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| Lynne Childs, RN, BN |
Marlene Donahue, RN, BN |
| CV Nurse Clinician |
Clinical Coordinator |
| New Brunswick Heart Centre |
Cardiac Surgery |
| Atlantic Health Sciences Corporation |
Foothills Medical Centre |
| Saint John, NB |
Calgary, AB |
| |
| Deborah Dunn, RN, MSN | Brendalyn Ens, RN, MSN |
| Senior Instructor | Cardiology Education Coordinator/Manager |
| University of Victoria | Continuing Medical and Nursing Education |
| School of Nursing | University of Saskatchewan |
| Vancouver, BC | Saskatoon, SK |
| |
| Nancy Frazer, RN, BNSc | Josee Gregoire, Inf. MSc |
| Clinical Educator | Clinical Nurse Specialist |
| Ottawa Heart Institute | Hopital Sacre-Coeur de Montreal |
| Ottawa, ON |
Montreal, QC |
| |
| Evelyn Kerr, RN, MScN | Karen MacRury-Sweet, RN, MEd, MN |
| Clinical Educator | Director of Nursing |
| Ottawa Heart Institute |
QEII Health Sciences Centre |
| Ottawa, ON | Halifax, NS |
| |
| Kari Thunberg, RN, BN |
Wendy Vlasic, RN, MScN |
| Staff Nurse CICU | Clinical Nurse Specialist/Critical Care |
| Foothills Medical Center |
London Health Sciences Centre |
| Calgary, AB | London, ON |
Cardiovascular disease continues to be one of the leading causes of death and
disability for Canadians at the turn of the millennium. It is timely and
appropriate that Canadian Cardiovascular Nurses undertake the task of revising
their standards of practice.
The development of the following Cardiovascular Nursing Standards has been
an extensive process identifying and bringing together the unique and diverse
practice of cardiovascular nurses from across Canada.
These standards reflect particular times and perspectives and therefore
require regular revisions.
The standards have been designed to reflect a minimum of two years practice
in cardiovascular nursing. They assume a competency in general nursing practice
and allow for recognition of excellence in a specialty practice. The standards
support the beliefs and values of the Canadian Council of Cardiovascular
Nurses (CCCN). The standards acknowledge and embrace the foundations of
standards previously developed by the Canadian Nurses Association (CNA),
Provincial Nursing Associations and other specialty nursing groups. These
standards are designed to guide cardiovascular nurses, in any area of practice,
to achieve quality care to persons manifesting with some aspect of cardiovascular
disease. The standards do not address a pediatric practice in cardiovascular
nursing.
The vision of Canadian Cardiovascular Nursing is to maximize the cardiovascular
health of all Canadians through five key areas: health promotion, disease
prevention, management of acute episodes and chronic conditions, palliation
and rehabilitation to resume optimal heart healthy living. This vision is
based on the ideals of primary health care. It is our belief that cardiovascular
nursing reflects the Primary Health Care Model adopted by the World Health
Organization (WHO, 1986) and the Canadian Nurses’ Association.
The cardiovascular nurse provides comprehensive care to individuals, families,
groups, communities and populations. Cardiovascular nurses are committed
to the provision of safe nursing care and work collaboratively with other
health care professionals. Cardiovascular nurses support initiatives that
enhance the unique body of knowledge that is Cardiovascular Nursing.
Cardiovascular Nursing is practiced in a wide range of settings, which vary
from tertiary care institutions to community health care agencies. These
practice settings provide primary, acute and long-term care and may be found
in both urban and rural settings.
The process of establishing standards of practice require the development of a
framework that captures the key concepts and factors influencing that specialty
practice. The framework for any nursing specialty practice is grounded in
the metaparadigm of client, health, nursing and environment. For clarity,
these foundational elements are presented in Appendix I.
The conceptual framework pictured below represents key elements that guided
the development of these Cardiovascular Nursing Standards. This framework
depicts specialized nursing care that encompasses values and beliefs inherent
to our practice of cardiovascular nursing and articulates that practice
beyond key concepts common to all nursing.
The client is the core of the framework, reflecting an essential belief
that the interventions of the cardiovascular nurse depend on what the client
is experiencing and not exclusively to what degree of disease the client
may possess.
At this point and time, Cardiovascular Nursing is influenced by the paradigm
of caring which in turn highlights the concepts of partnership and quality
of life. Furthermore, these concepts are influenced by factors such as critical
thinking, experience, research, education and leadership.
