Aligning the planets: The role of nurses in the care of patients with non‐ST elevation myocardial infarction

Abstract Background Studies have shown variation in care for patients with non‐ST elevation myocardial infarction (NSTEMI), including in the roles of specialist and advanced practice nurses in diagnosis, treatment and coordination of care. Aim The aim of this study was to describe the roles and responsibilities of specialist and advanced practice nurses in providing care for patients with NSTEMI. Methods Secondary analysis of observational field notes and interviews from an ethnographic study of variation in care for NSTEMI patients in 10 UK hospitals conducted 2011–2012. Data were thematically analysed to identify key concepts and themes related to the roles of specialist nurses. Results Seven of 10 hospitals had roles for specialist nurses in NSTEMI care. The major theme related to high demand and the complexity of patients and organizations (‘Aligning the planets’). In this theme, nurses contributed to improving services or compensating for deficiencies (‘Making the system work versus making up for the system’). Data collection for audit could take precedence over time with patients (‘Paying worship to the paper’). Nurses expressed a sense of ownership of cardiovascular patients that drove their desire to provide quality of care (‘They are our patients’).


| INTRODUCTION
Myocardial infarction (MI) is defined as myocardial cell death caused by prolonged ischaemia and designated according to whether or not there is development of ST segment elevation in two or more contiguous leads on electrocardiogram (ECG): ST elevation MI (STEMI) or non-ST elevation myocardial infarction (NSTEMI) (Thygesen et al., 2012).
NSTEMI is more common than STEMI in older people, but it is complicated by greater uncertainty in diagnosis and management because of frequent atypical symptoms, lack of diagnostic ECG changes and patients' age and comorbidities (Yeh et al., 2010;Zaman et al., 2014).
Specialist and advanced practice nurses (APNs) have had varying roles in the care of patients with MI, including nurse-initiated thrombolysis for STEMI prior to the wide-spread adoption of primary percutaneous coronary intervention (PPCI). The role and scope of responsibilities of specialist nurses in diagnosing and managing NSTEMI patients has been less well-defined. Few studies have evaluated the broader role of specialist chest pain or acute coronary syndrome (ACS) nurses and a This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. survey of 192 UK emergency departments (EDs) in 2006 reported that specialist 'chest pain' or thrombolysis nurses were employed in 72% of EDs with chest pain units and 48% of hospitals overall (Cross, Howe, & Goodacre, 2007;Dunckley et al., 2006Dunckley et al., , 2007Hamilton et al., 2008;Johnson, Goodacre, Tod, & Read, 2009;McLean, Phillips, Carruthers, & Fox, 2010;Smallwood, 2009;Tierney et al., 2013). The aim of our analysis was to describe the roles and responsibilities of specialist and advanced practice nurses in providing care for patients with NSTEMI in 10 hospitals in England and Wales.

