An evaluation of the psychological ... - University of Leeds€¦ · of Leeds (John Charles Centre, Kirkstall Centre, Armley Centre, John Smeaton and Holt Park). In terms of improving

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An evaluation of the psychological wellbeing and quality

of life of a small subsection of post-Myocardial Infarction

outpatients attending the Leeds Community Cardiac

Rehabilitation Service

Leanne Messham

Commissioned by Dr Penny Morris, Consultant Clinical Psychologist, Leeds Teaching

Hospitals NHS Trust

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1. Introduction

1.1 Myocardial Infarction

A Myocardial Infarction (MI) is an outcome of cardiovascular disease and is

commonly known as a heart attack. The British Heart Foundation released statistics

showing that within England in 2012, 141,000 people were hospitalised with an MI

(BHF, 2014). The subsequent impact can be life threatening and have significant

implications in the immediate time following the cardiac event (e.g. Alsén, Brink,

Brändström, Karlson, & Persson, 2010; Barth, Schumacher, & Herrmann-Lingen,

2004). Therefore, understanding the impact of an MI and the needs of this population is

important in improving healthcare and health outcomes, including service structure (e.g.

utilising resources) and its potential economic impact.

1.2 Impact of an MI

1.2.1 Psychological and physical wellbeing

There is evidence highlighting the higher prevalence of anxiety and depression

in post-MI patients compared to the general population. For example, Lane, Carroll,

Ring, Beevers, & Lip (2002) assessed patients at three time points following their

cardiac episode. They found that symptoms of both depression and anxiety were

present from the initial assessment during the acute phase of the MI (2-15 days). These

symptoms increased during the following first year, with half of the sample

experiencing a degree of anxiety and/or depression. Another study reported a lower

frequency (20%) of post-MI patients experiencing a clinically significant degree of

depression (Ruo et al., 2003).

The relationship between psychological wellbeing and physical functioning is

also well established in the literature. Physical health outcomes are rated by mortality

Service Evaluation Project Leeds Community Cardiac Rehabilitation ServiceService Evaluation Project Leeds Community Cardiac Rehabilitation Service

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and morbidity (risk of further cardiac events). There is an increased risk of sudden

death following an MI (Barth, Schumacher, & Herrmann-Lingen, 2004; Nielsen,

Vestergaard, Christensen, Christensen, & Larsen, 2013). One factor that influences

this association between MI and mortality is depression (van Melle et al., 2004;

Frasure-Smith et al., 2000); evidence suggests that even sub-clinical levels of

depression can affect this association (Bush et al., 2001). In terms of morbidity, a

meta-analysis of those having been assessed as depressed three months post-MI had a

2-2.5% increased risk of subsequent cardiac related problems within the following 2

years (van Melle et al., 2004). Post-MI patients’ mental health status was also

associated with an increased risk of secondary cardiac complications (Nielsen,

Vestergaard, Christensen, Christensen, & Larsen, 2013). Mental health status was

determined through a validated questionnaire assessing vitality, role-emotion and

mental health (p.2). Alongside cardiac disease severity, this relationship was also

related to factors such as physical activity, depression and anxiety all pertaining to a

persons’ quality of life (QoL).

It is noteworthy that these studies utilise different methods of identifying

psychological wellbeing. For example, identifying depression through interviews

versus self-report measures. Interviews are thought to be a conservative measure,

which may underestimate the severity of psychological difficulties, and may mask

other potential variables (Meijer et al., 2011). However, other evidence suggests that

there was no difference between these two methodologies when assessing for morbidity

factors (Barth et al., 2004).

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1.2.2 Health Related Quality of Life

The psychological wellbeing of post-MI patients is also known to impact on

their perceived QoL. A large-scale study was conducted analysing the difference in self-

reported QoL and health status between those showing signs of depression and those

who did not (Ruo et al., 2003). This included participants who have experienced a range

of difficulties with Coronary Heart Disease (CHD) with over half of the sample

experiencing an MI. Those who showed signs of depression based on the Patient Health

Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) were more likely to

experience mild symptom burden, mild physical limitation and mildly reduced QoL

(Ruo et al., 2003). However, studies specifically related to an MI found that after six

months anxiety and depression was significantly associated with greater problems

carrying out physical activities (Dickens et al., 2006). The greater level of impact

identified in this smaller scale study may be explained by the use of a HRQoL measure

that has greater sensitivity than broader QoL measures (Simpson & Pilote, 2003).