These concepts and factors operate across the five key cardiovascular nursing
elements: Promotion, Prevention, Rehabilitation, Acute/Chronic and Episodic
Interventions and Palliation. The lines of the framework are broken to depict
the interaction and the interconnectedness between elements. At any given
point in the cardiovascular experience of the client, the nurse should consider
all elements simultaneously to provide comprehensive quality care.
Three key concepts have been identified that are foundations to the nurse/client
relationship in cardiovascular nursing. These include caring, partnership
and quality of life.
Caring is an integral part of cardiovascular nursing and incorporates both the
art and science of nursing care. Cardiovascular nursing views the art of
caring as “being with” a client as opposed to “doing to” wherein a trusting
and supportive relationship exists to potentiate the health and well being
of the client. (Watson, 1994) Caring suggests support for the client’s unique
social, emotional and spiritual strengths during times when difficult therapeutic
decisions need to be made, or when unfavorable prognosis has been indicated.
The nurse facilitates a client’s internal and external supportive resources
and empowers the client with trust, confidence for decision making and hope
for outcomes in a timely and effective manner.
Partnerships are special helping-trusting relationships between nurses and clients.
Cardiovascular nurses build relationships with clients based on mutual respect,
authentic communication, cooperation and confidentiality. Each partner makes
contributions to the relationship and has complimentary rights and responsibilities.
Together the nurse and client strive to maximize their capacities and mobilize
all available resources to attain optimal heart health (McKnight & Kratzman,
1992).
Partnerships are supported indirectly by identifying barriers to achieving
optimal heart health. Early recognition and attention to barriers commonly
experienced by cardiovascular clients is an essential skill for cardiovascular
nurses. By partnering with the health care team and the client to address
these issues, many barriers become more manageable or possibly eliminated.
Quality of life is a personal value and outlook on life based upon beliefs, cultural
and socio-economic factors. It is dynamic in nature and reflects the client’s
personal choices in life and their particular situation. Cardiovascular
Nurses should respect individuals’ diversity and client choices.
Five factors influencing the evolving nature of the therapeutic nurse/client partnerships
are presented below. Cardiovascular nursing standards promote the integration
of these influencing factors into practice in all clinical settings to meet
client health goals. These factors include: critical thinking, research,
life long learning, leadership and clinical care.
- Critical Thinking – Cardiovascular nursing must consider a wide range of information and data to manage the care of patients. Critical thinking is an important skill to effectively and efficiently use for the benefit of clients. Critical thinking is “comprised of three different but interrelated skills: creative problem solving, clinical judgement and creative thinking. (Whiteside, 1997). Critical thinking is more than obtaining appropriate information and knowledge but also involves the integration of synthesis of research and educational information. It is also a process used to develop innovative strategies for managing complex client concerns/problems.
- Research – Cardiovascular nursing requires an open attitude toward inquiry in all practice settings in order to enhance established practices and implement innovative strategies that meet client needs.
- Life Long Learning – A major component of cardiovascular nursing uniqueness comes from the use of technology and complex therapies which are consistently changing. It is therefore essential that cardiovascular nurses be committed to life long learning in order to be confident and competent in providing care.
- Leadership - Cardiovascular nurses demonstrate initiative in building trusting relationships, articulating visions, advocating for clients and coordinating the implementation of innovative strategies that enable clients to achieve their goals. Cardiovascular nurses use their power and expertise in ways that create equitable relationships with clients and the health care team.
- Clinical Care – Clinical care reflects direct interaction between the client and the nurse. This can be applied in all cardiovascular nursing practice settings: home health, palliative care, rehabilitation and hospital-based practices. In all clinical practice opportunities, it is assumed that the nurse utilizes the other domains of education, research and leadership to guide his/her interventions and relationship with the client.
As demonstrated by the Framework, five key elements reflect practice areas for
cardiovascular nursing. These include, Promotion, Prevention, Acute/Chronic
and Episodic Interventions, Rehabilitation and Palliation. Although cardiovascular
nurses may practice primarily in one practice area, skills and assumptions
associated with all five areas are relevant to their practices and must
be integrated into comprehensive care of the cardiovascular client in any
setting. The five elements are not exclusive to cardiovascular nursing but
those characteristics unique to cardiovascular nursing are identified.
Health promotion activities strive to create optimal experiences of health and
well being for people and may simultaneously assist in decreasing their
risk of disease. The cardiovascular nurse assesses ways to enhance established
health behaviors in the client’s lifestyle and environment and fosters the
establishment of additional or new patterns that would result in optimal
cardiovascular health for the client. This proactive approach to nursing
also includes the identification of risk and encourages the use of innovative
strategies to minimize or eliminate their impact.
