Face-to-Face Nursing Promotion of Cardiac Rehabilitation

Practice Problem: The burden of cardiovascular disease is rising at global and national levels, and cardiac rehabilitation is recognized as one of the most beneficial and cost-effective strategies to manage it. One significant problem globally, nationally, and locally is the low numbers of eligible patients who enroll in cardiac rehabilitation. PICOT: In patients with isolated coronary artery bypass graft (CABG) (P), how does face-toface nursing promotion of cardiac rehabilitation (I) compared to the patients who do not have face-to-face nursing promotion (C), affect the percentage of patients enrolling in cardiac rehabilitation after discharge (O) within 8 weeks (T)? Evidence: The evidence used to guide this project included the need for a healthcare organization to have a systematic process for cardiac rehabilitation enrollment, face-to-face nursing promotion, improvement of the healthcare team’s knowledge about cardiac rehabilitation, and identification of patient barriers that hinder cardiac rehabilitation enrollment. Intervention: A systematic approach for cardiac rehabilitation was developed using the interprofessional team. After the healthcare team received standardized education, nurses in various roles provided face-to-face promotion, the ARNPs endorsed cardiac rehabilitation, and the care managers addressed barriers. Outcome: The cardiac rehabilitation enrollment rate increased by 16% among all patients admitted with an isolated CABG on the pilot unit. Conclusion: Implementation of face-to-face nursing promotion, ARNP endorsement, and reducing barriers were clinically significant in increasing the cardiac rehabilitation enrollment rate. FACE-TO-FACE NURSING PROMOTION OF CARDIAC REHABILITATION 4 Face-to-Face Nursing Promotion of Cardiac Rehabilitation Cardiovascular disease (CVD), also known as heart disease, is a global and national epidemic. Heart disease remains the leading cause of death globally and in the United States (American Heart Association, 2019). In 2016, global deaths from heart disease reached 17.6 million, and it is estimated by 2030, the death rate will reach 23.6 million (American Heart Association, 2019). In the United States, as of November 2017, it was estimated 121.5 million adults, approximately 48%, have some form of cardiovascular disease (Benjamin et al., 2019). The burden of cardiovascular disease is rising at global and national levels, and cardiac rehabilitation (CR) is recognized as one of the most beneficial and cost-effective strategies to manage it (Supervia et al., 2019). The benefits of cardiac rehabilitation are broad and compelling. One significant problem globally and nationally is the low numbers of eligible patients who enroll in cardiac rehabilitation (Ades et al., 2017; Gardiner et al., 2018; McIntosh et al., 2017; Pio et al., 2019). When patients are advocated for and given education, support, encouragement, motivation, a strong endorsement, and the option to enroll in cardiac rehabilitation, their health can improve dramatically. By choosing to enroll, resulting in the possibility to participate in cardiac rehabilitation, patients may decrease their mortality rate from a cardiac event and improve their quality of life. Individuals improving their health outcomes positively correlate with improving the overall public health status, and healthier people reduce healthcare costs. Significance of the Practice Problem Cardiac rehabilitation is an interprofessional approach to improving the patient’s health, emphasizing exercise, stress management, and nutritional education (Mayo Clinic, 2018). This program is a grade 1A recommendation for patients admitted to the hospital with cardiac-related FACE-TO-FACE NURSING PROMOTION OF CARDIAC REHABILITATION 5 ICD-10 diagnoses. The American College of Cardiology, American Heart Association, The Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention recommend that all patients hospitalized with a cardiac rehabilitation eligible diagnosis should be referred to a cardiac rehabilitation program before hospital discharge (Thomas et al., 2018). Only 54% of countries offer cardiac rehabilitation services to their community (Supervia et al., 2019). The staggering CVD statistics force national, regional, and local healthcare organizations to improve the current rate of 12% to 30% of patients enrolling in cardiac rehabilitation (Ades et al., 2017). The national benchmark for cardiac rehabilitation participation is 70%, and improving the enrollment rate is one of the first steps to increasing cardiac rehabilitation participation (Ades et al., 2017). The healthcare organization’s cardiac rehabilitation enrollment rate before the evidence-based intervention was approximately 13%. Impact on the Patient Cardiac rehabilitation reduced cardiovascular death from 10.4 % to 7.6% at the 3-year follow-up (Anderson et al., 2017). Thus, more patients participating in cardiac rehabilitation will decrease cardiac-related fatalities and improve the quality of life (Gardiner et al., 2017; Gardiner et al., 2018). In addition, there is a positive correlation between cardiac rehabilitation and improved patients’ biometric results (Gardiner et al., 2017; Graham et al., 2019; Sumner et al., 2017). Impact on the Healthcare System and Healthcare Cost The hospital may reduce the CVD health burden and economic strain by increasing patients attending cardiac rehabilitation. For example, if hospitals can increase cardiac rehabilitation participation from 20% to 70%, the consequence will be an estimated reduction in FACE-TO-FACE NURSING PROMOTION OF CARDIAC REHABILITATION 6 hospitalizations by 180,000 patients annually (Ades et al., 2017). In 2016, the United States healthcare system spent $555 billion on CVD, and by 2035, the cost is expected to skyrocket to $1.1 trillion (CDC, 2015). Premier benchmark data for CVD outcomes are monitored by the Centers for Medicare and Medicaid Services, which means hospital reimbursement directly correlates with patient outcomes and readmission rates. Cardiac rehabilitation effectively improves the patients’ health through guided lifestyle changes reducing the readmission rates for CVD by 4%, which equates to a significant amount of money (Anderson et al., 2016). Currently, the healthcare organization’s premier benchmark readmission rates and outcome measurements are no different or worse than the national average (Medicare.gov, 2020). Therefore, the healthcare organization will benefit from increasing the number of patients who enroll and participate in cardiac rehabilitation. Impact on the Community CVD is a priority for community health because it remains the leading cause of death (Xu et al., 2018). Enrolling 70% of the eligible patients in cardiac rehabilitation will drastically improve community health (Mayo Clinic, 2018). Patients participating in cardiac rehabilitation will improve individual health resulting in a healthier community (Pio et al., 2019).

