Phase II cardiac rehabilitation in rural Northland.

IntroductionCardiovascular disease accounted for almost half of all deaths in New Zealand in 2009, of which coronary artery disease was a core contributor (Ministry of Health, 2012b). It is therefore of little surprise thatthe Minister of Health (2012a) identified cardiovascular disease as a priority in the New Zealand Health Strategy. The number of people affected by cardiovascular disease is expected to continue to rise as a result of longer life expectancy and an ageing population (Alwan, 2011). The effects include reduced quality of life, interruptions in the ability to continue employment and, in some instances, a significant emotional impact. Coronary artery disease is particularly prevalent in males and among people of Maori descent (Riddell, Jackson, Wells, Broad, & Bannink, 2007; Sinclair & Kerr, 2006), and is further influenced by socio-economic risk factors (Best Practice Advisory Committee, 2011).Cardiac rehabilitation should be offered to clients following an acute coronary event such as myocardial infarction. In the New Zealand Guidelines Group's (2002) report, however, uptake rates of cardiac rehabilitation were shown to be consistently low, with a wide degree of variation in programme content. In addition, Valencia, Savage, and Ades (2011) have suggested that those living rurally exhibit, on average, fewer positive health behaviours than do individuals that reside in urban locales. As such, greater inputs therefore will be necessary to engage with, and improve the health of, rural clients. Furthermore, in rural areas additional challenges exist regarding the delivery of cardiac rehabilitation care. These limitations can include: limited access to services (Aude, Hill, & Anderson, 2006); socioeconomic factors, such as lower income and education (Oberg, Fitzpatrick, Lafferty, & LoGerfo, 2009); and a 'rural attitude' of getting on with life (De Angelis, Bunker, & Schoo, 2008).The primary health care setting has been identified as having the ability to improve cardiac rehabilitation care participation rates (Cupples et al., 2010). In most rural locations, the nursing staff account for a significant proportion of the health workforce and their role in primary health care delivery is, therefore, viewed as invaluable (Francis & Mills, 2011; Howie, 2008). Nevertheless, Wachtel, Kucia and Greenhill (2008a) claimed that in rural areas cardiac rehabilitation care management is typically approached on an ad hoc basis; Shepherd, Battye, and Chalmers (2003), however, suggested that rural nurses felt they lacked adequate training in cardiac rehabilitation.In New Zealand, evidence-based guidelines are available to facilitate health-care professionals' delivery of cardiac rehabilitation (New Zealand Guidelines Group, 2002). These guidelines acknowledge that their implementation in rural communities can be difficult for a variety of reasons, including geographic and social factors. In the ideal situation, cardiac rehabilitation care should adopt a multi-disciplinary approach. In many rural settings, however, this is simply not a realistic option despite the fact that the incidence rates of coronary artery disease are highest in these locations (Aoun & Rosenberg, 2004; Wachtel et al., 2008a).Cardiac rehabilitation should be initiated immediately following a coronary eventand consists of three phases. Phase I, inpatient care, centres on introducing a client to the concept of heart disease and preparation for discharge from hospital. Phase II, following a client's discharge from hospital, is the largest component. It consists of a programme that spans several weeks and is based on intensive education, particularly surrounding lifestyle interventions such as smoking cessation, exercise, diet, and aspects of social and psychological care. Phase III, long-term management, is focused on helping the patient develop the ability to continue implementing the changes initiated in Phases I and II (New Zealand Guidelines Group, 2002; World Health Organization, 2007). …