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 Sam Munian, Chantal F Ski, John X Rolley and David R Thompson

What does this paper contribute to the wider global clinical community? •    Targeted education has the potential to facilitate early recog- nition of the signs and symptoms of depression in the acute cardiac setting. •    Appropriate tools can increase nurse confidence in screening and referral of depression in cardiac populations.

Aims and objectives. The aim of this study was to evaluate nurses’ perceptions of an education programme and screening and referral  tool  designed  for  cardiac nurses to facilitate depression screening and referral procedures for patients with coronary heart disease.

Background. There is a high prevalence of depression in patients with coronary heart disease that is often undetected. It is important therefore that nurses work- ing with cardiac patients are equipped with the knowledge and skills to recognise the signs and symptoms of depression and refer appropriately.

Design. A qualitative approach with purposive sampling and semi-structural inter- views was implemented within the Donabedian ‘Structure-Process-Outcome’ eval- uation framework.

Methods. Semi-structured interviews were conducted with 14 cardiac nurses working in a major metropolitan hospital six weeks post-attending an education programme on depression and coronary heart disease. Thematic data analysis was implemented, specifically adhering to Halcomb and Davidson’s (2006) pragmatic data analysis, to examine nurse knowledge and experience of depression assess- ment and referral in an acute cardiac ward.

Results. The key findings of this study were that the education programme: (1) increased the knowledge base of nurses working with cardiac patients on comorbid depression and coronary heart disease, and (2) assisted in the identifica- tion of depression and the referral of ‘at risk’ patients.

Conclusions. Emphasis was placed on the translational significance of educating cardiac nurses about depression  via  the  introduction  of  a  depression  screening and referral instrument designed specifically for use in the cardiac  ward.  As  a result, participants found they were better equipped to identify depressive  symp- toms and, guided by the screening instrument, to confidently instigate referral procedures.

Relevance to clinical  practice. Much complexity lies in caring for cardiac patients with depression, including issues such as misdiagnosis. Targeted educa- tion, including  use  of  appropriate  instruments,  has  the  potential  to  facilitate early recognition of the signs and symptoms of depression in the acute cardiac setting.

 

Introduction

Depression is common in cardiac patients and is an inde- pendent risk factor for coronary heart disease (CHD) (Freedland &Carney 2013). When depression is linked with CHD, the outcome inevitably increases disease burden. Despite the strength of the link  between  depression  and CHD and guidelines recommending screening for  depres- sion in all patients with CHD (Lichtman et al.  2008, National Institute for Health & Clinical Excellence 2010, Colquhoun et al. 2013), routine screening is not a common practice; often the result of an absence of systems to facili- tate this process (Ziegelstein et al. 2005, Munson et al. 2007, Ski et al. 2012). Additionally, health care profession- als have been found to perceive depression  as  a  ‘normal’ part of suffering after a cardiac event (Worrall-Carter et al. 2012). Not surprisingly, the World Health Organisation (WHO) has predicted depression and CHD to be the two leading health causes of mortality and disability by 2020 (Murray & Lopez 1996) unless improvements in the identi- fication and management of depression  in  patients  with CHD are achieved(Lichtman et al. 2014).

Background

Depression has been established as a firm independent risk factor for CHD morbidity and mortality and has a three to four fold increase in the risk of subsequent cardiac events (Frasure-Smith et al. 2009, Freedland & Carney 2013). The prevalence of major depression in cardiac patient popula- tions is approximately 15–20%, with another 30–50% exhibiting  mild  to  moderate  symptoms  (Lesp’erance  &  Fra- sure-Smith 2000). Further, somatic symptoms such as fati- gue, loss of appetite, sleep disturbance and impaired concentration can be both depressive symptoms and conse- quences of hospitalisation and/or side effects of medications to treat heart disease, which increases the likelihood of under- or misdiagnosis of depression in this patient cohort (Ayalon et al. 2008, Ski et al. 2012). Adding to the com- plexity, cross-sectional and longitudinal data suggest a bidi- rectional association between depression and CHD (Khawaja et al. 2009). Today’s nurses need more knowl- edge to successfully manage the intricacies of this well- established comorbidity (Nemcek & Austin 2009).