HRQoL refers to the impact the specific health problem has on different areas of a

persons’ functioning such as ‘physical, mental, emotional, and social’ aspects (Healthy

People, 2017). In summary, this evidence shows that having an MI can have a

significant impact on a persons’ QoL and is associated with the extent that it affects a

person’s psychological wellbeing.

1.3 Cardiac Services

1.3.1 Cardiac Rehabilitation

The National Institute for Health and Clinical Excellence (NICE, 2013)

recommends that all MI patients should be referred to a cardiac community

rehabilitation (CCR) programme. This should address health education, exercise and

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stress management. Encouragingly, the 2016 annual report for the National Audit of

Cardiac Rehabilitation found that there has been an increase in CCR attendance up to

50% (BHF, 2016). However the BHF continues to emphasise the on-going need for an

improved understanding of MI patients’ needs and improvements to be made their

cardiac rehabilitation.

1.3.2 Leeds Cardiac Community Rehabilitation Education and Exercise

Programme

The Leeds Institute for Quality Healthcare (LIQH) leadership contributed to

improvements within the Leeds cardiology service. In collaboration with the wider team

they developed recommendations to progress the quality of psychological care of post-

MI patients. As medical professionals are found to under-recognise mental health

problems in this population they recommended the use of validated screening tools

(Ziegelstein et al., 2005). In light of this, the Community Cardiac Rehabilitation (CCR)

nurse-led team at Leeds are encouraged to implement measures of depression and

anxiety.

CCR includes home-based, individual and group based interventions, with

group-based interventions being the most commonly used in the UK (BHF, 2016). Part

of the Leeds CCR is the educational and exercise group programme targeted at those

who have been discharged from cardiac inpatient services. This involves a rolling 12-

session programme facilitated by cardiac-rehabilitation nurse specialists and a

specialist gym instructor. They also have access to a mental health practitioner and other

professionals who provide the educational sessions. Taken from the service leaflet, the

aim of this programme is to improve confidence in a safe environment, receive health

information and advice on their individual recovery, to facilitate peer


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support and improve physical fitness. These groups run at five locations across the city

of Leeds (John Charles Centre, Kirkstall Centre, Armley Centre, John Smeaton and Holt

Park).

In terms of improving the rehabilitation service further, the literature on the

impact of an MI has limited applicability because it does not assess those specifically

within this type of CCR service. Through consultation with the Leeds team it was

apparent that some members assumed that patients attending their community group

programme might not experience a significant impact on their HRQoL or psychological

wellbeing. However, there is little objective evidence about this.

1.5 Aims of this evaluation

The aims of this evaluation were developed through meetings with the

commissioner, the wider multidisciplinary cardiac team and the lead nurse specialist of

the CCR.

The primary aims of this service evaluation were:

1) To measure the prevalence of depression and anxiety in post-MI patients

2) To measure the disease specific health-related quality of life of post-MI

patients

3) To investigate the relationship between depression and anxiety with health-

related quality of life of post-MI patients


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This also included two additional exploratory aims:

1) To investigate the effect of participants’ time point in the programme on

the outcome measures. This was to explore whether those at different

points in the group programme require additional monitoring and support.

2) To provide any observations on the experience of using outcome measures

in this community-based setting.

A second evaluation conducted in partnership with this project aimed to

understand staff’s satisfaction with caring for the psychological needs of post-MI

patients and patients’ satisfaction receiving this service.

2. Methodology

2.1 Design & Analysis

This service evaluation was performed using a questionnaire survey

administered at one time point and used purposive sampling. Participants were at

different stages in the 12-session rolling group programme. At a group on any given

date, one participant may be in session 1 and another may be in session 5. Therefore,

the session number relates to the number of sessions attended by an individual

participant at their point of recruitment. Participants joined the programme at different

lengths of time since their MI and therefore this time frame does not relate to their

session number.

Three self-report questionnaires were administered and demographic

information including their employment status was also collected. Participants who

were not currently working but planned to return to employment were asked to rate

their confidence to return to work on a scale from 1 (‘least confident’) to 10 (‘most


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confident’). Recruitment took place between June and September 2017 on 14 separate

occasions. Recruitment difficulties occurred due to the limited number of eligible

participants attending the group programme during the recruitment time frame. Due to

the small sample size only descriptive statistics could be calculated due to insufficient

power for inferential statistics.

