Introduction
Cardiac Rehabilitation (CR) is a preventive and multi-component program generally composing of structured exercise training, psychological support and education to promote positive lifestyle changes (Wingham et al., 2019). CR consists of three phases and is shown to reduce mortality, hospitalisation, health care, and to improve exercise capacity, quality of life and psychological wellbeing. Core components in cardiac rehabilitation include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, risk factor control, patient education, psychosocial management and vocational advice (Wingham et al., 2019; Sumner, Harrison, & Doherty, 2017).
Outcomes assessment can be broadly divided into health outcomes (morbidity, mortality, health-related quality of life), clinical outcomes (e.g., improvements in risk factors, in functional capacity and in psychosocial measures), behavioural outcomes (e.g., an appropriate response to symptoms, improvements in diet and physical activity) and service outcomes (e.g., patient and staff satisfaction, access and utilisation of services, patient healthcare utilisation and other financial and economic outcomes) (Bäck, Hansen, & Frederix, 2017; Novo et al., 2020; Sumner et al., 2017).
Cardiac rehabilitation is designed to improve cardiovascular health if a patient has experienced a heart attack, heart failure, heart surgery and assistance devices (Uithoven, Smith, Medina-Inojosa, Squires, & Olson, 2020). Nowadays, interventions and health outcomes of people with heart disease in CR program are recognised. Most of the studies define that it's important to involve family (caregivers) after the diagnosis of heart disease to guarantee the success of treatment, and CR is not different. They contribute substantially to patient's management of and recovery from cardiovascular disease (Bouchard et al., 2020). When the patient takes part in a cardiac rehabilitation program, the team involves his caregiver to enhance the health outcomes for the person, impacting the family.
It must be realised that a caregiver's role due to the physical and emotional overload, associated or not with the sharing of risk factors (smoking, sedentarism, others) increases, for example, the risk of developing heart disease in the caregiver.
Caregiving demands have been frequently related to a heavy burden role, decreasing the quality of life with physical and mental exhaustion, such as depression and anxiety and other physical health conditions. Some CR interventions seem to be a crucial step to improve patients' evolution, helping them understand the influence of psychobiological risk factors and building strategies to control daily stress, so some interventions can be used in caregivers (Lang et al, 2018).
In addition to its role's, in some cardiac diseases, there is a genetic/hereditary component, and risk behaviours are often shared between cohabitants. For example, a sedentary lifestyle is one of the worrying cardiovascular risk factors shared by patients and caregivers. Still, the exercise component works as the primary prevention of cardiovascular disease for caregivers (Fletcher et al., 2018).
It is essential to understand which cardiac rehabilitation programs interventions can also be used to improve the caregivers' role and health.
What is known is that are a lot of different interventions of cardiac rehabilitation programs that help caregivers in different contexts and, in studies like Lang et al. (Lang et al., 2018), Wingham et al. (Wingham et al., 2019) Erlinda and Michael (The & Jarrett, 2019). However, information on implemented and evaluated interventions, their characteristics, contexts of application, and the population is dispersed in the literature, making it challenging to construct precise questions on the effectiveness of those interventions and, consequently, to conduct a systematic review.
This scoping review's primary purpose is to map which interventions have been implemented that support caregivers of patients with cardiac disease taking part in a cardiac rehabilitation program in their role and health.
A preliminary search on databases (JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, Academic Search Complete, CINAHL Complete, Communication Source, PsycARTICLES, PsycINFO, and PubMed) revealed no existing scoping or systematic reviews (published or in progress) of Cardiac Rehabilitation Interventions in Caregivers of the patient with cardiac disease.
This scoping review is part of a research project that may increase cardiac rehabilitation nurses' response to the patient and caregivers who have cardiac disease.
As the evidence in this area is dispersed, four guiding research questions were constructed:
What interventions are implemented and evaluated to provide support to caregivers of patients taking part in a cardiac rehabilitation program, in their role and promote their health?
What are the characteristics (duration, dose and frequency) of those interventions?
Which contexts (hospital, primary care, home) are the interventions implemented and evaluated?
Which populations (for example, caregivers of patients with heart failure, caregiver of patients with coronary disease, taking part in a cardiac rehabilitation) are interventions implemented and evaluated?
1. Methods
This protocol of scoping review was guided by the methodology proposed for Joanna Briggs Institute for the conduct of scoping reviews (M. D. J. Peters et al., 2015; M. Peters et al., 2015), and purpose to examine and map cardiac rehabilitation interventions implemented and evaluated to promote caregiver role and help the caregiver health. According to the Joanna Briggs Institute, "scoping reviews undertaken with the objective of providing a map of the range of the available evidence can be undertaken as a preliminary exercise prior to the conduct of a systematic review."(M. D. J. Peters et al., 2015, p. 6)
Articles will be analysed based on the following inclusion criteria:
Participants
This scoping review will consider all studies that focus on caregivers of patients with medical or surgery heart disease, assisted by cardiac rehabilitation teams.