ICD-10 diagnoses. The American College of Cardiology, American Heart Association, The Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention recommend that all patients hospitalized with a cardiac rehabilitation eligible diagnosis should be referred to a cardiac rehabilitation program before hospital discharge (Thomas et al., 2018).
Only 54% of countries offer cardiac rehabilitation services to their community (Supervia et al., 2019). The staggering CVD statistics force national, regional, and local healthcare organizations to improve the current rate of 12% to 30% of patients enrolling in cardiac rehabilitation (Ades et al., 2017). The national benchmark for cardiac rehabilitation participation is 70%, and improving the enrollment rate is one of the first steps to increasing cardiac rehabilitation participation (Ades et al., 2017). The healthcare organization's cardiac rehabilitation enrollment rate before the evidence-based intervention was approximately 13%.

Impact on the Patient
Cardiac rehabilitation reduced cardiovascular death from 10.4 % to 7.6% at the 3-year follow-up (Anderson et al., 2017). Thus, more patients participating in cardiac rehabilitation will decrease cardiac-related fatalities and improve the quality of life (Gardiner et al., 2017;Gardiner et al., 2018). In addition, there is a positive correlation between cardiac rehabilitation and improved patients' biometric results (Gardiner et al., 2017;Graham et al., 2019;Sumner et al., 2017).

Impact on the Healthcare System and Healthcare Cost
The hospital may reduce the CVD health burden and economic strain by increasing patients attending cardiac rehabilitation. For example, if hospitals can increase cardiac rehabilitation participation from 20% to 70%, the consequence will be an estimated reduction in hospitalizations by 180,000 patients annually (Ades et al., 2017). In 2016, the United States healthcare system spent $555 billion on CVD, and by 2035, the cost is expected to skyrocket to $1.1 trillion (CDC, 2015).
Premier benchmark data for CVD outcomes are monitored by the Centers for Medicare and Medicaid Services, which means hospital reimbursement directly correlates with patient outcomes and readmission rates. Cardiac rehabilitation effectively improves the patients' health through guided lifestyle changes reducing the readmission rates for CVD by 4%, which equates to a significant amount of money (Anderson et al., 2016). Currently, the healthcare organization's premier benchmark readmission rates and outcome measurements are no different or worse than the national average (Medicare.gov, 2020). Therefore, the healthcare organization will benefit from increasing the number of patients who enroll and participate in cardiac rehabilitation.

Impact on the Community
CVD is a priority for community health because it remains the leading cause of death (Xu et al., 2018). Enrolling 70% of the eligible patients in cardiac rehabilitation will drastically improve community health (Mayo Clinic, 2018). Patients participating in cardiac rehabilitation will improve individual health resulting in a healthier community (Pio et al., 2019).

PICOT Question
In patients with isolated coronary artery bypass graft (CABG) (P), how does face-to-face nursing promotion of cardiac rehabilitation (I) compared to the patients who do not have face-toface nursing promotion (C), affect the percentage of patients enrolling in cardiac rehabilitation after discharge (O) within 8 weeks (T)?
To align with a healthcare organization's priority project scope, the population was patients admitted with an isolated coronary artery bypass graft (CABG), which referred to using arterial or venous grafts only during surgical intervention (D'Agostino et al., 2019). The population included patients 18 years and older. The healthcare organization performs approximately 50 isolated CABG surgeries per month.
The intervention was implementing face-to-face nursing promotion of cardiac rehabilitation. The intervention did not focus on patient education; the main objective was to provide strong promotion for the patients to enroll in cardiac rehabilitation. Patient education only occurred during the initial scripted session. Nurses promoted cardiac rehabilitation as the next step in treatment, provided support by addressing concerns, motivated the patients to enroll, advocated by obtaining orders, and guided the patients during the enrollment process. The nurses collaborated with the care managers to reduce identified barriers.
The intervention was compared to the current standard treatment of the healthcare organization, which depended solely on the cardiologist. Retrospective data was collected before the project to determine the percentage of patients enrolled in cardiac rehabilitation compared to the percentage of patients who enrolled after receiving face-to-face nursing promotion.
The goal of face-to-face nursing promotion was to increase the enrollment percentage by 27% within 8 weeks. The change was expected to be seen quickly since cardiac rehabilitation is started 2-6 weeks after a CABG (Mendes, 2016).

