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Perceived learning needs of the patient undergoing coronary angioplasty: An integrative review of the literature
Perceived learning needs of the patient undergoing coronary angioplasty: An integrative review of the literature Catherine A. Gentz, RN, BSN, Rockford, Illinois
OBJECTIVE: This study presents, through an integrative review, a comprehensive account of the perceived concerns and learning needs of patients in the early recovery period after a coronary angioplasty. SCOPE: Nineteen studies involving the patient who has undergone coronary angioplasty were identified using CINAHL and MEDLINE. These studies were examined to compare samples, methods, findings, implications, and suggestions for future research. FINDINGS: Overall the subjects believed that undergoing coronary angioplasty was positive and beneficial, and they viewed it as a minimally invasive, routine procedure. Informational knowledge, such as risk factor education and survival management, were considered of high importance. The majority of subjects modified their behavior, and the most common modification was in diet. Both learned knowledge and lifestyle changes decreased over time. Self-efficacy expectations and levels of anxiety were predictors of behavior changes and knowledge retention in the early recovery period after the coronary angioplasty procedure. IMPLICATIONS: Health professionals must emphasize the seriousness and long-term outcomes of untreated heart disease. Education programs should be individualized and streamlined. Spouses and significant others have informational needs and should be included in education programs. Learning needs in the acute care setting differ from those in the outpatient setting. Continuing education and resources need to be available for patients who are recovering from percutaneous transluminal coronary angioplasty and their families, and should build upon knowledge obtained during hospitalization. (Heart Lung® 2000;29:161-72.)
T
he progression of coronary artery disease (CAD) is a significant health care problem. CAD, the leading cause of morbidity and mortality in the United States, affects 70% of the adult population to some extent and claims the lives of approximately 500,000 men and women each year.1 In addition, approximately 300,000 patients undergo percutaneous transluminal coronary angioplasty (PTCA) procedures yearly. Of these, approximately 40% will need additional treatment because of restenosis of the ballooned vessel(s).2 From the Graduate School of Nursing, Northern Illinois University, Rockford. Reprint requests: Catherine A. Gentz, RN, BSN, 1410 Geneva Ave, Rockford, IL 61108. Copyright © 2000 by Mosby, Inc. 0147-9563/2000/$12.00 + 0 2/1/106002 doi:10.1067/mhl.2000.106002
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Economically, the direct costs for treating patients with CAD are currently more than $150 billion a year and are expected to exceed $200 billion by the year 2000, with most medical costs occurring from hospitalizations. Although the treatment of cardiac disease symptoms has improved over the past decade with advances in diagnosis, interventional techniques, and medical therapy, this does little to treat the underlying causes of CAD.3 Evidence exists that the disease process can be slowed or reversed through the implementation of lifestyle changes and risk factor modifications.4,5 Improved patient quality of life and lessened financial burdens are likely outcomes of such lifestyle changes. Recognizing cardiac risk factors as causes of CAD is the first step for patients in reducing their risk by making lifestyle changes. Only then can the adop-
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tion of a healthful lifestyle follow.6 Past research suggests that this process of learning and changing, as well as other challenges, exists uniquely for the patient who has undergone a PTCA.7,8 A lesser tendency toward compliance, less favorable behavioral changes, and a decrease in healthful behaviors over time was seen in patients who had undergone PTCA versus those patients who had coronary artery bypass graft (CABG) surgery.7 An inaccurate perception of the seriousness of their disease among those who had a PTCA may be a result of the shorter hospital stay, shorter recovery period, and less discomfort when compared with those who had a CABG.8
PROBLEM The patient who has undergone a PTCA has a shorter hospital stay than the patient recovering from CABG surgery or a myocardial infarction (MI), creating a challenge for the health professional. Less time is allowed for nursing interventions that provide education to the patient and family; however, teaching patients in preparation for discharge from the hospital is the health professional’s responsibility. Because of the imposed time constraints, understanding what information the patient perceives as important aids in development of meaningful and effective nursing interventions to help the health professional meet patient needs.9-11 This article presents a literature review of a sample of studies on the perceived concerns and learning needs of patients in the early recovery period after PTCA to obtain a clearer understanding of areas that need to be addressed during this time. Patient education and valuable nursing time can be better focused to meet the goal of decreasing the progression of heart disease, thereby decreasing the likelihood of negative outcomes including restenosis and readmission.
