The Development of Cardiac Nursing and Its Positioning in The Healthcare System Based on the Requirements of Modern Medical Practice

    Authors

    Abstract

    The aim of this article was to describe the key segments and new trends in the development of education and the position of cardiac nurses in global and Croatian cardiac practice. Nurses are the most numerous healthcare professionals and must be recognized as a key factor in shaping the social and healthcare policies in their countries, as they can provide a great contribution to reducing the burden of cardiovascular diseases. Recent examples and results in modern global medical practice are a good indication of how to position cardiac nursing within the Croatian healthcare system.

    Keywords

    the role and position of cardiac nurses, cardiovascular practice, Croatia

    DOI

    https://doi.org/10.15836/ccar2019.275

    Full Text

    ## Introduction Cardiovascular diseases represent the leading cause of death in both developed and developing countries, and thus in Croatia as well. Advancements in biomedical and technological sciences in the last two decades have significantly influenced the reduction of mortality and improvements in quality of life in the general population. Diagnostic and treatment procedures, as well as the needs of patients, have become more complex and demanding, with a consequent increase of complexity in healthcare. Nurses have had to achieve higher levels of knowledge, skills, and competencies to ensure effective and high-quality care and protect the safety of patients, for which they have been responsible since the close of the last century. If we look at demographic and epidemiologic trends from the perspective of the future of cardiovascular diseases, it is likely that we will be faced with a multi-dimensional problem in the future. Aging of the population both at the global level and in Croatia increases the prevalence of cardiovascular diseases, while technological developments will continue to alter approaches in clinical practice, leading to increasingly demanding responsibilities in nursing work. Education of cardiac nurses in developed countries has followed the development trends of modern cardiologic practice, while the positioning of cardiac nurses in the healthcare system that is appropriate to competencies they have acquired has led to a general improvement in care. Cardiac nursing in Croatia is also always searching for new insights and development of professional excellence with the goal of improving care for Croatian patients. ## Education of cardiac nurses and their
position in the healthcare system in
European countries Cardiovascular diseases are the leading cause of mortality in the world and represent a significant global health burden. The healthcare challenges we are faced with today are the increasing aging of the population along with the epidemic of conditions associated with lifestyle habits such as obesity and diabetes ( 1 ). There will continue to be increasing demand for advanced technologies such as imaging and diagnostic services, since the current rate of technological innovations is rapidly continuing ( 2 ). This transformation can threaten the sustainability of providing healthcare services in some countries ( 3 ). According to different reports by the World Heart Federation and the European Society of Cardiology, the demands and challenges of modern cardiological practice are the same or similar in almost all countries, despite their starting points and healthcare situations being different. The Council on Cardiovascular Nursing and Allied Professions of the ESC (CCNAP) performed an analysis of the status of EU countries especially in the context of the care provided by nurses. The analyses showed that the differences in context are especially noticeable regarding education and the formal position of nurses. The differences are found in educational training of nurses and the scope of their role and associated responsibilities ( 2 ). Based on the fact that cardiovascular diseases are the leading cause of mortality and that this burden is expected to continue, the analyses that have been performed also provided guidelines on how to best address this issue. Good results were achieved in primary and secondary prevention. Successful cooperation between members of interdisciplinary teams and focusing on working with and supporting both healthy and at-risk populations in adopting a healthy lifestyle have achieved significant results in primary prevention. Wherever possible, the focus must be on proactive avoidance of poor health through prevention, as opposed to focusing on treatment after a health condition has already developed ( 3 ). The focus is on “care” instead of “treatment”, which represents a significant paradigm shift ( 2 ). Medical nurses, as the most numerous among healthcare professionals, have provided a large contribution to the implementation of this transformation in some developed countries. The education of cardiac nurses in developed countries has followed the development trends of modern cardiological practice. Programs and ways of implementing specialist residency programs for education and certification of medical nurses are defined through cooperation of the healthcare system and professional societies and according to the demands of clinical practice. In this way, nurses develop additional clinical competencies along with the combination of knowledge, skills, principles, and values acquired through their education. The World Health Organization has identified competencies as the key factor in the positioning of healthcare workers within the healthcare system. The development of specific clinical competencies in nursing has in many countries led to the transfer of certain competencies from physicians to nurses. In this way, nurses have adopted a key role in certain segments of care. Important advancements have been made in primary and secondary prevention of cardiovascular diseases, heart failure (heart failure nurses), arterial hypertension, intensive cardiological care, etc. Especially significant advancements have been made in the prevention and rehabilitation of cardiovascular diseases. Under the sponsorship of the World Heart Federation, the European and American nursing associations Preventive Cardiovascular Nurses Association (PCNA), ESC-CCNAP, and the Council on Cardiovascular Nursing of the American Heart Association (CCNAHA) published a document in 2011 under the title “Global cardiovascular disease: A call to action for Nursing”. This document details and explains the role and position of nurses and why they are crucial in the prevention of cardiovascular diseases today and will remain so in the future. Appropriate positioning of nurses based on the acquired competencies regarding implementing preventive cardiologic measures has led to significant reduction of risk factors, improvements in quality of life, and reduction of mortality in cardiac patients. The role of the nurse in the team is crucial and can be divided into three levels: the first level is technical, and its goal is cooperating and coordinating with other members of the team to get the clinical picture of the patient. The second level consists of providing the patient and their family with the information they need to come to terms with the disease and providing support in making steps towards desirable lifestyle changes. The third level is monitoring the implementation of measures and evaluation of