Johns Hopkins Nursing Evidence-Based Practice Model
Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) guided the evidencebased project. Consistently the literature supports cardiac rehabilitation as an effective treatment for CVD (Anderson et al., 2017). The initial evidence-based practice question was how a healthcare organization increases the percentage of patients enrolling in cardiac rehabilitation.

Practice Question
JHNEBP Question Development Tool guided the interprofessional leadership project team consisting of executive nursing leadership and the project manager to analyze the problem (Dang & Dearholt, 2017). The team defined the problem as the low number of patients who enroll in cardiac rehabilitation after having an isolated CABG. The evidence-based question was refined to ask what nursing can implement to improve enrollment percentages. The interprofessional team identified stakeholders for the project and individual responsibility using the JHNEBP Stakeholder Analysis Tool (Dang & Dearholt, 2017).

Evidence
The interprofessional leadership team collected internal data, and an evidence search strategy included searching various databases to obtain current literature for evidence that improves the practice problem. The literature was appraised using the JHNEBP Evidence Level and Quality Guide (Dang & Dearholt, 2017). The findings were summarized and synthesized to develop a recommendation to improve the practice problem (Appendix A and B).

Translation
The healthcare organization is actively trying to increase enrollment rates making the planned evidence-based project appropriate and feasible. The action plan was guided by the JHNEBP Action Planning Tool (Dang & Dearholt, 2017). The initial plan used nurses from various specialties to educate, support, advocate, promote, motivate, and endorse clients to enroll in cardiac rehabilitation. The healthcare organization was assessed for strengths, weaknesses, barriers, and costs using assessment tools. The evidence-based practice team captured dichotomous data if the patient attended the first scheduled cardiac rehabilitation session, obtained a cardiac rehabilitation order, or was active in the enrollment process. Weekly updates were emailed to the stakeholders with relevant information. The project manager monitored the project and made changes as needed. JHNEBP Dissemination Tool guided the sharing of key findings with the stakeholders and professionals interested in the project outcomes.

Stages of Change Theory
The Stages of Change Theory has become one of the most common theoretical frameworks for medical conditions requiring behavioral changes (Raihan & Cogburn, 2020). The leading cardiac rehabilitation authority, The American Association of Cardiovascular and Pulmonary Rehabilitation, recommends this theory to guide cardiac rehabilitation (Rohrbach et al., 2017). Cardiac rehabilitation aligns with this theory by supporting patients to make slow changes to their behaviors to improve their health.
The theoretical framework allows the healthcare team to support the patients as they move through six stages. After cardiac surgery, the patients will likely be in the contemplation stage, which means they recognize their choices and behaviors are problematic (Waight et al., 2015). The nurses will encourage and provide a strong endorsement of cardiac rehabilitation by emphasizing the benefits and allow the patients to ask questions and express concerns (York University, n.d.).
If the patients plan to enroll in cardiac rehabilitation, they have progressed to the preparation stage. The patients believe that their behavior and actions will improve their health outcomes (Krebs et al., 2020). During this phase, the healthcare team will provide motivation, positive reinforcement, and support (York University, n.d.).

Evidence Search Strategy
An electronic search of the EBSCO digital database was conducted using the University of St. Augustine's (USA) library. The multiple database search included 34 research articles from Cumulative Index to Nursing and Allied Health Literature (CINAHL), one research article from Cochrane Library of Systematic Reviews, 59 research articles from Gale Academic OneFile, 30 research articles from Medline, eight research articles from Academic Search Index, and five research articles from SPORTDiscus, which resulted in 137 research articles. The keywords using Boolean operators for the evidence search included cardiac rehab* (select a field: in the title) AND nurs* AND enrollment or utilization or utilisation. The search was narrowed by adding exclusion criteria NOT outpatient clinics or ambulatory care or outpatient services or outpatient care and NOT pediatrics. The initial search used keywords cardiac rehab* AND nurs* AND enrollment, which yielded 10 research articles requiring the search to be widened. Other unsuccessful searches included keywords face-to-face promotion and nurs* interventions. The British spelling of utilisation was included since many research articles are international. The search was not limited to CABG patients since this niche population was requested by hospital administration to fit a current project scope. The advance search options were limited to timeframe: 2015-2021, language: English, report type: full-text, peer-reviewed, and academic journals. The USA database search engine removed duplicate research articles.