Routine assessment of depressive symptoms together with appropriate referral has the potential to improve patient recovery post-CHD (Ski & Thompson 2011).  It  is  impor- tant that clinicians  recognise that  depression  is not a nor- mal expectation after a cardiac event. Given their consistent engagement with patients throughout an acute cardiac admission, nurses are well-placed to recognise the early signs and symptoms of depression. In the absence of formal training in mental health, nurses given targeted edu- cation can rapidly screen for depressive symptoms using validated screening instruments (Thompson & Froelicher 2006). Identification of cardiac patients at greatest risk of depression should subsequently facilitate efficient resource- allocation and improve patient outcomes.

Current nursing practice with regard to recognition of a chronic disease involves appropriate specialised clinical teams for treatment, once an anomaly is recognised. Argu- ably, the same procedure should also be followed with car- diac patients exhibiting signs of depression. The aim of this study was to evaluate the efficacy of an education pro- gramme designed specifically for cardiac nurses to promote accurate screening and appropriate referral of depression in patients with CHD.

Methods

Evaluation research was implemented; the assessment of pro- gramme outcomes that is conducted after completion of the programme (LoBiondo-Wood & Haber 1998). This method was implemented within Donabedian’s ‘Structure-Process- Outcome’ framework (Donabedian 1966). Donabedian’s classic work has been widely adopted as an evaluative model in the health services setting (Donabedian 1980, Smitz Naranjo & Viswanatha Kaimal 2011, Gardner et al. 2013). For the purpose of evaluating the current education pro- gramme on depression in CHD Donabedian’s framework was adapted as: structure being the cardiac ward where the educa- tion took place; process as the teaching method; and outcome as the knowledge and skills gained by cardiac nurses.

Setting, sample and recruitment

A purposive sample of 14 nurses was recruited from two cardiac wards (general medical and surgical) from a major

metropolitan hospital. Purposive  sampling  was  appropriate in this study as participants were cardiac nurses who had attended the education programme.  Before  commencement of the education programme, the attending nurses had the study verbally explained to  them  by  the  researcher  and were provided with a Participant Information and Consent Form sheet. Nurses were then invited to be a participant in the current study.

Intervention: education programme on depression and CHD

The education programme was aimed at improving nurse knowledge of the prevalence and identification of  depres- sion in cardiac patients. The education programme was interactive, encouraging feedback and group discussion throughout.  The  programme  ran  for  approximately  two and a half hours. The main topics covered included: recog- nition of the signs and symptoms of depression; definition/ differentiation of types of depression (mild, moderate and severe) as per the Diagnostic and Statistical Manual (DSM- IV-TR, American Psychiatric Association 2000); relation- ships between depression and CHD; and examples of good practice for referral and treatment of depression in cardiac patients. In addition, a significant component of this pro- gramme was the introduction of the depression screening instrument and referral instrument.

The depression screening and referral instrument was developed and evaluated in another study reported elsewhere (Worrall-Carter et al. 2012). Briefly, it was initially formu- lated based on a review of the literature, including best prac- tice guidelines for the management of depression and CHD, a medical record audit data obtained via a system-based track- ing mechanism in a major metropolitan health service, and expert advice from a multidisciplinary reference group. The instrument consisted of (1) the five-item Depression Scale Short Form (DS SF, Shi et al. 2008) to screen patients for depression, and (2) recommendations for referral based on patient level of risk; no risk, moderate and severe depression. The education programme on  comorbid  depression  and CHD was facilitated by members of the hospital education unit, a multidisciplinary team of health professionals involved in health education and research. The team works within the scope of clinical practice to implement outcomes of research

to improve standards of care for patients hospital-wide.

Ethical considerations

Ethics approval was gained from the service and university Human Research Ethics Committees. All participants gave informed consent to participate in the study.

