Approaches to nurse education and competence development in remote telemonitoring of heart failure patients with implanted heart devices in Italy: a cause for concern
Cardiac nurses require high levels of knowledge and expertise to meet the demands of a rapidly evolving medical and technical environment. Continuous professional development (CPD), and postgraduate education for nurses are priorities on the agenda of many nursing organizations internationally. In fact, developing a consistent approach to cardiac nursing education within Europe has become a key goal also for the European Society of Cardiology (ESC).1 Despite the progress made, it was evident at the ESC 2017 Heart Failure Congress in Paris that education is inconsistently provided across Europe and programs lack standardization.2 This is challenging for cardiac nurses internationally, especially in rapidly developing areas such as remote telemonitoring of patients with implanted cardiac devices (ICDs), where few nurses internationally hold particular expertise. In addition, the prevalence of implanted heart devices, such as pacemakers or ICDs, is constantly growing, partly due to the increasing prevalence of chronic heart failure (CHF).3 Telemonitoring enables timely monitoring of ICD data with subsequent early detection of arrhythmias and reports of device activation. Nurses play an important role in providing education for the self-management of CHF, including remote telemetry that supports patient autonomy and reduces in-hospital costs. Therefore, nurses require education to appropriately conduct remote telemonitoring, and ultimately reduce exacerbations and readmissions, and improve patients’ quality of life and reduce mortality by prompt detection and intervention.4-6
The scientific community, such as the Council of Cardiovascular Nursing and Allied Professions (CCNAP), are working on consensus documents and are trying to implement courses for cardiac nurses to provide uniform competences across Europe and promoting educational strategies aimed at improving clinical practice.7 However, in many countries, such as Italy, the professional development of nursing is in its infancy.8 In Italy, the entry level to nursing is the baccalaureate degree, but few nurses receive postgraduate education. Postgraduate education is limited to some areas, with few universities offering educational programs that can support nurses in practice. The only exception to this is the availability of some Masters in critical care. Education and training of cardiac nurses is more widely available in other parts of Europe. In Italy, cardiac nurses acquire their specialized competencies mainly from peers and clinical practice. Consequently, postgraduate education for cardiac nurses is predominantly aspirational. This is of concern given that the number of patients with IHD devices in Italy is steadily growing with patients frequently receiving home telemetry support.
In our experience, in the absence of specialized training for nurses, national guidelines are adhered to that have been translated into Italian from international ESC guidelines.9 Reading telemetry reports and responding to these does not follow a nationally standardized protocol in Italy, as it is not entirely recognized as an independent nursing activity. This approach varies depending on the organization. Telemetry is primarily the role of the physician with nurses taking on this role in an informal capacity. While nurses have a variety of education and training, most of their skills are developed in practice.10 Interviews with cardiac nurses in Italy (n=12) revealed that there is no standardized and well-defined course for nurses who perform remote telemonitoring activities.10 The majority reported that they gained their competencies directly through their experience in the field and after attending a short course in electrophysiology and electrostimulation.10 Nurses who perform remote telemonitoring activities do not receive consistent education and training. However, at the same time, a recent study of 65 patients with an ICD followed by this team over 1 year found that most (84%) of the patients’ adverse events were promptly detected by the nurse.11 There was also a 50% reduction of inappropriate shocks, a better quality of life and better patient compliance, despite the lack of formal training.11 The study also demonstrated a good level of satisfaction among patients who also expressed confidence in care. Patients were happy to be remotely monitored by a nurse because this increased their sense of security.11 Despite the small size, the results of the present study confirmed the use of the current ESC guidelines in Italy proved useful.11 Results indicate that this approach, informed by the ESC guidelines, is sensitively responding to adverse events and deemed satisfactory from the patients’ perspective. However, this study also identified that currently there is no standardized training and well-defined education for nurses who perform remote telemonitoring activities for patients with ICDs.10
The competence requirements for telemetry monitoring and management of heart failure patients with ICDs are complex and require specific skills. However, in Italy, to the best of the authors’ knowledge, no specific training is available in this field. Conversely, in many North European countries there is a long-standing educational and cultural tradition with regards to remote telemonitoring, where in fact there are many heart failure clinics that are totally run and led by nurses. Specific education and training in the field of remote telemonitoring is not available to cardiac nurses in Italy, and yet it is essential to have appropriate knowledge and training to effectively perform this type of activity and care. This specialized expertise is fundamental to reduce readmissions, improve quality of life and support family caregivers.12 Cardiac nurses need to be better prepared to educate families to improve care for CHF patients.13 In Italy, in line with the best international experiences, some positive experiences in the management of heart failure patients at home are reported.14 Expanding the nurse’s role in Italy to officially incorporate this specialty and develop appropriate competencies would also contribute to improving the professional status of cardiac nurses. In Italy, the development of appropriate education for cardiac nurses requires a stronger leadership in clinical practice, in universities and professional organizations. Italy will also look to international cardiac nursing colleagues to encourage this professional agenda.