SCOPE The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE databases were searched for studies by using the following subject headings: coronary angioplasty, perceived learning needs, coronary artery disease, and risk factor modification. The ancestry approach was also used to ensure that all potential studies were identified. Because the treatment regimen of patients who have undergone PTCA is continually changing, resulting in shorter hospital stays, and is increasingly being performed in the outpatient setting, the search was limited to studies completed between
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1989 and 1999 so that findings would be pertinent to current practices. Nineteen studies were included in this review (Table I). Two of the studies were written by the same authors and used the same subjects, but they had different objectives.9,12 Both articles offered valuable information regarding patient perceptions, so both were included in this review. Only studies that offered the perceived findings of patients who had undergone PTCA were included. The purpose of each study, the design, and data collection methods are included in Table I. The most frequent journal source was Heart & Lung: The Journal of Acute and Critical Care (42%). The remaining articles (58%) were published in 7 different nursing research journals. The majority of the articles were published between 1993 and 1998. All of the primary investigators were nurses. Quantitative research comprised the majority of the sample (74%)8,10,11,13-22 with more than half of these falling under the descriptive correlational design.8,11,15-17,19,20,22 The remaining research was qualitative.6,9,23,24 Of the 6 qualitative studies, 3 used focus groups,9,12,24 and the other 3 used semistructured interviews 6,23,25 to identify patient concerns and perspectives related to their PTCA experience. Nine studies identified a theoretical framework,6,8-9,13,15,17,18,20,24 and Bandura’s theory of self-efficacy was used in 2 of these.8,17
SAMPLES AND SETTINGS Sample sizes in the studies ranged from 14 to 251 subjects.10,25 Ages of the subjects ranged from 26 to 84 years.10,25 Mean ages were between 56.8 and 64 years, with 42% of the subjects between 61 and 62 years of age.6,11,12,15-17,22,23 The majority of the subjects were married (84%) men (68%). One qualitative pilot project had equal numbers of men and women as subjects.25 Two studies examined patients with heart disease and their spouses, and the majority of the patients with heart disease were men and the majority of spouses were women.11,24 Only 7 studies mentioned race.6,13,15,16,20,21,23 Of these, the majority of the subjects were white. Twelve of the studies (63%) reported the education level of the subjects.6,11-13,15,20,22-24 All subjects had a high school education or higher, including college or trade school. Criteria for subject selection were identified in all of the research studies; the most common inclusion criteria were age (at least 18 to 21 years), English speaking, no psychiatric or cognitive problems, and had recently undergone a PTCA. In the majority of the studies (42%), subjects underwent PTCA for
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the first time.9,12,14,17,19,25,26 A history of cardiac illness among some of the subjects was evident in 3 of the studies.10,13,15 One study specifically stated no history was present,6 whereas in 6 others it is not mentioned.8,11,18,20,22,23 Eight studies included subjects other than those patients who had recently undergone a PTCA.6,9,12,19,20,22-24 Two included patients who, in addition to PTCA, may have had an MI.9,12 Two compared patients recovering from MI with patients who had an angioplasty.6,22 Another included patients with angina and MI.23 Subjects who had an MI, CABG, or PTCA were included in 2 other studies.11,24 Patients who had undergone CABG surgery were compared with patients who had undergone PTCA in another study,19 and 2 other studies were nonspecific, describing their subjects as having CAD and angina with catheterization.18,20 Settings for the studies spanned North America, with 4 studies in Canada,10,19,22,25 4 in New York or New Jersey,15,16,18,24 3 on the West Coast,11,21,23 6 in the Midwest,8,9,12-14,17 and one each in the Midwest and on the East Coast.20 All patients had received their health care at large medical centers. Table II illustrates the setting and collection times for each study. The majority of the studies (39%) began in the hospital setting and carried over to the outpatient setting. More than 1 collection time was most common (56%).