goals ( 4 ). The importance of nurses specialized in heart failure for the reduction of the number of subsequent hospitalizations in patients hospitalized for acute decompensated heart failure has been demonstrated by numerous studies. A clinical study conducted as early as 1995 by Rich et al. provided a new perspective on the role of nurses in the treatment of patients with chronic heart failure. The study results showed that the work of nurses in educating patients and family members, planning hospital discharge, diet planning, providing detailed instruction for taking medications, and monitoring after discharge reduced the number of rehospitalizations within the first 90 days by 56% in comparison with the standard procedure ( 5 ). The role and position of cardiovascular nurses is defined and regulated in American cardiovascular practice. The development of certified education programs for nurses has followed the developments and demands in clinical practice. It is clearly defined who and after how many years of clinical practice may apply for certification as well as when and how re-certification is conducted for individual sub-specialist fields. Analyses conducted by CCNAP in European countries showed that educational programs attended by nurses to prepare for clinical practice differ by content, duration, deliver, and setup ( 2 , 6 - 12 ). Institutional education of cardiac nurses in most countries does not meet the demands of modern cardiological practice. Therefore, the CCNAP Education Committee created and published a specialist study program for cardiovascular nurses in 2015, “A core curriculum for the continuing professional development of nurses”. The goal of this program was to assist cardiovascular nurses in EU countries in their education as well as to equalize standards of European cardiological practice. ## Education of cardiac nurses and their
positioning in the Croatian healthcare system Today, Croatian cardiological practice stands side by side with cardiological practice in developed countries. As the most numerous healthcare professionals, nurses hold a central place in the interdisciplinary team. The way nurses respond to these professional demands is a significant factor in whether the results of care will be effective, safe, and efficient. Current clinical practice postulates the requirement of interdisciplinarity, which means that the roles of different professionals within a team intertwine with one another. Good coordination and proper integration results in consistent adoption of new knowledge, innovations, and new applications. Nurses are aware of their position and are always in search of new insights to provide creative solutions for current and future challenges in their areas of clinical responsibility. The Croatian Association of Cardiology Nurses (CACN) was formed in order to provide all nurses in Croatian cardiological practice with a consistent approach to new knowledge. The goal of CACN was to employ various educational programs to help nurses exchange knowledge, experience, and opinions with Croatian and international experts and to encourage critical thought in clinical analysis, which will contribute to the growth of professional excellence. Support in the foundation of CACN and great contributions to its development was provided by the president of the Croatian Cardiac Society (CCS), Academician Davor Miličić, as well as all members of the CCS. The successful cooperation between these two professional societies is presented every two years at the jointly organized national cardiological congress, as well as in the organization of symposiums and congresses by our working groups. The two societies have also formed a Working Group in order to stimulate the Croatian healthcare system to introduce education programs for the acquisition and development of formal competencies and the positioning of cardiac nurses in the healthcare system according to their acquitted competencies. The members of the working group defined the priorities and created programs for post-graduate courses for the following fields: prevention and rehabilitation, heart failure, echocardiography and arrhythmias, and cardiac electrical stimulation. CACN was recognized as a valuable partner by CCNAP, which grew into the Association on Cardiovascular Nurses and Allied Professions (ACNAP) in 2018. In 2015, CCNAP and CACN jointly organized the EuroHeartCare2015 congress in Dubrovnik, Croatia. Over 600 participants from approximately 50 countries attended the congress. Lectures at the congress were held by established international experts in cardiological practice, and the congress was an excellent opportunity to acquire knowledge and exchange experiences for over 200 nurses from Croatian cardiac practice. CACN has continued working with ACNAP and advocates the equalization of standards of nursing practice in EU countries. We are thus in agreement with ACNAP that the education of cardiac nurses should be performed through a specialty residency program. CACN has therefore initiated the procedure of creating occupational standards for cardiac nurses in Croatia. CCNAP has allowed us to translate the Core Curriculum. The Academic Council of the University of Zagreb School of Medicine has accepted the implementation of the specialty residency program for cardiological nurses. We expect cardiac nurses to be positioned appropriately within the healthcare system and cardiological practice, given their education and acquired competencies. The development of clinical competencies and positioning of nurses in the Croatian healthcare system based on these acquired competencies will surely contribute to improvement of quality of life and reduction in mortality for cardiac patients in Croatia. This issue of the Cardiologia Croatica journal will describe the structure and organization of work in intensive cardiac care – coronary units – in different hospital centers in Croatia. CACN and the Clinic for Cardiovascular Diseases of the “Sestre milosrdnice” University Hospital Centre jointly organized the 1 st Symposium for Acute Coronary Syndrome for Nurses on May 24, 2019. The symposium discussed the work and role of nurses in coronary units. The presented works and ensuing discussion emphasized the complexity and demanding role or nursing in coronary units. In developed countries, intensive care units – coronary units – do not employ nurses that have just entered clinical practice. After a certain amount of clinical experience, nurses go through a special advanced education program and, after completing an exam, are employed in intensive care based on the competencies they have acquired. ( 13 , 14 ) In order to support nurses in their efforts to encourage the authorities in the Croatian healthcare system to follow global trends in clinical practice, Professor Mario Ivanuša, the editor of the society’s cardiological journal, suggested describing the work of Croatian centers in the journal. ## Conclusion As the most numerous among healthcare professional, nurses must be recognized as a key factor in shaping the social and healthcare policies in their countries, as they can provide a great contribution to the reduction of the burden of cardiovascular diseases. The implementation of specialist residency programs for the education and positioning of nurses based on acquired competencies will lead to a general improvement in care. This is supported by examples of current cardiac nursing practice in developed counties of the EU and the USA.