The cardiovascular nurse:
- Identifies patterns of living for clients that promote heart healthy living.
- Encourages clients to continue established patterns of living that promote their health and the health of others.
- Assists clients to develop personal skills that will promote their cardiovascular health.
- Maintains current knowledge and awareness of epidemiological trends and demographic data to identify communities/populations that may be at risk for developing cardiovascular disease.
- Possesses an awareness of public policy that may impact on the cardiovascular health of clients, groups, or communities.
- Interprets meaning of public policy pertaining to cardiovascular health to clients and relevant stakeholders.
- Influences the creation of healthy public policy.
- Supports community action that clients undertake to preserve their cardiovascular health and prevent development of disease.
- Suggest resources and programs to clients that enable them to attain and maintain healthy living.
Prevention strategies include activities intended to reduce current or potential
cardiovascular risks. These risks may be related to lifestyle behaviors
or environmental factors. The cardiovascular nurse actively determines strategies
in partnership with clients to reduce health risks. Prevention implies three
levels for intervention depending on health and experiences of the client
at any particular time:
-
Primary Prevention - Client has presence of risk factors or other
characteristics that increase likelihood of experiencing a cardiovascular
event in the future.
The cardiovascular nurse:
- Identifies clients with cardiac risk factors that are amenable to
modification through lifestyle adjustments, interventions or environmental
modifications.
- Encourages clients to consider lifestyle changes.
- Provides support and information on ways to reduce cardiovascular
risk factors especially those associated with multiple risk factor
profiles.
- Identifies resources pertinent to risk factor management.
- Works with clients to meet their chosen goals for risk reduction.
- Facilitates client awareness of the signs and symptoms of cardiovascular
disease.
- Promotes participation of nurses in primary prevention population
health strategies.
-
Secondary Prevention – Client is experiencing or has experienced
a cardiovascular event, nursing activities focus on preventing another
event and promoting health.
The cardiovascular nurse:
- Assists the client to recognize and to manage existing or recurring
cardiovascular health problems.
- Supports the client in becoming informed about interventions to
improve condition.
- Identifies barriers to planned therapies and seeks approaches that
will facilitate client progress.
- Fosters client development of coping strategies for adjustment to
life long cardiovascular disease.
- Tertiary Prevention - Client is recovering from cardiovascular
events and in early phases rehabilitation.
The cardiovascular nurse:
- Maintains client motivation to choose healthy lifestyles.
- Helps prevent or minimize relapses
- Fosters client adjustment to disease process.
- Optimizes strengths in recovery process.
- Enables client to participate in ongoing rehabilitation.
Cardiovascular nurses use specialized skills and knowledge in the comprehensive
care of clients experiencing acute/chronic episodes and/or exacerbations
of established cardiovascular disease. The nature of cardiovascular disease
dictates that nurses be ever alert for sudden alterations in their client’s
health status. Such alterations may result in transient or permanent functional
disability, or death.
The cardiovascular nurse:
- Uses knowledge of cardiac anatomy, physiology and pathophysiology to make critical decisions on illness progression, hemodynamic stability and expected outcomes for the client.
- Uses knowledge of specialized skills essential for comprehensive assessment of cardiovascular clients including but not limited to electrocardiographic interpretation, auscultation of heart and lung sounds and basic hemodynamic principles.
- Uses knowledge of expected/unexpected effects and multi-system interaction for cardiovascular pharmacological therapies commonly administered to cardiovascular clients in their acute and chronic phase of care.
- Provides appropriate information to client regarding invasive procedure associated with diagnostic and emergent technologies.
- Interprets cardiovascular laboratory tests and results in relation to the client’s clinical condition and implements appropriate nursing action.
- Monitors client progress during critical episodes and initiates emergency interventions in accordance with national BCLS and ACLS standards.
- Supports and includes the client in all choices or decisions regarding care including cardiac emergency situations.
- Implements strategies to optimize comfort.
- Uses knowledge of both common and unexpected trajectory of cardiovascular disease, to anticipate clients needs.
- Includes client’s advanced directives in nursing care.
- Assists clients through grieving process due to potential disability or imminent death.
Rehabilitation is an ongoing process to restore optimal level of cardiovascular
function. It encompasses health promotion activities, addresses health risk
behaviors identified in prevention phase and considers potential for acute/episodic
recurrences.
A life long plan is collaboratively formed by the nurse and the client emphasizing
aspects of client health including modifiable/non-modifiable risk factors.
The plan also includes enhancement of psychosocial well being and promotion
of self-actualization. Principles of behavior change are taught and reinforced.