| METHODS
Our data came from a large ethnographic study of processes that facilitated good quality care for patients with NSTEMI. Eight hospitals in England and Wales were purposively selected on the basis of variation (four in the top and four in the bottom tertiles) in 30-day case mix adjusted mortality in the Myocardial Infarction National Audit Project (MINAP). Hospitals were also selected for variation in teaching status, geography, coronary intervention and patient volume. Field work methods were piloted in two additional hospitals and data from all 10 hospitals were used in the analyses. Hospitals were not aware of where they were on the spectrum of 30-day cardiovascular mortality.
Eleven hospitals were approached for participation and one declined to take part. All of the research team were blinded to hospital mortality data until after analysis of the data. Initial permission for interviews and observation was obtained from the cardiology clinical lead at each hospital and individual written consent was obtained prior to observation and interviews of staff and patients. Ethical approval was obtained from an NHS medical research and ethics committee (ref: 10/H0107/75). Each hospital was visited by an experienced research associate who undertook an intensive 2-week observation period between June 2011 and August 2012. During this period, the researcher observed activities, followed NSTEMI patients through their hospital course, reviewed medical records and interviewed patients, families, clinicians and managers. Patients and families were also interviewed 30 days after discharge. Observation and interviews took place in emergency departments, medical assessment units, coronary care units (CCU), catheter laboratories, cardiac and general medical wards and focused on the processes of admission, diagnosis, treatment and discharge. Selection of staff participants maximized variation in roles and patient participants were purposively selected for diversity of age, gender and clinical factors. Patients were introduced to the research associate by staff, who had ascertained if they were willing to talk about their experiences. Patients were visited more than once during the course of their hospitalization. Observational data were collected in detailed field notes and verbal data were audio-recorded with permission and transcribed verbatim. A total of 732 hours of observation was conducted. Social desirability bias was minimized through comparison of observation and accounts of care and utilizing the perspectives of multiple staff and patients. Table 1 shows the number of patients and staff observed and interviewed and the total hours spent in observation in the 10 hospitals and Table 2 provides information about each hospital.
In the initial analysis of the data, it was evident that nurses were integral to the care of patients with NSTEMI, but their roles and responsibilities varied across the ten hospitals. The secondary analysis reported in this paper focused on specialist nurses and APNs who had responsibilities in identifying and managing patients with NSTEMI and who worked across different departments in the organization. The research team searched for relevant field notes and transcripts of interviews with or about specialist nurses. Four multiprofessional researchers then read and discussed the interviews and notes, focusing on nurses' roles, contributions to processes of care and their perspectives on their work and care for patients with NSTEMI. A constant comparison approach (Strauss & Corbin, 1998) was used to identify similarities and differences in the data. Emerging themes and examples were discussed with other team members at one face-to-face meeting and refined via email and telephone exchanges. Themes and illustrative quotations and observations from field notes were organized using a spread sheet and shared electronically. All authors have reviewed and contributed to the final analysis and paper.

| RESULTS
Seven of the 10 hospitals had specialist nurses or APNs in key roles for patients with NSTEMI and in two other hospitals the senior nurse managers and cardiac rehabilitation nurses provided some similar activities. Analysis revealed extensive and diverse clinical and administrative responsibilities. The researcher observed myriad roles undertaken by specialist nurses in some hospitals and multiple job ti-  In an organization, emergency departments and cardiology services were not always well aligned in policies, practice and communication and professional boundaries could interfere with best practice. Emergency department clinicians were often criticized by cardiology specialists for not investigating chest pain properly, resulting in unnecessary admissions.

Nurses often found themselves in liaison positions between departments:
There is inevitably conflict between cardiology and A&E

| Making the system work versus making up for the system
The diagnostic uncertainty and high demand for beds and services could often lead to systems that did not function well to find and treat patients. Observations in some hospitals indicated that ACS nurses were often employed to make up for system insufficiencies, although there were examples of nurses reforming the system to be more effective. In one example, the ACS nurses previously had spent most of their time on the telephone arranging transfers for NSTEMI patients needing angiography and intervention. The ACS nurses worked with their hospital and transferring hospitals to make needed changes to the system: they were able to 'ring-fence' or reserve beds for NSTEMI patients and they collaborated with the information technology service to create a confidential electronic referral form for elective patients. This allowed them to prioritize patients and importantly to spend time with patients rather than on transfer coordination.
Making the system work also involved communication and support to transferring hospitals: One of the things that having the electronic form does for us is that it gives us as nurse practitioners more time to spend with the patients than on the phone…

| Paying worship to the paper
The MINAP database provides important information about the outcomes of care for patients with MI and is a rich source of data for audit and research. However, the data for MINAP need to be collected from patient records, a time-consuming task that often falls to nurses. Other quality improvement initiatives in the UK incentivise hospitals to document that evidence-based care is being provided to patients, including those with MI. Nurses' concern for cardiac patients meant that they tried to ensure that cardiac patients received the care that they believed necessary.
The nurse leading the rehabilitation service in one hospital confessed to following up patients with unstable angina post-discharge by telephone despite this not being a service that was commissioned. Other nurses also found that talking to patients and understanding their individual situations led them to be less judgemental and to appreciate the reasons some patients persisted in unhealthy risk behaviours:

| DISCUSSION
This analysis has documented the versatility and varied roles and responsibilities of specialist cardiac and advanced practice nurses involved in the care of patients with NSTEMI. The variation in nursing roles and responsibilities for patients with NSTEMI highlights that these roles have developed in complex systems largely in response to service needs and preferences and skills of nurses and cardiologists. This is in contrast to nationally defined protocols such as nurseinitiated thrombolysis in STEMI. For seven of the 10 hospitals studied, these nurses were central to ensuring patients with NSTEMI were identified, transferred as appropriate, managed, educated, often followed up as out-patients and that care was documented for audit.
These are broadly consistent with the roles identified in a previous review of nurses' contribution to NSTEMI care: patient assessment, triage, coordination of care and education (Tierney et al., 2013), although the roles, responsibilities and activities identified in this study were more extensive. The other three hospitals studied did not have these specific roles although in two of the other hospitals senior cardiac nurse managers and rehabilitation nurses undertook some similar activities. Although the data were not collected to explore ACS nurse roles, staff in hospitals without these posts did note a need for the role especially related to liaison between departments and support for providers. Cardiology services often found themselves too stretched to be able to respond quickly to A & E requests for assessment and departmental relationships were often tense. Although patient interviews were scrutinised, no data related specifically to ACS nurses was found in these.
We also had no data on the effect of ACS nurse roles on patient outcomes, but other studies have documented the impact of nursing roles on outcomes (David, Britting, & Dalton, 2015;Johnson et al., 2009;Mehta et al., 2006;Smallwood, 2009 were not randomised, there were no significant differences by demographics, clinical characteristics or interventions between the groups. The better outcomes were attributed to the continuity provided by the CAPN, relationships built with multi-professional teams in acute and community services, expertise developed and the teaching and family support provided by the CAPN (David et al., 2015). Other studies have found greater NSTEMI patient satisfaction with information when a specialist nurse was involved and greater adherence to guideline-based care (Johnson et al., 2009;Mehta et al., 2006;Smallwood, 2009). Many of the ACS nurses were involved in audits of evidence-based care and were in a position to report on adherence and remind providers of recommended treatment. Others commented on ACS nurses' influence on care provided especially when less experienced medical or nursing staff were involved. Their roles in 'finding' ACS patients admitted throughout the hospital and in moving patients to cardiac wards could also affect the evidence-based care provided.
Although the ACS nurses may have contributed to improving services at times, their roles often seemed to be trying to make up for system deficiencies or intervening where differing priorities and perspectives, or professional boundaries interfered with delivering care.
Frustrations were frequently expressed regarding targets, funding and resources for services and the challenges of organizing and delivering care in a high-pressure healthcare system. Observation by the research associate documented the intricacies of delivering care and the multiple problems that often occurred and needed to be resolved in complex organizations.
The strength of the study lies in its multiple perspectives in interviews and longitudinal observations providing an in-depth view of processes of care and interaction among providers, patients and systems in 10 varied hospitals. The analysis is limited by being a secondary analysis of data collected for a study of variations in care across the 10 hospitals and the lack of opportunity to question and focus on ACS nurse roles. Effort was made to include a wide variety of providers in different roles and to minimise bias through multiple interviews and observations, but important persons and factors may have been missed. The findings are not linked to patient outcomes from the hospitals and may not be transferable to other settings. Nonetheless, the analysis does provide an extensive view of the roles and activities of ACS nurses in providing care for NSTEMI patients.

| CONCLUSION
In contrast to national or hospital protocol-driven roles of nurses in management of STEMI (primarily initiation of thrombolysis), roles related to NSTEMI patients have developed from the bottom up based on needs in hospitals and to some extent the expertise and preferences of nurses and cardiologists. Identified themes illustrated the specialist nurses' roles in coordinating and facilitating appropriate care, their roles in changing or compensating for dysfunctional systems and the frustrations inherent in delivering care for heterogeneous and often complicated patients in complex systems. Greater understanding of these roles and their effectiveness in improving patient care and outcomes would be beneficial.

FUNDING
This study was funded through a Research for Patient Benefit grant from the National Institute of Health Research, UK.