Data collection

Six weeks post the education programme, during which the depression screening and referral instrument was imple- mented in the cardiac wards, focused semi-structured inter- views lasting for 30–45 minutes were held in quiet rooms located in the cardiac  wards.  Interview  questions  were aimed at gaining a description of participants’ skill set and knowledge base of comorbid depression and CHD. The interview schedule consisted of seven questions   (see Table 1).

Participants were prompted to elaborate or clarify their responses during the interviews. All interviews were recorded. Data collection and analysis were undertaken in parallel; repetition, reiteration and clarification of responses were sought throughout the interviews as a validity check of data. Data saturation was used as an essential guiding principle to determine when to cease the interviews. Accordingly, data collection and analysis continued until no new themes emerged from subsequent interviews. At this point, no further participants were recruited.

Data analysis

Halcomb and Davidson’s (2006) pragmatic data analysis approach was adhered to for the purpose of interview data analysis. This six-stage approach is illustrated in Fig. 1. To summarise, stage one allowed participant responses to be explored in more  detail  during  each  interview.  In  stage two, reflective journaling allowed  for  further  review  of notes immediately after each interview and addition of sup-

Table 1 Interview questions

1. Describe, in your own words, how you would define depression?
2. Explain how your understanding of depression was influenced by the education you received?
3. Describe any signs and symptoms of depression you observed in your patients after a cardiac event?
4. Explain by providing examples, if possible, how you found the information presented in the education on depression to be of use in your practice?
5. Describe the steps you would take upon recognition of signs and symptoms of depression?

6a. On a scale of 1–10, how competent do you feel now after having participated in the education programme in assessing patients with depression?

6b. On a scale of 1–10, how competent did you feel in assessing patients with depression prior to participating in the education programme?

7. Do you feel as though you could benefit from further education on depression? (if so) What area of education on  depression would be most beneficial to you?

Stage 1 Audio-recording data and note taking at time of data collection

Table 2 Participant demographics

Characteristic                                                                        n (%)

Sex (female)                                                                          12 (86)

Stage 2 Reflective journaling immediately post-interview

Country of birth (Australia)                                                  10 (72) Occupation

Full-time                                                                             6 (43)

Stage 3 Listen to recording and revise field notes

Part-time                                                                             8 (57)

Education

Stage 4 Preliminary content analysis

University training                                                            10 (71)

Hospital training                                                                 4 (29)

Professional development in cardiac care

Postgraduate Certificate                                                       4 (29)

Postgraduate Diploma                                                         4 (29)

enhanced nurse knowledge of depression; (2) improved self-

Stage 6 Thematic review

efficacy in identifying depression in the cardiac ward; and

(3) improved referral procedures for patients at risk of co- morbid depression and CHD.

Figure 1 Pragmatic interview data  analysis  as  described  by Halcomb and Davidson (2006).

plementary information to assist with interpretation. Stage three involved listening to the audiotape to ensure the accu- racy of notes taken. In stage four, interview  transcripts were re-reviewed and common responses were grouped to form themes. Stage five involved a fellow researcher review- ing the notes and listening to the audiotapes for secondary validation of themes. Lastly, in stage six, the data were linked to findings from the associated literature.

Results

Participant characteristics

Most of the 14 cardiac nurse participants were female (12), 10 were born in Australia and 10 had tertiary-based prereg- istration studies (see Table 2). The age range of nurses was 24–45 years (±7-2). Registered nurse experience ranged between 2 and 21 years (±6-7), and cardiac nurse  experi- ence ranged between 0 and 18 years (±6-0).

Interview data

Analysis of interview data using Halcomb and Davidson’s (2006) pragmatic approach identified three key themes: (1)

Theme 1. Enhanced nurse knowledge of depression

Theme 1 revealed participants’ knowledge and understand- ing of depression. When asked to define depression, the majority of participants responses pertained  to  low  mood and feelings of sadness, for example:

Basically, it’s a state of feeling negative, low in one’s mood.. ..