    Cardiologia Croatica
    Back to search

    The Development of Cardiac Nursing and Its Positioning in The Healthcare System Based on the Requirements of Modern Medical Practice

    Review Article
    Issue11-12
    Published
    Pages275-280
    PDF via DOIhttps://doi.org/10.15836/ccar2019.275
    the role and position of cardiac nurses
    cardiovascular practice
    Croatia

    Authors

    Ana Ljubas*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    Abstract

    The aim of this article was to describe the key segments and new trends in the development of education and the position of cardiac nurses in global and Croatian cardiac practice. Nurses are the most numerous healthcare professionals and must be recognized as a key factor in shaping the social and healthcare policies in their countries, as they can provide a great contribution to reducing the burden of cardiovascular diseases. Recent examples and results in modern global medical practice are a good indication of how to position cardiac nursing within the Croatian healthcare system.

    Full Text

    ## Introduction Cardiovascular diseases represent the leading cause of death in both developed and developing countries, and thus in Croatia as well. Advancements in biomedical and technological sciences in the last two decades have significantly influenced the reduction of mortality and improvements in quality of life in the general population. Diagnostic and treatment procedures, as well as the needs of patients, have become more complex and demanding, with a consequent increase of complexity in healthcare. Nurses have had to achieve higher levels of knowledge, skills, and competencies to ensure effective and high-quality care and protect the safety of patients, for which they have been responsible since the close of the last century. If we look at demographic and epidemiologic trends from the perspective of the future of cardiovascular diseases, it is likely that we will be faced with a multi-dimensional problem in the future. Aging of the population both at the global level and in Croatia increases the prevalence of cardiovascular diseases, while technological developments will continue to alter approaches in clinical practice, leading to increasingly demanding responsibilities in nursing work. Education of cardiac nurses in developed countries has followed the development trends of modern cardiologic practice, while the positioning of cardiac nurses in the healthcare system that is appropriate to competencies they have acquired has led to a general improvement in care. Cardiac nursing in Croatia is also always searching for new insights and development of professional excellence with the goal of improving care for Croatian patients. ## Education of cardiac nurses and their
position in the healthcare system in
European countries Cardiovascular diseases are the leading cause of mortality in the world and represent a significant global health burden. The healthcare challenges we are faced with today are the increasing aging of the population along with the epidemic of conditions associated with lifestyle habits such as obesity and diabetes ( 1 ). There will continue to be increasing demand for advanced technologies such as imaging and diagnostic services, since the current rate of technological innovations is rapidly continuing ( 2 ). This transformation can threaten the sustainability of providing healthcare services in some countries ( 3 ). According to different reports by the World Heart Federation and the European Society of Cardiology, the demands and challenges of modern cardiological practice are the same or similar in almost all countries, despite their starting points and healthcare situations being different. The Council on Cardiovascular Nursing and Allied Professions of the ESC (CCNAP) performed an analysis of the status of EU countries especially in the context of the care provided by nurses. The analyses showed that the differences in context are especially noticeable regarding education and the formal position of nurses. The differences are found in educational training of nurses and the scope of their role and associated responsibilities ( 2 ). Based on the fact that cardiovascular diseases are the leading cause of mortality and that this burden is expected to continue, the analyses that have been performed also provided guidelines on how to best address this issue. Good results were achieved in primary and secondary prevention. Successful cooperation between members of interdisciplinary teams and focusing on working with and supporting both healthy and at-risk populations in adopting a healthy lifestyle have achieved significant results in primary prevention. Wherever possible, the focus must be on proactive avoidance of poor health through prevention, as opposed to focusing on treatment after a health condition has already developed ( 3 ). The focus is on “care” instead of “treatment”, which represents a significant paradigm shift ( 2 ). Medical nurses, as the most numerous among healthcare professionals, have