarction") OR "myocardial infarct" OR "heart attack" or "acute coronary syndrome"
Cochrane	(nurs)" AND "cardiovascular rehab" OR "post myocardial" OR "post-myocardial" OR "cardiac rehab*" OR "MeSH descriptor: [Cardiac Rehabilitation] explode all trees" OR MeSH descriptor: [Cardiovascular Diseases] explode all trees" AND "MeSH descriptor: [Myocardial Infarction] this term only"
Scopus	(TITLE-ABS-KEY(( "nurs" ))) AND ((TITLE-ABS-KEY(( "cardiac rehab" OR "post myocardial infarction program" OR "post myocardial infarction program" OR "cardiovascular rehab" ))) OR (TITLE-ABS-KEY(cardiovascular disease))) AND (TITLE-ABS-KEY(( "myocardial infarct" OR "heart attack" OR "acute coronary syndrome" )))

Table 2 is available in the Supplementary Files section.

No competing interests reported.

Table2JBernier.docx

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The characteristics of cardiac rehabilitation interventions provided by nurses: A scoping review

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Abstract

Figures

Background

Methods

Design

Step 1: Identify the research question

Step 2: Identify relevant studies

Search strategy

Step 3: Selection of studies

Step 4: Data mapping

Data extraction

Results

Step 5: Extract and organize the data

Characteristics of included studies

Conceptual frameworks

1) Characteristics favoring early recruitment of participants

2) Technology-based interventions

3) Interventions based on multiple monitoring modalities

4) Interventions based on surveillance and monitoring activities - education

Discussion

1.) Enrolment is an essential component of cardiac rehabilitation programs

2.) The use of technology to support activities

3) Interventions based on multiple monitoring modalities

4.) Interventions based on surveillance and monitoring activities - education

Strengths and limitations

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

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