DEFINITIONS Three main categories were identified from the studies: perceived learning needs, perceptions surrounding the angioplasty experience, and cardiac recovery behaviors. Perception is the level of understanding and insight the involved person(s) has about a particular event, in this instance, the PTCA procedure and diagnosis of CAD. The patient uses his or her senses and knowledge to sum up how he or she views the experience. Learning needs are the identified skills or knowledge that are lacking because of the introduction of a new situation. A person’s learning needs are influenced by his or her perceptions. The angioplasty experience includes the time frame from when the patient is informed of the need for the procedure, during the procedure, during hospitalization after the procedure, and the recovery period at home as it relates to the angioplasty itself. Cardiac recovery behaviors are those lifestyle modifications that promote healthful outcomes by decreasing cardiovascular risk factors thus contributing to a decreased risk of CAD. These behav-
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iors include diet, exercise, smoking cessation, weight, and the management of hypertension, diabetes, cholesterol levels, and job and family stress.
FINDINGS Findings from the studies were categorized into 1 of 3 areas: perceived learning needs, perceptions surrounding the angioplasty experience, and cardiac recovery behaviors. Because the scope of the researchers’ studies often overlapped, findings from a particular study may be in more than 1 category.
Perceived learning needs Seven of the studies offered information from the patients on their perceived learning needs. 10-12,18,20,21,23 Ranking highest among the learning priorities of patients who had undergone a PTCA before discharge were informational needs and survival management. Informational needs included understanding the outcome of the procedure, 11,12 anatomy and physiology, risk factor management and lifestyle changes, and medications.10,11,18,23 Gaw25 reported that only 50% of the subjects were able to identify risk factors associated with their cardiac diagnosis. Survival management involved knowing how to manage cardiac symptoms should they return at home.10,11,23 Karlik et al18 found that patients have a greater preference to learn cardiac information from physicians rather than nurses in all categories. The needs of spouses’ of patients undergoing PTCA were examined in 2 separate studies by Dickerson24 and Moser et al.11 Informational needs were ranked as important in both studies. Providing information about emotions and feelings they would be experiencing during the recovery period of the patient,11 as well as information on available resources and firsthand sources, such as roommates and support groups the spouse could talk with, were recommended.24 Dickerson also found spouses preferred to be present when patient teaching was being done. Two studies compared nurses’ perceived rankings of patient learning needs with the rankings done by the patients.10,18 Both patients and nurses were in agreement that all the categories were important, ranking risk factor modifications and medications as the top 2 items, but considerable differences in the rankings appeared after this.10,18 Brezynskie et al10 found patients ranked knowing their test results and outcome considerably higher than the nurses did. Anatomy and physiology
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Table I Summary of studies Author and date
Purpose
Bliley & Ferrans13 (1993)
Explore effect of PTCA on perceived quality of life
Brezynskie et al10 (1998)
Identify perceived learning needs of patients who have under gone PTCA Compare with nurses’ perception of learning needs of patients who have undergone PTCA
Czar et al23 (1997)
Identify perceived learning needs and level of importance of patient with CAD at hospital and follow-up clinic visit
Dickerson24 (1993)
Determine the perceived support needs of cardiac patients’ spouses
Gaw25 (1992)
Identify patient’s concerns and perceptions of PTCA
Gaw-Ens and Laing22 (1994)
Compare and contrast lifestyle modifications of patients who have undergone PTCA with those of patients who have had an MI
Gulanick and Naito14 (1994)
Examine concerns and risk factor modification behavior in early recovery period of patients who have undergone PTCA
Gulanick et al12 (1998)
Describe the PTCA experience from the patient’s perspective
Gulanick et al9 (1997)
Identify: patient’s reactions to lifestyle changes, barriers and facilitators to risk reduction, sources of health information, and suggestions for nursing interventions
Jensen et al8 (1993)