provided a large contribution to the implementation of this transformation in some developed countries. The education of cardiac nurses in developed countries has followed the development trends of modern cardiological practice. Programs and ways of implementing specialist residency programs for education and certification of medical nurses are defined through cooperation of the healthcare system and professional societies and according to the demands of clinical practice. In this way, nurses develop additional clinical competencies along with the combination of knowledge, skills, principles, and values acquired through their education. The World Health Organization has identified competencies as the key factor in the positioning of healthcare workers within the healthcare system. The development of specific clinical competencies in nursing has in many countries led to the transfer of certain competencies from physicians to nurses. In this way, nurses have adopted a key role in certain segments of care. Important advancements have been made in primary and secondary prevention of cardiovascular diseases, heart failure (heart failure nurses), arterial hypertension, intensive cardiological care, etc. Especially significant advancements have been made in the prevention and rehabilitation of cardiovascular diseases. Under the sponsorship of the World Heart Federation, the European and American nursing associations Preventive Cardiovascular Nurses Association (PCNA), ESC-CCNAP, and the Council on Cardiovascular Nursing of the American Heart Association (CCNAHA) published a document in 2011 under the title “Global cardiovascular disease: A call to action for Nursing”. This document details and explains the role and position of nurses and why they are crucial in the prevention of cardiovascular diseases today and will remain so in the future. Appropriate positioning of nurses based on the acquired competencies regarding implementing preventive cardiologic measures has led to significant reduction of risk factors, improvements in quality of life, and reduction of mortality in cardiac patients. The role of the nurse in the team is crucial and can be divided into three levels: the first level is technical, and its goal is cooperating and coordinating with other members of the team to get the clinical picture of the patient. The second level consists of providing the patient and their family with the information they need to come to terms with the disease and providing support in making steps towards desirable lifestyle changes. The third level is monitoring the implementation of measures and evaluation of goals ( 4 ). The importance of nurses specialized in heart failure for the reduction of the number of subsequent hospitalizations in patients hospitalized for acute decompensated heart failure has been demonstrated by numerous studies. A clinical study conducted as early as 1995 by Rich et al. provided a new perspective on the role of nurses in the treatment of patients with chronic heart failure. The study results showed that the work of nurses in educating patients and family members, planning hospital discharge, diet planning, providing detailed instruction for taking medications, and monitoring after discharge reduced the number of rehospitalizations within the first 90 days by 56% in comparison with the standard procedure ( 5 ). The role and position of cardiovascular nurses is defined and regulated in American cardiovascular practice. The development of certified education programs for nurses has followed the developments and demands in clinical practice. It is clearly defined who and after how many years of clinical practice may apply for certification as well as when and how re-certification is conducted for individual sub-specialist fields. Analyses conducted by CCNAP in European countries showed that educational programs attended by nurses to prepare for clinical practice differ by content, duration, deliver, and setup ( 2 , 6 - 12 ). Institutional education of cardiac nurses in most countries does not meet the demands of modern cardiological practice. Therefore, the CCNAP Education Committee created and published a specialist study program for cardiovascular nurses in 2015, “A core curriculum for the continuing professional development of nurses”. The goal of this program was to assist cardiovascular nurses in EU countries in their education as well as to equalize standards of European cardiological practice. ## Education of cardiac nurses and their