Evidence Search Results
Even though the articles followed the search criteria, many of the research articles identified did not apply to the PICOT. Titles and abstracts of 137 articles were reviewed for PICOT relevance, which focused on increasing cardiac rehabilitation enrollment rates utilizing face-to-face nursing promotion. Eighty-eight articles were excluded for various reasons.
Exclusion criteria included a research goal to solve patient barriers to enrollment, interventions to improve the referral and implementation of cardiac rehabilitation, and interventions to increase patient adherence and participation. The research articles that focused on increasing enrollment numbers into cardiac rehabilitation were excluded if the articles concentrated on patient-provider interaction, patient's perception about enrollment, clinical practice guidelines, interventions included mobile apps or telemedicine, and enrollment was for cardiac rehabilitation phase I. A full-text survey of the remaining 49 articles was conducted to locate the best research articles supporting increasing cardiac rehabilitation enrollment using face-to-face nursing promotion. The full-text survey resulted in a final number of seven primary research studies and one systematic review with meta-analysis summarized using a PRISMA figure located in Figure   1.
Each of the seven articles was appraised for its strength using the evidence level and quality grading based on the JHNEBP guide (Dang & Dearholt, 2017). The seven articles ranged in evidence levels from level I through level III. Four of the articles were experimental randomized control trials (RCT), resulting in an evidence level I (Ali-Faisal et al., 2016;Cossette et al., 2012;Grossman, 2015;Scott et al., 2013). The systematic review with meta-analysis (Pio et al., 2019) and a mixed-method study resulting in standardized online provider education specific to cardiac rehabilitation enrollment (Santiago de Araújo Pio et al., 2020b) are categorized as evidence level II. Ades et al. (2017) meta-synthesis was a significant catalyst for the healthcare system to focus on improving enrollment rates into cardiac rehabilitation is classified as level III. Table 1

Themes with Practice Recommendations
The themes were determined after a thorough investigation and synthesis of each article listed in the evidence table (Appendices A and B). The research article's participants all had a cardiac rehabilitation eligible diagnosis, but the admitting diagnoses varied among the studies but did not impact the conclusions about increasing cardiac rehabilitation enrollment. The type of medical unit the patients received care on did impact the enrollment rate into cardiac rehabilitation (Ali-Faisal et al., 2016). High-quality research was conducted in numerous countries, which did not impact the interventions that increase enrollment rates.

Healthcare Organization Systematic Process
The literature strongly advocates for healthcare organizations to start with a systematic approach for cardiac rehabilitation enrollment to streamline communication, reduce ambiguity, and coordinate roles among the healthcare team (Ades et al., 2017). The enrollment strategy should include standardized staff and patient education using a script to improve the accuracy of the patients' message (Ades et al., 2017;Santiago de Araujo Pio et al., 2020b).

Face-to-Face Cardiac Rehabilitation Promotion
Strong evidence supports that patients who receive cardiac rehabilitation promotion via face-to-face communication correlates with increased enrollment rates. A discrepancy noticed among the literature is which member of the healthcare team should complete face-to-face promotion. A physician endorsement has the most significant impact on enrollment (Ades et al., 2017); however, the nurse's endorsement is meaningful and impactful (Cosette et al., 2012;Grossman et al., 2015;Pio et al., 2019). Nursing face-to-face promotion is supported by substantial evidence as the ideal intervention to increase enrollment rates by an average of 27% (Cosette et al., 2012;Grossman, 2015, Pio et al., 2019. Face-to-face promotion was also successful with using an allied health member functioning in a patient navigator's role to promote, encourage, educate, advocate, motivate, and guide the patient through the enrollment process (Ades et al., 2017;Scott et al., 2013). Cardiac rehabilitation promotion includes education, a strong endorsement, support, motivation, and encouragement, and provides an opportunity to ask questions, advocate, initiate the enrollment process, and disseminate printed patient informational handouts (Ades et al., 2017;Santiago de Araujo Pio et al., 2020b).

Lack of Healthcare Provider Cardiac Rehabilitation Knowledge
According to Schopher et al. (2016), 72% of healthcare providers lack knowledge about cardiac rehabilitation. The healthcare team's lack of knowledge leads to inaccurate and insufficient patient education, advocacy, promotion, encouragement, and support resulting in a failure to enroll in cardiac rehabilitation (Ades et al., 2017;Ali-Faisal et al., 2016). After the healthcare providers receive education, they report a positive attitude about cardiac rehabilitation and are more likely to promote it to their patients (Santiago de Araujo Pio et al., 2020b). The healthcare team should use available educational tools endorsed by cardiac rehabilitation experts to improve their knowledge about benefits, promotion techniques, resources, and outcomes (Pio et al., 2019;Santiago de Araujo Pio et al., 2020b).