Rehabilitation phases reflect timeframes for interventions: from early onset
in the acute setting to an out patient community focus. Phases of rehabilitation
include inpatient rehabilitation stage, outpatient rehabilitation stage
and life long management.
In the inpatient rehabilitation phase, the cardiovascular nurse:
- Implements current standards for rehabilitative therapy.
- Determines client risk status and psychosocial therapy.
- Initiates rehabilitation process as soon as possible following an acute cardiovascular event by identifying client’s perceptions of existing risk factors and desire to change
- Initiates referrals to community systems that will enhance other rehabilitative phases
In the outpatient rehabilitation stage, the cardiovascular nurse:
- Assesses client’s current cardiovascular risk and psychosocial status
- Monitors client progress and compares to expected benchmarks
- Re-evaluates plan of care in consultation with health care team
- Identifies barriers to planned therapies and seeks approaches that will facilitate client progress.
- Alters nursing interventions to accommodate client’s progress in rehabilitation process.
In life long management, the cardiovascular nurse:
- Enables the client to identify own progress
- Encourages the client to maintain rehabilitation goals
- Facilitates problem solving for client to sustain rehabilitative efforts
- Assists client to adapt to changes/progression of cardiovascular disease
- Alters nursing interventions to changing needs or life changes of the client.
Comprehensive cardiovascular nursing care incorporates palliative interventions
as required by the client’s status and in accordance with the client’s wishes.
The client’s health may include a permanent functional disability, or imminent
death.
The cardiovascular nurse:
- Uses knowledge of expected/unexpected effects and multi-system interaction for cardiovascular pharmacological therapies commonly administered to clients in the chronic phase of care.
- Provides appropriate information to client regarding invasive procedure associated with palliative technologies.
- Supports and includes the client in all choices or decisions regarding care.
- Implements strategies to optimize comfort and quality of life.
- Uses knowledge of both common and unexpected trajectory of cardiovascular disease, to anticipate client’s needs.
- Includes client’s advanced directives in nursing care.
- Assists clients through grieving process due to potential disability or imminent death.
- Respects spiritual needs of client.
- Functions as a member of the health care team in assisting the client to work through end of life issues.
Cardiovascular nursing continues to evolve. As cardiovascular nurses, we are involved
in health promotion, disease prevention, management of acute/chronic and
episodic therapeutics, rehabilitation and palliation. These standards are
designed as goals to achieve the highest level of care available for our
cardiovascular population.
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CLIENT
Client includes individuals, families (as defined by the client), groups, communities
and populations. Cardiovascular nursing views the client holistically, incorporating
the biological, psychological, social, cultural, developmental and spiritual
dimensions of life experiences. Cardiovascular nursing respects informed
client choices. Nursing relationships with the client are authentic, trustworthy
and respectful of diversity.
HEALTH
Health is a resource for living, a positive concept, the extent to which an individual
or group is able to realize aspirations, to satisfy needs and to change
or cope with the environment (World Health Organization, 1984a).
Health is relative, dynamic and more than the absence of disease. A client’s
meaning of health is unique and is constructed from their experience of
living within a certain context. The cardiovascular client experiences a
range of health manifestations from chronic to sudden and unexpected presentations
requiring an adjustment that will be modified throughout the continuum of
life.
NURSING
Nursing is a dynamic and supportive profession that is guided by its code of ethics,
is rooted in care, a concept evident throughout its four fields of activity:
practice, education, administration, and research. In assisting people to
achieve and maintain optimal health, nurses practice in a variety of settings
and work collaboratively with other disciplines. Nursing’s contribution
to health is made explicit through any one of the various conceptual models
for nursing (Canadian Nurses Association, 1987b
Nursing provides a unique opportunity for us to form helping relationships
in health and illness related circumstances to the best of our ability.
This is done in accordance with established practice driven and ethical
guidelines.
Cardiovascular nurses demonstrate both leadership and professionalism by
advocating for clients, being accountable for actions, promoting ethical
behavior in the nurse/client relationship, encouraging cooperation and interdisciplinary
team building, providing evidence based practice, creatively seeking solutions
to problems, promoting life long learning and participating in social/political
lobbying for continued enhancement of health service programs.Cardiovascular
nursing activities span the elements of health promotion, prevention, rehabilitation,
acute/chronic and episodic interventions, rehabilitation and palliation.
ENVIRONMENT
Environment includes the following dimensions: physical, psychosocial, political
and economic, spiritual, cultural and organizational.The environment impacts
on the cardiovascular health of clients whether or not they are aware. Cardiovascular
nurses recognize that broader social, political and ecological factors influence
the cardiovascular health of clients. |
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