It has been a huge privilege to be awarded ‘runner-up’ in the Cardiovascular Nurse of the Year category of the BJN Awards 2020. Although my name is attached to the award, I feel it belongs to the whole team who have worked tirelessly to make the changes demanded of them. This has enabled us to incorporate new patient groups and mould the service into what it has become today: one we are all very proud of.
Our journey started in 2010 following a review of the national coronary heart disease (CHD) standards (NHS Quality Improvement Scotland, 2010). We identified some major shortfalls in arrhythmia management throughout Scotland's Health Boards. In Tayside, we attempted to tackle this by submitting a bid to the British Heart Foundation (BHF), for two part-time positions to develop three identified workstreams:
At this time, arrhythmia nursing services in Scotland were few and far between, but were well-established in England, so we took the opportunity to carry out a study tour of various arrhythmia nursing services there and establish networks locally and nationally. We spent time mapping existing services within our Health Board and identifying the gaps in provision. We took the opportunity to meet with key stakeholders to identify how best to develop the identified workstreams.
Atrial fibrillation management
By 2013, we had developed 11 rapid access atrial fibrillation clinics per month throughout the Tayside region, streamlining the patient journey and providing timely review and treatment. Our initial focus was on newly diagnosed patients with atrial fibrillation. However, as the clinics developed we incorporated more complex patients requiring anti-arrhythmic drug management, and counselling regarding advanced treatment strategies.
Inherited cardiac conditions management
Inherited cardiac conditions (ICC), such as the channelopathies and cardiomyopathies are areas of cardiology that require in-depth knowledge of conditions with an often limited evidence base. We are not blessed with the large randomised trials that are often seen in other areas of cardiology. Working as a specialist nurse within this field, was, and continues to be, a huge but very interesting learning curve. It was very clear that this patient group, although small in comparison to the other workstreams, had significant support needs. It is not uncommon for the first presentation to clinic to be the result of the sudden cardiac death of a family member. Not only are the patients grieving, but they are also worried about their own mortality, and of other family members.
We became embedded in the twice monthly cardiogenetics multidisciplinary team (MDT) meetings and established a monthly ICC MDT clinic, again streamlining the number of hospital visits and seeing a number of family members in the same visit. Being an integral part of these MDT meetings and clinics allows us to provide this much needed support and ongoing contact beyond hospital visits.
Complex implantable device support
Complex implantable device support is often linked to those with inherited cardiac conditions so these workstreams often overlap. In fact, we have a number of patients who are troubled with atrial fibrillation due to an underlying channelopathy or cardiomyopathy, who also require an implantable cardiac defibrillator. Being able to provide expert knowledge and support to patients with such complex conditions ensures their journey is as seamless as possible.
Evidence shows that patients who have an implantable cardiac defibrillator often suffer from high anxiety and isolation (Tagney et al, 2003). We therefore felt it was important to integrate this patient group into our long-established cardiac rehabilitation exercise programme. In many instances this has resulted in improved independence and confidence, allowing re-integration into society and improved self-value and self-worth.
Following the 2 year BHF-funded period, these three workstreams were integrated into our specialist nursing service. This project was robustly evaluated and provided valuable data to present at various forums to promote different models of delivering care in a sustainable and resilient way during this difficult financial climate and to allow us to provide care to an often neglected group of patients. We were also very fortunate to be awarded the BHF Alliance Award in 2017 for Integrated Care, showcasing the value in taking time to review and refresh our service delivery, keeping patient centredness and quality of care at its core.
Education, mentorship, and sharing knowledge and experience with colleagues is a key responsibility of the arrhythmia nurse specialist role. Embedded within the role is the responsibility for organising and contributing to various teaching and patient forums. The arrhythmia nurse team have developed a professional educational course, ‘Current perspectives in cardiac care’ in collaboration with Dundee University School of Nursing and NHS Tayside. It targets health professionals from multidisciplines, and is delivered 3 times a year. We also run in-house ECG study events 2–3 times a year, and have been involved in the development of e-learning modules together with Chest Heart & Stroke Scotland. We have been invited to present at various forums nationally, sharing the work we have done over recent years within our atrial fibrillation clinics. We have also been involved at Scottish Government level, contributing to the Cross Party Working Group Inquiry into Atrial Fibrillation in Scotland.
The Familial Arrhythmia Network Scotland (FANS) was established in 2008, and in March 2020 it widened its remit to become the Network for Inherited Cardiac Conditions Scotland (NICCS). We have been integral to this Network since the establishment of our arrhythmia nursing service, contributing to developing the service, education events, patient forums and patient engagement work. My hope, as part of this network, is to help establish a stronger specialist nurse group to develop workstreams identified by the wider Network. Due to the limited number of arrhythmia nursing services within Scotland, this has previously been a logistical challenge, but our most recent bid to the BHF-Miles Frost Foundation (MFF) in 2017 may help to address this shortfall.
Following a successful bid at the end of 2017 to the BHF-MFF, to develop an East of Scotland Service for patients with, or at risk of, hypertrophic cardiomyopathy (HCM), the remit and scope of work of the specialist nurses has grown. The funding was to provide support and education to specialist nurses in each of the 5 Health Boards within the East of Scotland, to link and improve the education and support for patients with HCM within their own area, and to offer surveillance, education and support to relatives ‘at risk’ of developing this condition. Together with the West of Scotland Health Boards, which were successfully awarded funding from the BHF MFF project the previous year for a similar project; this offered us a great opportunity to network, support and share experience and good practice.
This continues to be work in progress, but has been hindered significantly by the current COVID-19 pandemic. This patient group rely on surveillance echocardiograms and other diagnostic tests, which have almost come to a halt during the pandemic. Added to this was our redeployment to the acute setting to help support the organisation during this difficult time. Throughout this period we maintained a skeleton specialist nursing service and continued to man our advice line to help support our patient group by dipping in and out of our emails between our shifts! Fortunately, we are now back to our ‘day jobs’ and doing our best to pick up where we left off, catching up on lost time, with us and our patients, adjusting to our ‘new normal’.
Looking back, we are very proud of what we have achieved. It has not always been easy and there have been many obstacles along the way. It is well recognised that there is frequently resistance to change, but we have been hugely fortunate that we have had clinicians with the vision and determination to improve services, and a team who have the willingness to adapt to see where our journey takes us. We appreciate the opportunities our organisation and the BHF have allowed us, and for having the courage to invest in us. Our patients' continue to be our motivation and is why we do what we do. Thank you for placing your trust in us.