Address Patient Barriers to Enrollment
Patients face barriers to participating in cardiac rehabilitation that decreases enrollment rates, which will logically increase if the barriers are addressed. Common barriers identified in the literature include the distance to the location of the cardiac rehabilitation center (Ali-Faisal et al., 2016;Cossette et al., 2012), transportation (Cosette et al., 2012), cost (Scott et al., 2013, and lack of education (Ades et al., 2017;Santiago de Araujo Pio et al., 2020b). The enrollment strategy will need to include the care management team members to address and attempt to solve the patients' barriers that hinder enrollment. Face-to-face nursing promotion will improve the lack of knowledge.

Recommendation
The evidence was obtained from seven high-quality, evidence level I-III primary research articles with consistent outcomes. The recommendation is based on the thorough and rigorous review of the synthesized information and summarized in Figure 2. The first step was the healthcare organization developing a systematic approach focusing on the cardiac rehabilitation enrollment strategy. Face-to-face promotion consistently remains the best practice to increase enrollment rates; thus, the recommendation was to have the nurses implementing face-to-face promotion. Nurses are interacting with clients frequently, so face-to-face promotion was easily embedded into their current workflow. Instead of engaging the physicians, which is difficult, the recommendation was to include cardiac rehabilitation face-to-face promotion from the nurse practitioners (ARNP). The recommendation included the care managers to communicate with the patients about barriers and find possible solutions. Before the nursing face-to-face promotion begins, the recommendation was the nurses receive standardized education about cardiac rehabilitation and promotion.

Setting, Stakeholders, and Systems Change
The healthcare organization is a 2,247-bed Christian-based, non-profit hospital providing comprehensive medical services to Central Florida patients. The mission is to extend Christ's healing ministry through whole-person care addressing the mind, body, and spirit. The hospital provides cardiovascular care to 72,000 patients each year treated by a team of more than 1,000 specially trained healthcare providers. The pilot unit will be Ginsberg Tower (GT) 8, cardiovascular surgery progressive care unit.
In January 2020, the executive leadership team focused on cardiac rehabilitation low enrollment rates, making it an organizational project scope for 2020-2025. Face-to-face nursing promotion of cardiac rehabilitation perfectly aligned with the project scope. The PICOT and recommendations were strongly supported by the chief nursing officer, executive director of cardiovascular services, nursing director of cardiovascular services, and cardiac rehabilitation nurse manager. These key stakeholders strongly advocated for participation from other stakeholders, including GT8 nurse manager, nursing education, clinical data analyst, institutional outcome and value analyst, executive director of clinical outcomes, registered nurses, cardiovascular surgical ARNPs, cardiac rehabilitation care coordinators, care managers, and a patient representative.
The interprofessional collaboration occurred between the GT8 registered nurses, cardiovascular surgical ARNPs, care managers, cardiac rehabilitation care coordinators, discharge nurses, data abstractors, and data analysts. The project remained net-neutral; thus, the interventions were embedded in the caregivers' current workflows to maintain sustainability.
The SWOT analysis was discussed with key stakeholders regarding the organization's ability to implement the project (Figure 3). The strengths included considerable resources and leadership support to implement and sustain change. The weaknesses included resistance to change, staff fatigue, and burnout due to COVID-19. The opportunity was improved outcomes and increased reimbursement. The threats included increase workload, RN turnover, and changes in payors.
The micro-level system changes included purposeful interactions and patient empowerment, which were currently undervalued. The change consisted of the daily clinical practice of providing isolated CABG patients with endorsement, education, encouragement, motivation, support, advocacy, and tools to enroll in cardiac rehabilitation. The project provided purposeful, meaningful, and high-quality interactions during face-to-face promotion, which allowed the patients to ask questions in a supportive environment empowering the patients to make informed decisions about their health. Changes to the system at the meso-level improved the nurses' lack of cardiac rehabilitation knowledge, which resulted in inconsistent patient education, endorsement, encouragement, support, and reduced enrollment in cardiac rehabilitation. The system change involved educating the nurses about cardiac rehabilitation, tools, techniques, and the new systematic process to increase enrollment rates.
The macro-level system change focused on the intersectoral links that are overlooked.
Numerous team members attempted to improve low enrollment rates; however, they worked in silos. There was no feedback loop and communication among the team resulting in gaps and inconsistent information given to the patients. The system change developed an integrated process of coordination of roles to reduce duplication, provide consistent information, and improve interprofessional communication.