The cardiac team had concerns about the feasibility of more sophisticated

methodologies e.g. repeated measures. This was due to the nurses’ limited capacity to

support data collection and the risk of burdening patients as another evaluation was

also being conducted with the CCR. This limited the design and research questions

that could be answered. As a result a new tool for measuring disease (MI) specific

HRQoL was used to provide novel findings that fit within the time constraints of the

service.

Ethical approval was gained from the University of Leeds (MREC16-093) and

R&D approval from Leeds Community Healthcare NHS Trust. Difficulties occurred

when seeking R&D approval as this required additional information regarding the

wellbeing of patients to participate. Through liaising with Health Research Authority,

the local R&D team and the cardiac MDT the protocol was adapted and approval

gained.

2.2 Participants

Twenty-three participants took part in this evaluation that met the following

inclusion criteria:

o Experienced an Myocardial Infarction (MI)

o Currently attending the Leeds Cardiac Community Rehabilitationeducation and exercise programme


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o MI was their only identified cardiac-related health problem

o English as a spoken language

2.3 Measures

Generalised Anxiety Disorder (GAD-7)

The GAD-7 (Spitzer, Kroenke, Williams, & Lowe, 2006) is a short self-report

questionnaire assessing symptoms related to anxiety. Participants rate how frequently in

the past two weeks they have experienced each of the items from 0 (‘not at all’) to 4

(‘nearly every day’). These scores are classified into four categories of anxiety: 0-4

‘minimal’, 5-9 ‘mild’, 10-14 ‘moderate’ and 15-21 ‘severe’. For the purpose of this

evaluation, scores of 0 were categorised as ‘no symptoms’ and 1-4 as ‘minimal’

symptoms totaling five categories.

Patient Health Questionnaire (PHQ-9)

The PHQ-9 (Kroenke, Spitzer, & Williams, 2001) is a short self-report

questionnaire assessing symptoms related to depression. Participants rate how

frequently in the past two weeks they have experienced each of the items from 0 (‘not

at all’) to 3 (‘nearly every day’). The data was then categorised into the five clinical

classifications of depression of 0-4 ‘minimal’, 5-9 ‘mild’, 10-14 ‘moderate’, 15-19

‘moderately severe’, and 20-27 ‘severe’. For the purpose of this evaluation, scores of 0

were categorised as ‘no symptoms’ and 1-4 as ‘minimal’ symptoms totaling six

categories.


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Myocardial Infarction Dimensional Assessment Scale (MIDAS-35)

The MIDAS-35 (Thompson et al., 2002; Appendix B) is a self-report

questionnaire assessing the impact of health related difficulties specifically for post-MI

patients and recommended for cardiac rehabilitation. A licence was obtained from the

University of Oxford. The questionnaire has proven to have good construct validity

between the subscales of the MIDAS-35 and a generic QoL measure, and a very high

internal consistency on both single items and subscale scores.

This measure includes seven subscales of physical activity, insecurity,

emotional reaction, dependency, diet, concerns over medication and side effects.

Participants are asked to score how frequently they experience each of the items on a

scale of 0 (‘not at all’) to 4 (‘all of the time’). The total percentage for each subscale is

calculated and an overall total. The higher the percentage the more difficulties they

experience and the worse their health is understood to be. To make sense of this data,

the scores were split into five categories (0-20%, 21-40%, 41-60%, 61-80% and 81-

100%). Missing data was limited and handled according to the MIDAS-35 manual,

imputing the average total score for that individual.

2.4 Procedure

Participants were recruited from all centres used by the CCR. Initially, the lead

nurse of each group identified potential participants who met the inclusion criteria and

all of these patients were invited to take part in the evaluation. The researcher provided

each potential participant with the information sheet to read and an opportunity to ask

any questions before they decided whether to participate. Participants provided written

consent, completed the self-report questionnaires with guidance from the researcher


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and had the opportunity to debrief while waiting for the group session to begin.

Participation took approximately 15 minutes.

3. Results

3.1 Service and sample

3.1.1 Demographic information

During the recruitment period, a total of 278 outpatients having experienced an

MI were referred to the Leeds CCR. Approximately 50% of these outpatients were

assessed for and were reported to have completed the group programme.

