Evaluating the Relationship between Nursing Care Quality and Hospital Anxiety and Depression among Old Patients with Cardiovascular Disease

Introduction: Cardiovascular disease (CVD) is a prevalent condition among older adults’ hospitalizations leading to psychological complications. Nursing care is the longest intervention the patient receives. This study evaluated the relationship between nursing care quality and anxiety and depression among old patients with CVD. Methods: This is a descriptive cross-sectional correlational study that included 250 old patients with CVD admitted to an ‘age-friendly hospital’. Using the convenience sampling method. The data collection tools included the Hospital Anxiety and Depression Scale (HADS) and the Quality Patient Care Scale (QUALPACS). Data were collected through conducting interviews and analyzed in SPSS ver.13 via statistical tests such as correlation coefficients, independent t-test, and ANOVA. Results: Overall, 229 (91.6%) of patients received the desired nursing care quality. The mean (SD) scores for anxiety were 1.52 (1.14) and depression 2.18 (1.51), indicating a less than average hospital anxiety and depression. There was an inverse correlation between anxiety and nursing care quality. Conclusion: A combination of high-quality nursing care and clinical governance criteria in an age-friendly hospital can reduce anxiety in old patients.

and depression are both common complications of heart disease and are caused or exacerbated by the medical environment. 19 Hospitalization leads to stress and anxiety, which results in complications. 20 Anxiety and depression increase heart rate, blood pressure, hemodynamic instability, cortisol, and repair defects. 21,22 Health care systems should strive to improve the quality of care given the growing elderly population and the increase in CVD. 23 The main features of age-friendly hospitals include accessibility, appropriate health and medical services for older adults, trained personnel, and an age-friendly environment and geriatric wards. 24 Since age-friendly hospitals have recently started providing services in Iran, it is necessary to assess nursing care quality in these hospitals. Hospital Anxiety and depression are one of the criteria for assessing the quality of nursing care in the hospital. Therefore, this study evaluated the association between nursing care quality and anxiety and depression among old patients with CVD.

Methods and Materials
This is a descriptive cross-sectional correlational study was done in Coronary Care Units of Firoozabadi hospital in Tehran, Iran, which is an age-friendly hospital. Clinical governance is established in this hospital. The necessary permits were obtained from the relevant authorities and the Research Ethics Committee of Iran University of Medical Sciences approved the study protocol (IR.IUMS. REC.1397.1047). We obtained written consent from all participants. Moreover, the participants were free to leave the study at any stage, and they were assured that their information would remain confidential.
For data collection, the researcher visited the units at a suitable time and date announced by the nursing authorities. The participants answered the questionnaires at the time of discharge, which usually took twenty minutes. The purpose of the study was explained to the participants. The sample size was calculated with α = 0.05, β = 0.2, and correlation coefficient = 0.03 for hospital anxiety and depression in the old patients with CVD. The sampling method was the convenience method. Two hundred and fifty old patients with CVD were included from various cardiac units (post coronary care unit, coronary care unit1, and coronary care unit2).
Data were collected through interviews with each participant. Participants were assured that their information would remain confidential and that they had the right to leave the study at any stage. Inclusion criteria were age over 60, no history of heart surgery, and no history of depression.
Data collection tools included a demographic questionnaire (age, gender, marital status, occupation, and education); the Quality Patient Care Scale (QUALPACS); the Hospital Anxiety and Depression Scale (HADS). Ten experts confirmed the content validity and face validity of the tools. The QUALPACS, developed by Wandelt and Ager in 1974, 25 includes 65 items in three dimensions (physical: 24 items, psychosocial: 28 items, and communication: 13 items). The Likert scale is ranked zero to two with answers (rarely: zero, sometimes: 1, most often: 2). Scores ranged from zero to 130 and are categorized into three levels (unfavorable: 0-43, desirable: 44-87, and very desirable: 88-130). Cronbach's α was 0.91 in this study.
The HADS, designed by Zigmond and Snaith in 1983, 26 is a self-report tool to determine the anxiety and depression symptoms in patients. This tool is valid for assessing anxiety (seven items) and depression (seven items) and is run within approximately 10 minutes. The Likert scale is ranked zero to three. The minimum score is zero and the maximum is 42. The range of zero-seven is considered normal, eight-ten mild, and 11 to 21 severe. Persian version of this scale had Cronbach's α of 0.83. The HADS was validated by Montazeri et al. 27 Another study reported Cronbach's α = 0.85 and 0.70 for anxiety and depression, respectively. 28 The data were analyzed by SPSS software ver.13. Descriptive data were described as frequency, mean, and standard deviation. Data were analyzed using independent t test, ANOVA, and Pearson correlation coefficients (α ≤ 0.05).
The mean (SD) and standard deviation of nursing care quality was 84.08 (17.16)  The mean )SD) of anxiety was 1.52 (1.14) and depression was 2.18 (1.51). There was a significant difference in anxiety and depression scores in old women and old men ( Table 2).
The results of Pearson's correlation coefficient showed that there is a significant negative correlation between hospital anxiety with psychosocial, physical, and communication (Table 3).