Implementation Plan with Timeline and Budget
The project team utilized the JHNEBP model to determine the project question and an evidence-based solution. There was sufficient internal data to support the need to increase the current cardiac rehabilitation enrollment rate, and high-quality literature supported nursing faceto-face cardiac rehabilitation promotion would be beneficial. The activities' schedule is listed in a Gantt chart that provides detailed steps with the timing of the intervention and evaluation process (Appendix C).
The objective that determined the project's impact was the cardiac rehabilitation enrollment rate of patients with isolated CABG admitted to the pilot unit would increase by 27% 8 weeks after implementing face-to-face nursing promotion. Due to time constraints, enrollment was measured by the patients who obtained an order for cardiac rehabilitation from their provider, active in the enrollment process, or attended their first scheduled cardiac rehabilitation session. The objective was met through system change by empowering the patients through purposeful and meaningful face-to-face nursing promotion, educating the nurses to become cardiac rehabilitation experts to promote enrollment, and creating a systematic collaboration process among the interprofessional team.
A systematic process was developed and implemented to improve coordination among the intersectoral links, improve interprofessional team communication, and designate clear roles.
After completing a SWOT analysis and key stakeholder assessments, a process was developed.
The systematic approach is described in Figure 4.
The nurses and care managers worked together to address a different aspect of cardiac rehabilitation promotion. They shared the patient status specific to their focus during the daily interprofessional collaboration (IPC) rounds on the pilot unit to improve communication, continuity of care, and collaboration. The interprofessional team collaboration checklist facilitated communication and held team members accountable for compliance using face validity (Appendix D). The healthcare organization meso-level system change addressed the evidence theme that healthcare providers lack education about cardiac rehabilitation. The objective was 90% of the nurses will demonstrate an understanding of cardiac rehabilitation, benefits, the enrollment process, and face-to-face promotion with patients who have an isolated CABG within 2 weeks after receiving standardized education. The objective was met by providing nurses with standardized education based on the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) (York University, n.d.). After educating the nurses, they took a post-test and needed to score a minimum of 90% to be considered successful.
An objective focused on standardized face-to-face nursing promotion among the CR champions. Within 8 weeks of implementing the project, 90% of the CR champion's initial faceto-face nursing promotion sessions followed the defined process. The initial face-to-face promotion included the CR champions using a script (Appendix E), providing an iPad for the patient to watch an informational video about cardiac rehabilitation called Cardiac rehabilitation: Your journey back to heart health (CardioSmart, 2016), and delivering the cardiac rehabilitation promotion packet (Appendix F). This process supported the patients in the Stages of Change Theory's contemplation stage by providing the benefits of cardiac rehabilitation, answering questions, and addressing concerns. The objective was met because the CR champions received education and the tools required.
The patients admitted with an isolated CABG received face-to-face nursing promotion by nurses in various specialty roles. Of the patients who had an isolated CABG on GT8, 90% would receive face-to-face cardiac rehabilitation nursing promotion from the CR champions, staff nurses, cardiovascular surgical ARNPs, and discharge nurses, including having barriers addressed by the care managers 8 weeks after implementation of the project. This objective was met because of the systematic process in place, cardiac rehabilitation education, interprofessional team collaboration, and nurses did have the required tools to promote cardiac rehabilitation. The role of each team member is described in Figure 4.
The healthcare organization did not provide a project budget forcing the project to remain net-neutral (Table 2). Embedding the intervention into the current workflows helped keep the project net-neutral and increased sustainability. The project manager received a grant to cover the cost of patient educational material and a statistician.
The project manager supported the interprofessional team, collected data, provided weekly communication with the stakeholders, adjusted the project as needed based on limitations and ethical concerns, and monitored compliance with surveillance and electronic health record documentation review. Leadership qualities and skills included promoting a positive work environment, empowering the team, demonstrating openness for new ideas, incorporating opinions for changes, and fostering a sense of team.
After a thorough risk assessment, the key stakeholders and project manager determined a low risk for patient harm in correlation with the evidence-based project. Cardiac rehabilitation has inherent risks, but these risks did not apply to face-to-face nursing promotion and enrollment.
Other areas of risk included staff noncompliance, obtaining timely data, and budget. The strategy to address noncompliance and budget risks was mitigation. The elimination strategy was used to manage the risk with delayed data dissemination. The healthcare organization owns the cardiac rehabilitation center, and an increase in participation will increase revenue, which was a conflict of interest.