Of all those invited to take part (N =26), one patient declined taking part,

another was unable to take part due to their significant auditory difficulties and

another was omitted later on as it was medically unclear whether the individual had

experienced an MI. The final sample was a small subsection of MI patients (N =23).

The participants were comprised of 71% males and 29% females. This is similar to the

UK prevalence rates with approximately three times more men experiencing an MI

than women (Bhatnagar et al., 2015). This sample had a total average age of 61 years

old with a lower average age for men (58 years old) and women (67 years old)

compared to some published national data on MI patients (UCL, 2014).

As stated in the methodology, Graph 1 shows that participants took part in the

evaluation at different sessions (more information in Appendix C) and more

participated earlier on in the group programme. Within the same session participants

were generally at different lengths of time since their MI. As it was obscured on the

graph, two participants from different groups participating at session three were 63

days since their MI and two participants scored within close range (51 and 52 days) at

session five.


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Graph 1. Relationship between participants’ group session number and the number of

days between their MI and participation

3.1.2 Employment

Out of the sample, nine participants reported working. Three of these

participants reported working fewer days per week since their MI with one of these

participants reporting that this was because of psychological factors. Furthermore, ten

participants reported that they had retired. Three of those reported retiring after their MI

with one stating that this was a direct consequence of the physical impact of their MI

and the other two participants reporting that this was an expected retirement for their

age. Lastly, three participants reported not working but had not retired. Of these,

one stated this was for both physical and psychological reasons and reported their

confidence returning to work as very low (2 out of 10). The other two reported this


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was because of physical reasons and were confident about returning to work (10 out of

10). One participant did not provide any employment information.

3.2 Primary Aims

3.2.1 Anxiety and depression

These descriptive statistics are taken from the GAD-7 and PHQ-9. The subscales

pertaining to emotional and psychological wellbeing from the MIDAS-35 are presented

in the HRQoL results section.

Graph 2. The prevalence of anxiety post-MI

No symptoms Minimal Mild Moderate Severe

Clinical Classification of Anxiety

Graph 2 represents the prevalence of anxiety following an MI. One in 5 (22%)

of the sample showed signs of anxiety falling within a clinical classification (mild-

severe, N = 5). Specifically, as displayed in graph 1, two participants showed signs of


Pe

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45%

40%

35%

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at least mild anxiety and two showed signs of moderate anxiety, with one participant

scoring within the severe range. Three participants scored above the threshold for a

possible diagnosis of generalised anxiety disorder (>10). The majority of the sample

experienced some degree of anxiety, with nearly half of the sample experiencing

minimal anxiety (N = 11).

There is no published data for the UK general population using the GAD-7

therefore data from a German sample has been provided (Lowe et al., 2008). The

normative sample (n=5036) had an average age of 48.4 years old that is below the

average age in this sample and fewer male participants (approximately 50%). The

prevalence rates available showed that a larger proportion of the MI sample scored in

the moderate (9%) and severe (4%) ranges compared to the general population (5%

and 1% respectively).

Graph 3. The prevalence of depression post-MI

Nosymptoms

Minimal Mild Moderate Moderatelysevere

Severe

Clinical Classification of Depression


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Graph 3 represents the prevalence of depression following an MI. One in four

(26%) of the sample showed signs of depression falling within a clinical

classification (mild-moderately severe, N = 6). Specifically, three participants showed

signs of mild depression with another three scoring within the moderately severe

range. No participants showed symptoms of depression at a moderate and severe

range. However, the majority of the sample experienced some degree of depression

symptoms, with just below half of the sample showing minimal signs of depression

(N= 10).

There is no published data for the UK general population using the PHQ-9 so

data from a German sample has been provided (Kocalevent, Hinz, & Brähler, 2013).

Data was taken from a subsection of this population (N=2693) that have similar

characteristics to the current sample (Hinz et al., 2016). The average age is 62.3 years

old with a larger proportion of male participants (59%). The normative data combined

the moderate severe (≥15-19) and severe (≥20-27) classifications used in this current

evaluation into one classification (severe: ≥15-27). The prevalence rates showed that a

smaller proportion of the MI sample scored in the mild range (13%) and the moderate

range (0%) compared to the general population (21.2% and 5.1% respectively). A

larger proportion of the MI sample scored in the moderately severe and severe range

combined (13%) compared to the general population in the severe range (1.5%).