Discussion
This study found that most patients reported the desired quality of nursing care quality. All patients had low levels of hospital anxiety and depression. The finding indicated that there was a reverse relationship between hospital anxiety and nursing care quality.
The findings of this study were consistent with other studies evaluating the nursing care quality in hospitals. 18,29,30 However, our findings did not agree with the results of some studies, 19,20 that showed the rising anxiety and depression in the old patients hospitalized in Coronary Care Unit. These differences might be due to the units in which they measured old patients' anxiety and depression in hospitals with no clinical governance. There are opportunities for improving the safety and quality of clinical practices through clinical governance within hospitals. 31 Clinical governance is one of the most important policy developments in health systems. Clinical governance is related to the performance of all health care professionals to provide high-quality and cost-effective services. 32 Hospital anxiety and depression can have a negative effect on health outcomes (e.g. hemodynamic instability) and length of stay in patients during hospitalization. The level of anxiety in patients with CVD is relatively high, so it is important to evaluate the mental health of the old patients with CVD due to its consequences. 28 Therefore, it is necessary to take action to reduce anxiety and depression in hospitals.
The results of this study also found that anxiety and depression were higher in old women patients than in old men ones. Mental disorders are a risk factor for CVD, 33 which has also been confirmed in the studies by   Polikandrioti et al, 18 Khan et al 19 and Orujlu & Hemmati-Maslakpak. 30 Patients' anxiety and depression levels were low in this study and this may be due to clinical governance and age-friendly environment in hospitals. 20,21 Future studies should focus on qualitative approaches in the field of new health policies and the impact of that on the care quality and mental health of old patients. 34 The health professionals seriously consider clinical governance because it is necessary to move from routine actions to innovative approaches. 35 Azimbeik et al demonstrated that the workability of nurses was at an appropriate level in hospitals in Iran which could result in patients' experiences and satisfaction. 36 There are some limitations in the present study. First, this study evaluated only old patients with CVD in a medical center. It is recommended that a study be conducted on a larger sample size in several hospitals to increase the generalizability of the findings. Second, it is better to study in a continuous process to assess the relationship between anxiety and depression and the quality of care. 37,38

Conclusion
This study aimed to evaluate the relationship between nursing care quality and anxiety and depression among old patients with CVD. The results of this study confirm care quality effects on anxiety and depression. By facilitating the admission and hospitalization processes of the elderly patients in age-friendly hospitals, it is possible to reduce stress, anxiety, and depression among old patients. The scores of care quality in the hospital with clinical dominance were high, and the scores for anxiety and depression were low.
Policymakers and hospital managers can use these findings as a guide to improve nursing care quality and clinical governance alongside the age-friendly hospital.
What is the current knowledge? -The prevalence of CVD is about 20-25% of the total population; however, more than half of the cases are related to elderly people. -The goal of clinical governance is to maximize the quality of care services. -The quality of nursing care means achieving the most desirable care and health processes. -Anxiety can be affected in a short time and it can be assumed that depression can be reduced during long hospital stays.
What is new here? -Most patients (91.6%) reported the desired quality of nursing care in this study. -There was significant negative correlation between the patients' anxiety and quality nursing care.