positioning in the Croatian healthcare system Today, Croatian cardiological practice stands side by side with cardiological practice in developed countries. As the most numerous healthcare professionals, nurses hold a central place in the interdisciplinary team. The way nurses respond to these professional demands is a significant factor in whether the results of care will be effective, safe, and efficient. Current clinical practice postulates the requirement of interdisciplinarity, which means that the roles of different professionals within a team intertwine with one another. Good coordination and proper integration results in consistent adoption of new knowledge, innovations, and new applications. Nurses are aware of their position and are always in search of new insights to provide creative solutions for current and future challenges in their areas of clinical responsibility. The Croatian Association of Cardiology Nurses (CACN) was formed in order to provide all nurses in Croatian cardiological practice with a consistent approach to new knowledge. The goal of CACN was to employ various educational programs to help nurses exchange knowledge, experience, and opinions with Croatian and international experts and to encourage critical thought in clinical analysis, which will contribute to the growth of professional excellence. Support in the foundation of CACN and great contributions to its development was provided by the president of the Croatian Cardiac Society (CCS), Academician Davor Miličić, as well as all members of the CCS. The successful cooperation between these two professional societies is presented every two years at the jointly organized national cardiological congress, as well as in the organization of symposiums and congresses by our working groups. The two societies have also formed a Working Group in order to stimulate the Croatian healthcare system to introduce education programs for the acquisition and development of formal competencies and the positioning of cardiac nurses in the healthcare system according to their acquitted competencies. The members of the working group defined the priorities and created programs for post-graduate courses for the following fields: prevention and rehabilitation, heart failure, echocardiography and arrhythmias, and cardiac electrical stimulation. CACN was recognized as a valuable partner by CCNAP, which grew into the Association on Cardiovascular Nurses and Allied Professions (ACNAP) in 2018. In 2015, CCNAP and CACN jointly organized the EuroHeartCare2015 congress in Dubrovnik, Croatia. Over 600 participants from approximately 50 countries attended the congress. Lectures at the congress were held by established international experts in cardiological practice, and the congress was an excellent opportunity to acquire knowledge and exchange experiences for over 200 nurses from Croatian cardiac practice. CACN has continued working with ACNAP and advocates the equalization of standards of nursing practice in EU countries. We are thus in agreement with ACNAP that the education of cardiac nurses should be performed through a specialty residency program. CACN has therefore initiated the procedure of creating occupational standards for cardiac nurses in Croatia. CCNAP has allowed us to translate the Core Curriculum. The Academic Council of the University of Zagreb School of Medicine has accepted the implementation of the specialty residency program for cardiological nurses. We expect cardiac nurses to be positioned appropriately within the healthcare system and cardiological practice, given their education and acquired competencies. The development of clinical competencies and positioning of nurses in the Croatian healthcare system based on these acquired competencies will surely contribute to improvement of quality of life and reduction in mortality for cardiac patients in Croatia. This issue of the Cardiologia Croatica journal will describe the structure and organization of work in intensive cardiac care – coronary units – in different hospital centers in Croatia. CACN and the Clinic for Cardiovascular Diseases of the “Sestre milosrdnice” University Hospital Centre jointly organized the 1 st Symposium for Acute Coronary Syndrome for Nurses on May 24, 2019. The symposium discussed the work and role of nurses in coronary units. The presented works and ensuing discussion emphasized the complexity and demanding role or nursing in coronary units. In developed countries, intensive care units – coronary units – do not employ nurses that have just entered clinical practice. After a certain amount of clinical experience, nurses go through a special advanced education program and, after completing an exam, are employed in intensive care based on the competencies they have acquired. ( 13 , 14 ) In order to support nurses in their efforts to encourage the authorities in the Croatian healthcare system to follow global trends in clinical practice, Professor Mario Ivanuša, the editor of the society’s cardiological journal, suggested describing the work of Croatian centers in the journal. ## Conclusion As the most numerous among healthcare professional, nurses must be recognized as a key factor in shaping the social and healthcare policies in their countries, as they can provide a great contribution to the reduction of the burden of cardiovascular diseases. The implementation of specialist residency programs for the education and positioning of nurses based on acquired competencies will lead to a general improvement in care. This is supported by examples of current cardiac nursing practice in developed counties of the EU and the USA.