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3.2.2 Disease Specific HRQoL

These descriptive statistics below represent the HRQoL scores from the MIDAS-

35.

Graph 4. The frequency of participants scoring within each severity range for the

HRQoL sub-scales

MIDAS-35 Subscales

The worst health status was identified as those scoring in the highest range (81-

100%). As displayed in graph 4, the subscales that participants reported had the

greatest impact on their health status were concerns about medication (range 0-100%),

followed by diet (range 0-92%) and dependency (range 0-92%). At least one

participant scored within the 61-80% range for each subscale and at least one participant

scored within the 41-60% range for all subscales except for dependency. For all

subscales at least three participants scored with the 21-50% range.


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0-20%

21-40%

41-60%

61-80%

81-100%

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The largest proportion of participants for all subscales scored within the 0-20%

range, which was the lowest scoring category. A greater number of participants

reported experiencing milder but noteworthy problems with side effects (range 0-

63%), then emotional reaction (range 0-69%) followed by insecurity (range 0-61%). In

addition, all participants experienced difficulties with physical activity (range 2- 67%)

although only 9 participants rated problems in this area above 20%.

3.2.3 HRQoL, Anxiety and Depression

The HRQoL results were then stratified by the individuals’ clinical classification

of depression and anxiety.

Graph 5. Average total HRQoL score for those within each clinical classification of

anxiety

No symptoms Minimal Mild Moderate Severe

Clinical Classifications of Anxiety


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Graph 6. Average total HRQoL score for those within each clinical classification of

depression

Nosymptoms

Minimal Mild Moderate ModeratelySevere

Severe

Clinical Classifications of Depression

Graph 5 and 6 show that those who experience more severe anxiety and

depression also experience a larger subjective impact on their overall HRQoL. There

was also a difference between those who experienced no symptoms of anxiety and

depression with those who experience minimal symptoms. Those with minimal levels of

anxiety and depression whose scores didn’t reach a clinical classification experience

lower HRQoL demonstrated by a worse score on the impact of their health, compared to

those experiencing no symptoms.

3.3 Additional Exploratory Aim

3.3.1 Time point in the programme and outcome measures

Further exploratory analysis looked at the effect of participants’ time point in the

programme (the patients session number when competing the evaluation) on the

outcome measures. From graphical data there was a weak correlation suggesting that


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those earlier on in the group may experience a worse HRQoL and greater difficulties

with anxiety and depression.

4. Discussion

Overall this evaluation provides evidence on the HRQoL and prevalence of

anxiety and depression in a small subsection of post-MI patients within the Leeds CCR

group programme. The results are discussed in light of the literature and the Leeds

service.

4.1. Primary aims

4.1.1 Anxiety and depression

In relation to their psychological wellbeing, 22% of the sample experienced

symptoms of anxiety and 26% experienced symptoms of depression that fell between

mild-severe ranges. This shows that some of those attending the CCR groups experience

a clinically meaningful impact on their psychological wellbeing that warrants

monitoring and may be consistent with diagnostic criteria. When compared to

the general population, those in this MI sample may experience more severe

depression and anxiety at a clinical level (≥10; Hinz et al., 2016, Lowe et al., 2008).

This may also support the need for targeted intervention in this area for MI patients.

However it is difficult to draw conclusions from this comparison due to the differences

in sample size, demographics and culture. There was also evidence of a significant

psychological impact from the measure of HRQoL (subscales of insecurity and

emotional reaction) with patients experiencing difficulties such as feeling irritable, bad

tempered, stressed and anxious about dying. These findings challenge the

Service Evaluation Project Leeds Community Cardiac Rehabilitation ServiceService Evaluation Project Leeds Community Cardiac Rehabilitation ServiceService Evaluation Project Leeds Community Cardiac Rehabilitation Service

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assumption that those within the CCR education and exercise group are functioning

well and show that there is a spectrum of severity in relation to their psychological

wellbeing.