(nurse one);

Depression is no interest for life. (nurse two); and

.. . being depressed – is feeling low, teary, suicidal thoughts and sense of hopelessness. (nurse three)

Their statements provided clear evidence that the nurses understood the symptomatology of depression as per the DSM-TR-IV.

Other than describing the signs and symptoms of depres- sion, most participants indicated their perceptions of depression as a mental illness:

It is a mental illness, which is fairly common, that affects people’s enjoyment and interaction in life. (nurse four);

I guess depression is a chemical imbalance in the brain, where you can’t produce enough serotonin which can be either hereditary, or brought on by a stressful event. (nurse five)

These descriptions demonstrate a comprehension of depression as a mental illness and its potential to be

idiopathic, and therefore a recognition of the difficulty of diagnosis.

A depth of knowledge  of depression  was  also  displayed in participant descriptions of the patient experience. The meaning of being depressed covered subjects such as a sense of helplessness, frustration, anxiety, and death:

Probably, I guess, a feeling of sadness sometimes overwhelming not just affecting mood and motivation, but a sense of  helplessness. Anger and fear of about life in the now, I think there is a sense of them coming close to dying and there is a fear that it may happen again. (nurse fourteen)

Many participants described their recognition of patients having lost interest in performing their daily tasks, such as:

The cardiac patients do not want to talk to you, not interested in daily activities. (nurse seven);

Lots of people don’t want to get out of bed, they just want to stay in bed, not doing anything, not talking to visitors. Long term patients just want to be alone and do not want to get involved with physiotherapist, or anyone who comes to talk to them. (nurse eight); and

Just withdrawn from family and staff, not  engaging  in  conversa- tion. Generally they are quiet and not functioning very well in their ADLs (activities of daily living). (nurse nine)

In addition to demonstrating nurses’ identification of depressed patients as psychologically unwell, participants statements also corresponded with specific symptoms pro- vided in the education  programme  that  were  drawn  from the American Psychiatric Association (2000); such as, social isolation, withdrawal and a display of a volition.

Theme 2. Improved self-efficacy in identifying depression in the cardiac ward

All participants commented that the education programme was helpful in terms of its impact on their ability to suc- cessfully recall the signs and symptoms of depression on the cardiac wards. The comment below was typical of the sam- ple:

I now look for signs and symptoms I can now say in my head

that I know it is a sign of depression. I guess it gives me more con- fidence in my assessment. (nurse ten)

Arguably, communication is the one of  the most impor- tant skills in nursing. Participants relayed the importance of engaging with their patients in an ongoing effective manner to assist in improving patient outcomes as a result of the education received. The following quotes emphasise the

change in nurse confidence in addressing depression  with their patients:

.. . probably, how to better deal with depressed patients and how we, the nurses, can help them once we recognised they are depressed… I guess I have the confidence to try to help, not wor- sen, the situation. Also, I’m no longer scared to talk about it and I certainly don’t ignore it. (nurse eleven), and

I think I’m better in recognising depression. In no way mean that I can cure someone with depression. I just mean I understand better, what words, conversations you can have with patients to provide them with reassurance. (nurse six)

Nearly all participants also described how they used the depression screening and referral instrument as part of enhancing their practical and verbal skills. As a result, they identified that they were  able  to  provide  reassurance  to their patients suffering from depressive symptoms postcar- diac event. This is reflected below:

First fill your clinical pathway. Ask the patients how they feel since the surgery – probably give some reassurance. It’s quite normal post-cardiac surgery to experience some depression, anxiety and as well as confusion. If I were seriously concerned, I would speak to the treating team. I’m now aware that I can  make  a  referral  to mental health nurse. (nurse twelve), and

Generally, I’ll ask family and friends who know the patient well; Is it normal for them to be depressed or what is their mood  is normally like? At least we can offer them  reassurance  and  refer them for psychological care using  the  screening  tool.  (nurse thirteen)