Summary of Bandura’s self-efficacy theory and the Perkins study of patients who have undergone PTCA and cardiac recovery behavior
Karlik et al18 (1990)
Compare learning needs of patients with CAD and nurses who care for them and compare rankings of intended adherence to prescibed medical regimens with rankings of identified learning needs
Kimble15 (1998)
Explore relationships among identified variables in early recovery of PTCA
Kimble and King16 (1998)
Examine patient perceptions of side effects and treatment benefit of PTCA and determine if variables were associated with perceptions
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Design and theoretical framework
Sample
Data collection methods
One group pretest-posttest; Ferrans conceptual framework
n = 40 Convenience PTCA only
Ferrans and Powers quality of life index—cardiac version, structured interview and mailed questionnaire; medical record
Open, cross-sectional, onetime survey; no theoretical framework
n = 251 patients n = 45 nurses Convenience PTCA only
PTCA learning needs inventory; questionnaire
Longitudinal, exploratory; no theoretical framework
n = 28 male only Convenience Angina and/or MI
Everything You Ever Wanted To Know About Heart Disease (self-administered questionnaire); personal data sheet
Qualitative; grounded theory approach for analysis
n = 13 spouses Convenience PTCA, MI, CABG
Focus groups
Qualitative (investigative project); no theoretical frame work
n = 14 Convenience PTCA only
Semistructured interview
Descriptive, correlational; no theoretical framework
n = 210 PTCA n = 258 MI Convenience
Prediction of habits or lifestyle modification questionnaire
Descriptive; no theoretical framework
n = 54 Convenience PTCA and MI, or PTCA only
Profile of mood states; selfreport of recovery
Qualitative; no theoretical framework
n = 45 Convenience PTCA, stent, atherectomy
Focus groups
Qualitative; Cox interaction model of client health behavior
n = 45 Convenience PTCA, stent, atherectomy
Focus groups
Descriptive, correlational; Bandura self-efficacy theory
n = 90 Convenience PTCA
Profile of mood states; selfefficacy scale
Correlational; model of reasoned action
n = 30 patients n = 15 nurses Convenience Angina with catheterization
Cardiac patient learning need inventory; educator preference tool; health intention scale; health behavior scale
Prospective, correlational; cognitive appraisal theory
n = 58 Convenience Elective PTCA
Life orientation test; treatment appraisal scale; heart disease threat scale; bipolar profile of mood states
Descriptive, correlational; no theoretical framework
n = 62 Convenience PTCA
Interview questionnaire by semistructured telephone interview Continued.
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Table I (Cont’d) Author and date
Purpose
Merritt20 (1991)
Determine learning style preferences of CAD patients and if the differences are related to demographic differences
Moser et al11 (1993)
Identify and compare the needs of patients and spouses during months after a cardiac event
Murphy et al21 (1989)
Evaluate an educational program designed for patients undergoing PTCA
Perkins and Jenkins17 (1998)
Develop knowledge about patient decision making in selected cardiac recovery behaviors and psychologic factors in patients having PTCA
White and Frasure-Smith19 (1995)
Explore psychosocial differences between patients who have undergone PTCA and patients who have undergone CABG
Zerwic et al6 (1997)
Examine patient perceptions about causes and timeline of CAD and the accuracy of the perceptions
knowledge was ranked higher by patients and lower by the nurses in both studies.10,18 Psychologic needs were ranked low in both studies by the patient, but Karlik et al18 found that nurses rated this need higher than patients did. Merritt20 and Murphy et al21 examined learning preference styles of the patient who had undergone a PTCA. Merritt found a low preference for reading; instead, active participation of the patient with visual and oral instruction was found to be important. Murphy et al reported the need to tailor education programs to the specific coping style of the patient. In addition, knowledge gained from education programs was not retained past 6 months after having a PTCA.21 Gaw25 found that patients between the ages of 61 and 82 years felt less informed about their disease condition and the reasons for having a PTCA. Once discharged, subjects in one study reported feeling “cut off” after leaving the hospital.12 Sug-
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gestions to help meet the educational needs of patients and families at this recovery stage included a video library, newsletters providing the latest information, and a nurse hot line.