There was also evidence that a larger proportion of this subsection of post-MI

patients experience sub-clinical levels of depression and anxiety compared to no

reported difficulties at all. Even milder psychological difficulties are known predict

further cardiac-related problems (Bush et al., 2001). This suggests that using clinical

classifications may not offer an adequate or effective assessment of a client’s needs. The

second part of this service evaluation addresses how the nursing team are using

psychological measures. It may be that a more flexible approach to analysing the

information gained through screening tools needs to be taken.

4.1.2 HRQoL

In relation to the impact on HRQoL, all areas assessed appeared to be

important, with several participants experiencing their most frequent difficulties in the

areas of medication concerns, diet and side effects. There were a higher number of

participants experiencing less frequent but noteworthy difficulties across all other

subscales (physical activity, instability, emotional reaction and dependency). This

evidence shows that there is a spectrum of discrete factors that have the potential to be

unrecognised in relation to a persons’ HRQoL and therefore may signify possible

unmet need. This also adds to the importance of identifying how measures are used

within this service, for instance it may be that reading the items instead of using scores

may provide a better sense of a person’s experiences in order to better meet their

needs.

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In relation to physical activity, all participants rated some degree of difficulty

in this area (e.g. being slowed down, lacking energy and thinking twice about

undertaking physical activity). Albeit this was one of several subscales where fewer

people rated more significant problems in this area. Alongside most participants

functioning well enough that they could engage in some level of activity (e.g.

continuing work or engaging in exercise). However this contrasts other studies (e.g.

Dickens et al., 2006) that have found a greater impact of the MI on physical activity.

This may be due to the specificity of the measures used in other studies to target

physical activity and not address the variety of QoL factors assessed by this project.

Although the MIDAS-35 is a valid measure there are two important factors

limiting the interpretation and application of its outcomes. As this measure is specific

to myocardial infarction there is no normative data available to assess how the results

compare to other population groups. Also, there were difficulties interpreting what

signifies a clinically significant impact on their QoL and subjectively applied

classifications had to be applied to analyse the data.

4.1.3 Anxiety, depression and HRQoL

In addition to these findings, those experiencing more frequent symptoms of

anxiety or depression experienced a greater impact on their overall HRQoL. This

evaluation also showed that seven participants reported a degree of physical or

psychological impact on their ability to work causing them either to retire, work at a

slower pace or were delayed returning to work. It may be appropriate to assume that

having an MI may have financial implications for the individual, and economically for

employers and healthcare services. Therefore, addressing these difficulties may also

impact on someone’s ability to continue working (Kisley & Simon, 2005). However,

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there may be other variables contributing this effect. Also, potential participants not

attending the group when the researcher was present limited the sample size and

therefore the generalisability of these findings. Despite these limitations, these findings

are consistent with the wider literature on post-MI patient’s psychological wellbeing

affecting their QoL (e.g. Ruo et al., 2003).

4.2 Additional exploratory aims

4.2.1 Time point in the programme

There was preliminary evidence suggesting that those earlier on in the group

programme may experience worse HRQoL, depression and anxiety. Anecdotal

support comes from several participants who referred to having greater difficulties at

the beginning of the group. This suggests that patients earlier in the group programme

may require additional monitoring and support. However, this is only preliminary

evidence with no inferential statistical analysis. In addressing these secondary

exploratory aims there were a number of limitations of note. For instance, the spread

of participants across group sessions was limited (no participants from sessions 10

and 11). Furthermore, there may be confounding variables such as individual

characteristics and stressful life events that may influence patient outcomes. Finally,

the analysis did not take into account the length of time since each participant’s MI.

Therefore, the data must be interpreted with caution and no definitive conclusions can

be drawn. Future investigations using a repeated measures design would allow for a

robust assessment of the effectiveness of the group programme at improving patient

outcomes.


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4.2.2 Observations

The current service pathway for addressing the psychological wellbeing needs

of those attending the group includes the advised use of two standardised measures

used during the assessment, a mental health talk within the education part of the group

programme which addresses stress and stigma and the ability to signpost the

individual to the mental health practitioner for further support. Precise figures on

referral rates to the individual support service were unable to be provided but the

mental health practitioner believed that referrals from the group programme were very

few. Compared to the findings of this service evaluation, this may not reflect the level

of need within this part of the service. This is not a novel finding that patients with

depression post-MI may not receive appropriate healthcare for this and has been

attributed to a lack of confidence and competence of medical practitioners (e.g.

Dickens et al., 2006; Ziegelstein et al., 2005).