Theme 3. Implications of education in clinical practice

The last theme explored the clinical implications of imple- menting the education programme on comorbid depression and CHD and use of the screening and referral instrument in the cardiac wards. The ‘user-friendly’ application of the screening and referral instrument often referred to as the ‘screening tool’ was emphasised by the majority of partici- pants through comments such as:

To record in the progress notes and inform the resident who  is looking after the depressed patient was an uncomplicated process. (nurse two)

The tool is self-explanatory and it’s not difficult to read and to fol- low. (nurse fourteen)

A few participants raised the importance of the need for a depression screening instrument on the cardiac ward. The

following commentaries demonstrate the clinical value of implementing the screening tool:

The tool has been useful being able to score, using a quantitative method of scoring assists when interpreting the data and in identi- fying patient risk of depression. Where previously, I could say they seemed moderately or  not depressed, and do  nothing about it. Now I can actually classify it. (nurse six), and

Yes, it’s because of the tool. You know using the tool to assess the patients with depression. It was  easy. The  tool is self-explanatory and it is not difficult to read and  to  follow.  My  concern  is  that these forms don’t get lost in the system. (nurse fourteen)

Also, one participant highlighted the importance of using the screening instrument on the cardiac ward to differenti- ate between somatic complaints and depressive symptoms and stated:

I think the problem that you have in cardiac surgery is that the vast majority of patients have a lot of signs and  symptoms of  depres- sion, not as a result of being depressed but after having cardiac sur- gery – feeling frustrated, feeling low of appetite  –  all  fairly common. I am now able  to  understand  how  to  pick  the  people who are really depressed from people who are postoperatively recovering. (nurse four)

An increased interest in learning more about comorbid depression and CHD was also expressed by most partici- pants, for example:

First of all I will speak to the doctors, if I’m concerned, encourage them (the doctors) to do a psych referral and, if I can, possibly talk to the psychiatric liaison myself nurse to get even more knowledge of what I can do. (nurse one), and

I now first talk to both our nurse in charge whether they think that I’m correct and then talk to the treating team, doctors and also, if necessary, try to talk to the patients if they know why  they  are feeling like that. (nurse three)

Summary of findings

Figure 2 depicts the three key themes along with the corre- sponding sub-themes identified. To summarise, in theme 1, nurse participants articulated the benefit of the education programme with regard to providing them with a depth of knowledge on comorbid depression and CHD in recognis- ing and understanding its impact on the patient. Theme 2 exemplified nurses’ newfound confidence in identifying depression and applying the ‘screening tool’. Theme 3 high- lighted the clinical implications of implementing the instru- ment in terms of improved referral procedures for patients with CHD at risk of depression.

Discussion

Comorbid depression and CHD is  often  under-recognised and under-treated and increases the relative risk of death (Ziegelstein et al. 2005). The complexity involved in caring for patients with this comorbidity lies not only in identify- ing often overlapping symptoms, but also in the intense environment that is the cardiac ward  (i.e.,  busy,  demand- ing, short stays) (Ayalon et al. 2008). Primarily due to lack of evidence-based systems to facilitate the process, routine screening and referral are not performed (Munson  et al. 2007, Worrall-Carter et al. 2012).  This  study,  therefore, was aimed at increasing identification and referral of

Theme 1 Enhanced nurse knowledge of depression
	Subthemes:
	Understanding signs and symptoms of depression Depth of knowledge

Figure 2 Depression and coronary heart disease education: key themes and sub-themes.

patients at risk of depression in the cardiac wards of a major metropolitan hospital via (1) increasing the knowl- edge base of nurses working with cardiac patients on comorbid depression and CHD, and (2) introducing a depression screening and referral instrument.