Perceptions surrounding the PTCA experience Four of the studies evaluated the feelings of patients regarding the PTCA and found them to be positive; patients described the experience as beneficial and, overall, were satisfied with the experience.9,14-16 Care was characterized as meeting or exceeding their expectations. Positive feedback included contentment with comfort measures and trust in team competence,9 as well as feeling adequately prepared for the PTCA procedure from educational videotapes.25 Negative feedback included patients who expressed feelings of dehumanization and frustration with their lack of control in decision making.9
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Design and theoretical framework
Sample
Data collection methods
Ex post facto test only with a descriptive survey method; Canfield model of learning style
n = 125 Convenience
Patient learning style questionnaire
Descriptive, correlational; no theoretical framework
n = 49 couples Convenience PTCA, MI, CABG
Needs assessment instrument developed by investigator; sociodemographic questionnaire
Quasi-experimental, onegroup pretest-posttest; no theoretical framework
n = 97 Convenience First PTCA
Coronary angioplasty risk factor inventory; Taylor manifest anxiety scale; Spielberger state-trait anxiety inventory; health locus of control scale; Wechsler adult intelligence scale; Norbeck social support question
Descriptive, correlational; Bandura’s self-efficacy theory
n = 90 Convenience PTCA
Jenkins’ self-efficacy expectation scales; Jenkins’ activity checklist; Profile of mood states inventory
Descriptive, correlational; no theoretical framework
n = 22 PTCA n = 25 CABG Convenience
Mishel uncertainty in illness; general health questionnaire; perceived social support scale
Qualitative; common sense model of illness
n = 105 Convenience PTCA or MI
Semistructured interview
Gulanick et al9 and Kimble15 found that patients perceived the PTCA to be minimally invasive, nonthreatening, and routine. Low tension and anxiety were reported in the Gulanick and Naito study.14 The potential for restenosis was not a concern for patients in the 2 studies that examined this issue.14,16 Perkins and Jenkins17 reported the level of mood disturbance among the subjects was low after the procedure and at 2 weeks after discharge. The degree of threat from heart disease was determined to be mild to moderate by Kimble,15 and the study showed that positive moods predominated and psychologic distress was low. A notable finding of this latter study15 was that as patients’ heart disease threat increased, their psychologic well-being decreased. Gaw25 included family perceptions of the PTCA experience, with the predominant feeling of worry before the procedure and the predominant concern of recurrence of cardiac symptoms after hos-
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pital discharge. Concerns after hospitalization included the complaint of groin discomfort and unusual sensations in the chest.16 Two studies reported contradictory findings on medication.14,16 Kimble and King16 found that medication reactions were a posthospitalization concern for patients but were not considered an issue by Gulanick and Naito.14 Quality of life was the focus of a study by Bliley and Ferrans.13 A significant increase in scores that reflected patient perceptions of improved quality of life after PTCA was reported. This same study reported fatigue as the the major symptom negatively affecting quality of life.