In terms of the Leeds CCR, one hypothesis for this is that the psychological

measures already being implemented are not highlighting an accurate sense of a

persons’ psychological wellbeing. Observations made during this service evaluation

suggest potential factors that may be contributing to this discrepancy. Firstly, the nurses

have limited opportunities to spend on-to-one time with patients to ensure their

understanding and mindful reflection upon their experiences. This appeared to be

affected by the size of the group on the day, lack of privacy and the needs of the other

group members. There were also suggestions of patient factors such as their willingness

to receive mental health support, which may be due to stigma. It is hoped that the

secondary CCR evaluation will obtain more valid and reliable information about staff

and patients experiences of using these tools/psychological care.


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4.3 Recommendations

A more detailed copy of the recommendations can be found in appendix A.

Ø To promote the mental health and QoL needs of those post-MI patients

attending the Leeds CCR education and exercise programme amongst the

nursing team.

Ø For nurses to improve how consistently they implement and use the outcomes

from psychological screening tools.

Ø To consider implementing a MI-specific QoL measure such as the MIDAS-35

utilised in this evaluation, to improve the identification of the specific needs of

these patients.

Ø To review the content of the CCR group programme, comparing the needs

highlighted from this evaluation to the current content.

Ø To review the ways in which individual’s needs are identified and met, namely,

considering the way in which these tools are delivered to ensure meaningful and

accurate recordings, and how the information is used.

4.4 Dissemination of findings

The findings of this service evaluation have been presented to the Leeds doctoral

course and commissioners. In addition, they will be disseminated within the Leeds

cardiology service and at the Leeds Community Healthcare NHS Trust research event.

This will also be written up for publication in conjunction with the second part of this

service evaluation.


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4.5 Conclusions

The Leeds CCR service provides a range of support in the important time

period following patients’ MI, as advocated by NICE guidance (2013) and British

Heart Foundation (2014, 2016). Their education and exercise group programme treats

people with varying experiences. There is evidence that a small proportion of this

population group are experiencing problems with their psychological wellbeing with

some reaching levels warranting clinical monitoring, diagnosis and intervention for

anxiety and depression. In addition, a greater proportion of this population report

problems with their quality of life related to their MI across the areas of physical

activity, insecurity, emotional reaction, dependency, medication concerns, diet and

side effects. In light of this, recommendations associated with clinical practice have

been provided.


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Appendix A

Full Recommendations

Ø To promote the mental health and QoL needs of post-MI patients in the Leeds CCR

education and exercise programme amongst the nursing team. This is with the

purpose of developing their awareness that a small proportion of this population are

experiencing significant difficulties with anxiety and depression, and a greater

proportion experience significant problems across a range of factors associated with

HRQoL.

Ø For nurses to improve how consistently they implement and use the outcomes from

psychological screening tools, at least at initial assessment and discharge

appointments. Assessing these difficulties between the beginning and end of the

group programme may enable more individualised and effective healthcare through

improved identification of needs in line with guidelines (NICE, 2013).

Ø To consider implementing a MI-specific QoL measure such as the MIDAS-35 utilised

in this study, to improve the identification of the specific needs of these patients.

This may help tailor the group programme and individual support. The advantages

of this particular measure are that it also encompasses an assessment of

psychological wellbeing and it may be considered to replace the two current

screening measures so not burden patients. However consideration must be taken

before such a change is made and consultation with patients is advised.

Ø To review the content of the CCR group programme, comparing the needs highlighted

from this evaluation to the current content. For example, evaluating whether the

mental health talk adequately addresses the range of potential emotional and

psychological problems experienced.


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Ø To review the ways in which individual’s needs are identified and met, namely,

considering the way in which these tools are delivered to ensure meaningful and

accurate recordings, and how the information gathered is used. This may include

reviewing the competing demands that nurses are under during the group to

meaningfully utilise objective measures of wellbeing and functioning. This will be

directly addressed within the second part to this service evaluation.


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Appendix BMI Dimensional Assessment Scale (MIDAS-35)

Removed from online report for copyright reasons.

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Appendix C

Table 1. Number of participants recruited at each session in the group programme

Session Number ofNumber Participants

1 1

2 3

3 4

4 4

5 3

6 2

7 1

8 0

9 3

10 0

11 0

12 2


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