Evaluation of the educational programme, in terms of outcome (‘knowledge and skills gained by nurse partici- pants’), was achieved via exploration of participant experi- ences and perceptions of the programme and implementation of the depression screening and referral instrument in the cardiac wards. Two key outcomes of clini- cal significance were identified: (1) all participants regardless of experience or position articulated sound knowledge of depression, including recognition of the key signs and symp- toms of depression, and (2) application of the screening and referral tool assisted in the identification of symptomatic depression and referral of ‘at risk’ patients. These findings endorse the National Heart Foundation of Australia’s recent consensus statement, advising that a simple tool for depres- sion screening can be incorporated into usual clinical prac- tice with minimal interference (Colquhoun et al. 2013).

The breadth of knowledge gained from the education programme also extended to enhancing nurse self-efficacy when caring for patients  with  comorbid  depression  and heart disease. The screening  and  referral  instrument  not only allowed patients’ depressive symptoms to be identified, it also provided a point of reference  for  discussion  with other clinicians, including fellow nurses,  cardiologists  and the mental health team. As described by  Nemcek  and Aus- tin (2009), actively seeking further information and knowl- edge in the clinical setting enriches the therapeutic relationship between nurse and patient.

Depressive symptoms can be vague and hard to recognise especially when comorbid, which makes identification all the more challenging. The depression screening and referral instrument was designed to guide nurses with either limited or no formal training in mental health care. Essentially, the majority of participants became advocates of the ‘screening tool’, as denoted in the various depictions of its clinical use- fulness in the cardiac wards. Nurses expressed how being able to quantify those at risk of depression led to improved documentation and referral procedures. Such actions have the potential to reduce patient burden and poor quality of life (Ayalon et al. 2008). As part of clinical and legal con- siderations, documentation is an important part of the nurs- ing profession (Austin 2011). Accurate documentation was emphasised throughout the education programme. Of note, screening alone is not sufficient for improved patient out- comes; screening and referral must be followed up with appropriate treatment (Ski & Thompson 2011).

Limitations

The sample size (n = 14) was small which may have limited the findings. However, data saturation was reached and no new themes emerged from the data sources during data analysis. The purposive sample used was appropriate to this study, as we required nurses who had attended the educa- tion programme. Whilst the two and a half hours education programme was designed in a short time frame so as not to interrupt care in the cardiac wards, some nurses declined to participate due to workloads and time constraints; as such, the sample may not be reflective of the entire nursing popu- lation working on these two cardiac wards.

Conclusion

The concept of implementing depression education  along with a screening and referral instrument arose from the explicit need to improve identification of depression  in cardiac patients and to promote pathways for early inter- vention (Thompson & Froelicher 2006, Khawaja  et al. 2009). Hence, it is important to have not only the knowl- edge but also the appropriate tools. These findings demon- strate how targeted education incorporating a simple screening instrument has the potential to facilitate early recognition of  the  signs  and  symptoms  of  depression  in the acute cardiac setting. Based on these findings, we rec- ommend that educating cardiac nurses on depression should be considered a core competency in the nursing curriculum.

Relevance to clinical practice

The clinical relevance of this research lies in the complexity of caring for cardiac patients with depression. Misdiagnosis is a persistent issue. Thus, emphasis was placed on the translational significance of educating nurses on depression by means of the introduction of a screening and referral instrument for use in the cardiac ward, something previous studies have failed to do (Davies et al. 2004). In doing so, participants found they were better equipped to identify depressive symptoms, and guided by the screening tool, to confidently instigate referral procedures.

Acknowledgements

The authors thank the hospital education and research unit who conducted the education programme on the cardiac wards, and the nurses who participated in this research for their generous support.

Disclosure

The authors have confirmed that all authors meet the IC- MJE criteria for authorship credit (www.icmje.org/ethi- cal_1author.html), as follows:  (1)  substantial  contributions to conception and design of, or acquisition  of  data  or analysis and interpretation of  data,  (2)  drafting  the  article or revising it  critically  for  important  intellectual  content and (3) final approval of the version to be published.

Funding

The author(s) received no financial support for the research, authorship,and/or publication of this article.

Conflict of interest

No conflict of interest has been declared by the authors.

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