Evaluation Results
After approval from the University of St. Augustine's EBP Project Review Council (EPRC) and the executive leadership team at the healthcare organization, the implementation and evaluation process began. The participants included patients on GT8, status post isolated CABG.
Appendix G explained the type of data collected, who collected it, which statistical tools were used per data measurement, the frequency of data collection, where the data was accessed, categorical measures, and benchmarks.
The interprofessional team member's roles (Figure 4), interprofessional collaboration, data collection tool (Appendix H), and interprofessional team collaboration checklist (Appendix D) maintained the integrity of the data collection process. The data collection resources were valid and reliable since the data came from project manager surveillance, interprofessional team member documentation in the electronic health record, and information from the health information management system. Listwise deletion was used to deal with missing data so that only data with all observations were used for every analysis. The project team set a limit of 5% missing data was acceptable before corrective action. The data collected that contained personal health information was stored on the healthcare organization's encrypted, HIPAA compliant share-drive.
A statistician used descriptive and inferential statistics to determine the impact of face-toface nursing promotion of cardiac rehabilitation on cardiac rehabilitation enrollment. Descriptive statistics measured different variables such as enrollment rate, impact enrollment rate into cardiac rehabilitation, barriers resolved, face-to-face promotion, nurse cardiac rehabilitation education, and nursing face-to-face promotion compliance. Inferential statistics assessed the associations among variables. The chi-square tests were used to test the associations among categorical dependent and categorical independent variables. Independent sample t-tests were used to assess whether statistically significant associations exist between continuous dependent and categorical independent variables. Variations were considered statistically significant at p < 0.05. There were N = 73 patients in the sample whose age ranged from 38 to 88 years (M = 64.35, SD = 10.57) and included 53 (72.6%) males and 20 (27.4%) females and most patients had Medicare, 42 (57.5%) ( Table 3). There were 67 (91.8%) patients that received face-to-face nursing promotion by the cardiac rehabilitation champion and six (8.2%) did not receive it (Table 4). There were 21 (28.8%) patients that enrolled in cardiac rehabilitation, 28 (38.4%) did not, and 24 (32.9%) were not candidates (Table 5). A cross-tabulation of cardiac rehabilitation enrollment of face-to-face nursing promotion was conducted. Out of 45 cardiac rehabilitation eligible patients that received face-to-face nursing promotion, 19 (42.2%) enrolled in cardiac rehabilitation, whereas 26 (57.8%) did not enroll (Table 6). These results were not statistically significant, χ2(1) = 0.091, p = .763 (Table 7). However, this data is clinically significant because, among cardiac rehabilitation eligible clients, face-to-face promotion increased the enrollment rate by 29%.
Results of the project did not show a statistically significant association between face-toface nursing promotion and cardiac rehabilitation enrollment. A factor that may have influenced the results was that of sample size. The sample size required to achieve 80% statistical power was at least 88, based on a G*Power sample size calculations ( Figure 5). This reduced sample size in this project resulted in lower statistical power, which may have affected the results.
However, there was an overall increase of 16% in cardiac rehabilitation enrollment (21 clients enrolled out of 73) after the project compared to the 13% initial enrollment rate, which is clinically significant. Clinical significance was determined using descriptive data to assess the impact on the current processes and outcomes. Supplementary analysis was conducted to determine if there were significant associations between cardiac rehabilitation enrollment with ARNP endorsement, GT8 RN support, discharge nurse endorsement, and care manager assistance with overcoming barriers. Chi-square tests were conducted to test these associations.
Regarding ARNP endorsement, there was no statistically significant association with enrollment, χ2(1) = 2.457, p = .117. Within those enrolled, there were 13 (61.9%) with ARNP endorsement versus those with non-ARNP endorsement, (eight, 38.1%) (Tables 8 and 9). There was more enrollment with ARNP endorsement, which is clinically significant. Regarding the association between cardiac rehabilitation enrollment and GT8 registered nurse support, results of the chi-square test revealed no statistically significant association, χ2(1) = 0.791, p = .374 (Tables 10 and 11); however, the low GT8 RN compliance rate of 22% was clinically significant.
Regarding the association between cardiac rehabilitation enrollment and discharge nurse endorsement, results of the chi-square test revealed no significant results, χ2(1) = 0.244, p = .621. The proportion of discharge nurse endorsement in both cardiac rehabilitation enrollment and non-enrollment was similar (Tables 12 and 13). Regarding the association between enrollment and patient barriers, there was a statistically significant association, χ2(6) = 12.519, p = .021 (Table 14). One noticeable feature is that, within non-enrollment, the location was the most frequent barrier. In the cardiac rehabilitation enrollment group, most clients denied having any barriers to cardiac rehabilitation enrollment. Removing barriers may increase cardiac rehabilitation enrollment, which is clinically significant.

Impact
The evidence-based project provided a systematic process that addressed gaps within the healthcare organization by implementing change at various system levels. The evidence-based project improved the gap of general knowledge about cardiac rehabilitation among most healthcare providers. The project incorporated the interprofessional team to work in tandem with clear roles and enhanced communication, increasing cardiac rehabilitation enrollment rates among isolated CABG patients by 16%. The interprofessional team members are now providing consistent cardiac rehabilitation promotion that has reduced the gaps in information and education the clients receive.
Future implications of the project involve providing face-to-face nursing promotion to all patients admitted with eligible cardiac rehabilitation ICD-10 diagnoses. The healthcare organization will need to budget for an increase in the number of nurses who will function in the cardiac rehabilitation champions' role to provide a strong, scripted initial face-to-face promotion.
The healthcare organization can anticipate reducing cardiac-related readmissions and a reduced cost in treating cardiovascular disease as the percentage of cardiac rehabilitation enrollment continues to increase.
To improve practice in the future will require continuous education of the healthcare team about cardiac rehabilitation, the benefits, and the healthcare organization's cardiac rehabilitation enrollment process. The cardiac rehabilitation care coordinators will need to dedicate a minimum of one patient encounter specific for cardiac rehabilitation to provide a purposeful, client empowering session that remains scripted. The nurse practitioners will need to continue to endorse cardiac rehabilitation during rounds. Finally, the healthcare organization will need to dedicate resources to reducing barriers to enrolling in cardiac rehabilitation.
The cardiac rehabilitation department will need to provide surveillance to ensure compliance of the cardiac rehabilitation champions and nurse practitioners. The health information management team will continue to collect data about cardiac rehabilitation enrollment rates to determine if the project remains effective. Identified barriers that impacted the project's outcomes that will need to be addressed include the continual use of float nurses with limited education about cardiac rehabilitation, minimal support by physicians, and lack of authority to hold the ARNPs accountable.