Concept
This scoping review will consider all studies that focus on interventions implemented to the caregiver of patients taking part in cardiac rehabilitation.
This scoping review will consider all studies that address cardiac rehabilitation interventions implemented and have the role and the health of caregivers into account (for example, education, counseling, exercise, health advice).
Context
This scoping review will consider all interventions implemented in all the contexts. This will include specifically hospital, primary care, home, cardiac rehabilitation centre, ambulatory.
Types of sources
This scoping review will consider quantitative, qualitative and reviews studies. Quantitative designs include any experimental study designs (including randomised controlled trials, non-randomised controlled trials, or other quasi-experimental studies, including before and after studies) and observational designs (descriptive studies, cohort studies, cross-sectional studies, case studies and case series studies).
Qualitative designs include any studies that focus on qualitative data such as, but not limited to, phenomenology, grounded theory and ethnography designs.
Reviews study include any Systematic Reviews.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of Pubmed was followed (oct 2020) by analysing the text words contained in the title and abstract and of the index terms used to describe the articles. Table 1.
A second search using all identified keywords and index terms will then be undertaken across all included databases.
Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English, Spanish and Portuguese will be considered for inclusion in this review. Studies published since 1950 will be considered for inclusion in this review to capture how rehabilitation interventions implemented and evaluated to provide the caregiver role because it is
the data when are developed cardiac rehabilitation programs. The databases to be searched include: CINAHL Complete; PubMed; Scopus; SciELO; Cochrane Library; PEDro. The search for unpublished studies will include: DART-Europe; OpenGrey; RCAAP .
Initial English language keywords to be used will be:
(Cardiac rehabilitation) OR (rehabilitation interventions) AND (caregiver) AND (heart disease) OR (heart surgery) AND (role).
Information sources
Study selection
Articles searched will then be assessed for relevance to the review, based on the title and abstract's information, by two independent reviewers. The full article will be retrieved for all studies that meet the inclusion criteria of the review. If the reviewers have uncertainties about a study's relevance from the abstract, the full article will be retrieved.
Based on full texts, two reviewers will examine independently whether the studies conform to the inclusion criteria. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Studies identified from reference list searches will be assessed for relevance based on the study's title and abstract.
Data extraction
Data will be extracted from papers included in the review using a charting table aligned to this research's objective and question, as indicated by the methodology for scoping reviews developed by the Joanna Briggs Institute (The & Jarrett, 2019).
A data extraction instrument was developed (Appendix II); however, this may be further refined for use at the review stage. Two reviewers will extract data independently. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. The two reviewers, independent of each other, will chart the "first five to ten studies using the data charting form and meet to determine whether their approach to data extraction is consistent with the research question and purpose", as suggested by Levac, Colquhoun and O'Brien (Levac, Colquhoun, & O'Brien, 2010, p. 6). Besides, if it is necessary, primary authors will be contacted for further information/clarification of the data, as suggested by Arksey and O'Malley's framework (Arksey & O'Malley, 2005).
Data presentation
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with this review's objective. A descriptive summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and question.
A summary of each article will include the author(s), year of publication, country of origin, purpose, population, sample size, methodology, concepts of interest and key findings relating to the review questions.
For question 1 and 2 the tables and charts may include data indicated in Table 2:
For question 3, the tables and charts may include data indicated in Table 3:
For question 4, the tables and charts may include data indicated in Table 4:
2. Results
It's the objective of this scoping inclusion of several studies that describe interventions in cardiac rehabilitation programs, aimed to caregivers of people with heart disease.
An initial researched describe cardiac rehabilitation impact on caregiver outcomes, improve their confidence to support self-management, and be perceived to help maintain their role as caregivers (Wingham et al., 2019). Interventions like physical activity, educational intervention, resuscitation-retraining program, psychological intervention are described (Gonzalez-Salvado, et al., 2019), Sommaruga M,. et al., 2018). Home-based appears most referenced.
3. Discussion
It’s important to recocognise if caregiver role has impact in tthe caregivers health and what interventions will prevent or treat that effects. At the same time, some caregivers share cardiovascular risk factors, so it's essential to prevent them. Exercise and psychology intervention could help caregivers in this role but can help their health, and some preliminary studies prove this.
Simultaneously, when we reflected on caregiver's of people with heart disease, we see that sometimes they have the same cardiovascular risk factors, so one component of CR is educational intervention can be used to help caregivers.
Conclusion
Therefore, this map will identify relevant issues to help advance evidence-based health care, develop knowledge, identify possible gaps and inform systematic reviews. Besides, this mapping will help inform the development of the appropriate and effective intervention(s) for caregivers of patients with heart disease to provide them with comfort and help other levels of studies.