Dissemination Plan
Dissemination of the project results will be presented to the project stakeholders, allowing the nurses and case managers to see their impact and provide a feedback loop. There will be another presentation for the healthcare organization's executive board during their monthly meeting, sharing the project's clinical significance and the impact on the organization's project scope to increase enrollment rates into cardiac rehabilitation. Due to the COVID-19 pandemic, the presentations will be conducted virtually by sharing the information via a PowerPoint presentation. The presentation will be recorded and shared with healthcare professionals interested in the clinical significance of the project and its impact on the problem.
A poster presentation will be given at the annual Chi Upsilon Chapter of Sigma research day (November 2021) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) annual conference (October 2021). A manuscript of the evidencedbased project and outcomes will be submitted to the Journal of Cardiopulmonary Rehabilitation and Prevention (JCPR). JCPR is chosen because it is a peer-reviewed professional journal dedicated to improving multidisciplinary clinical practice and expanding research evidence specific to cardiac rehabilitation. JCPR is the official journal of the AACVPR, which remains the leading expert on cardiac rehabilitation. Before submitting an abstract, manuscripts, and poster presentations, the information will be peer-reviewed for accuracy, validity, strengths, weaknesses, and quality. The peer reviewers will be scholarly experts in the field of cardiac rehabilitation. The evidence-based project manuscript will be published in SOAR@USA.

Conclusion
Based on a thorough investigation and synthesis of high-quality research articles, the evidence-based project utilized an interprofessional approach of nursing face-to-face promotion of cardiac rehabilitation for patients admitted with an isolated CABG to increase cardiac rehabilitation enrollment rates by 27%. The project resulted in a 16% cardiac rehabilitation enrollment increase. Face-to-face promotion, ARNP endorsement, and reducing barriers were clinically significant in increasing the enrollment rate.
The evidence-based project was guided by the John Hopkins Nursing Evidence-Based Model, the Stages of Change Theory, and the healthcare organization's needs, resulting in system changes occurring at various levels. Themes synthesized from the research articles include developing a systematic approach for cardiac rehabilitation enrollment, educating the nurses about cardiac rehabilitation, reducing patient barriers to enrollment, and providing face-to-face nursing promotion of cardiac rehabilitation, which the project incorporated. Each interprofessional team member had a role-specific to their current workload to promote face-toface nursing promotion of cardiac rehabilitation and reduce barriers with collaboration that addressed each patient's individualized needs to promote cardiac rehabilitation enrollment.    Table 6. Studies included in quantitative synthesis (n = 6) Systematic review with meta-analysis (n = 1) CINAHL (n = 34) Cochrane Systematic Reviews (n = 1) Gale Academic (n = 59) Medline (n = 30) Academic search Index (n = 8) SPORTSDiscus (n = 5) Figure 2.

Recommendation to Answer the PICOT Question
Note. This is a visual depiction of the recommendations from synthesizing the primary articles to increase enrollment rates into cardiac rehabilitation.
Create a systematic process focusing on increasing enrollment rates into cardiac rehabilitation utilizing an interprofessional team

Face-to-Face Nursing Cardiac Rehabilitation Promotion Systemic Process
Figure 5.

G*Power Sample Size Calculation Required for Chi-Square Test
Appendix A Week 3

Summary of Primary Research Evidence
Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Planning Phase Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Plan an intervention for ARNPs to endorse CR during rounds Create a checklist for the process for compliance Measure and Analysis Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Interpretation of interventions and the number of patients enrolled in CR Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Our goal through cardiac rehabilitation is to help you: • improve your health • prevent further problems related to your cardiovascular disease • reduce your symptoms-and feel better! You can expect many healthcare team members to recommend cardiac rehabilitation as your next step during your stay. If we obtain an order from your cardiologist, we can start the sign-up process in the hospital. Otherwise, the rehabilitation team will contact you at home to set up your first appointment.
Your first appointment will be an educational session to help guide you through the process. Our team will create an individualized plan to give you the best results. Remember, the program is more than just exercise. We will help you manage stress, provide health education classes, and offer information about eating a heart-healthy diet.
If you have any cardiac rehabilitation questions, please ask any healthcare team member or call us.
With best wishes for your recovery, CR before implementation (denominator).