Cardiac recovery behavior Nine studies focused on aspects of cardiac recovery behavior.12-15,17-19,22,25 The majority of the studies were conducted at 12 weeks or less after the procedure.13-15,17-19,25 Of these, 5 studies
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Table II Summary of study setting and data collection times Study
Collection times
Studies in a hospital setting Zerwic et al6 Brezynskie et
Not specified al10
Patients: evening before or morning after PTCA Nurses: while employed and caring for patients who have undergone PTCA
Studies beginning in the hospital setting and carrying over to the outpatient setting Bliley and Ferrans13
(1) Night before PTCA (2) 4-6 wk after
Czar et
al23
(1) Before discharge (2) First clinic time
Gaw25
(1) Night before PTCA (2) 2-8 h after procedure (3) 2-3 wk after
Jensen et
al8
(1) Before discharge after PTCA (2) 2 wk after
Kimble15
(1) 24 h before procedure (2) Before discharge (3) 2 wk after
Perkins and
Jenkins17
(1) Before discharge (2) 2 wk after
Murphy et
al21
(1) Before and after PTCA (2) 6 mo after (3) 2 y later
Studies conducted in the outpatient setting Gulanick et al12 Gulanick and
Naito14
3-18 mo after procedure (1) 1 wk after PTCA (2) 6 wk after (3) 12 wk after
Kimble and Moser et
King16
al11
Dickerson24 White and
Frasure-Smith19
2 wk after 3-6 mo after 2-4 wk after cardiac event (1) 1 mo after PTCA or CABG (2) 3 mo after
Continued.
PTCA patients: as outpatients (one time). *This is a subgroup under the Gaw-Ens and Laing22 study.
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Table II (Cont’d) Study
Studies conducted in both inpatient and outpatient setting Karlik et al18 Merritt20 Gaw-Ens and Laing22
Collection times
15 inpatients and 15 outpatients Both inpatients and outpatients Patients with MI (subgroup)*: (1) as inpatient (2) at 3 mo after (3) at 6 mo after
reported the majority of subjects made at least some lifestyle changes.12,13-15,22 Most frequently considered behavior modifications concerned diet, smoking, and physical activity. Changes in diet were reported in 4 studies as being the most successful lifestyle modification made.12,14,15,22 Bliley and Ferrans13 reported the changes included “cheating” by the subjects. Of 3 studies examining smoking behaviors,13-15 the majority of subjects reported positive changes.13,14 Stress management was a problem for the subjects in 3 studies12,14,19; Gulanick and Naito14 reported that participants felt less confident in their ability to manage stress, and Gulanick et al12 identified coping with stress as a barrier to making lifestyle changes. Subjects’ feelings about their success with lifestyle changes varied among the studies. Gaw25 reported that on hospital discharge, less than half of the participants had planned lifestyle behavior changes. Subjects in this same study thought that making lifestyle modifications to reduce cardiac risk was more difficult to carry out than they had anticipated. Gaw-Ens and Laing11 found patients who had undergone a PTCA were knowledgeable about risk factors but were less compelled to make changes. Bliley and Ferrans13 reported slight satisfaction among their subjects with regard to the changes they had made. Feeling frustrated because of a lack of family support for healthpromoting activities was reported. In addition, patients felt a sense of powerlessness to stop the progression of CAD, even if health-promoting activities were instituted.10 Dickerson19 found that those patients with high levels of perceived social support had significantly less psychologic stress and uncertainty than those with low levels of support. Facilitators in making behavior changes included participation in cardiac rehabilitation programs, tailored diet instructions, and permission to cheat. HEART & LUNG
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Five studies investigated mood status, motivation, or self-efficacy expectation of the subjects in relation to behavior modification performance.14,15,17,22,25 Self-efficacy, which is the “individual’s perceptions that they will be capable of carrying out a given behavior in a set of circumstances,”8 was found to relate directly to the behavior changes made by the subject in the 2 studies examining this concept in the early recovery period after the PTCA.14,17 Those with higher self-efficacy scores tended to have higher behavior performance scores. Lower levels of mood disturbances were noted in the study by Perkins and Jenkins17 also. Similarly, Kimble15 reported that a more positive mood increased the likelihood of high selfefficacy expectations resulting in behavior changes. Gaw-Ens and Laing22 and Kimble15 found that motivational tendencies to initiate and maintain lifestyle changes were low.
IMPLICATIONS DERIVED FROM INTEGRATIVE SUMMARY Perceived learning needs Patients who had undergone PTCA in these studies and spouses from 2 studies11,24 reported informational needs on risk factors and feeling prepared for a future cardiac emergency as their most important needs. Czar et al23 reported no difference in perceived learning needs between hospitalization and the first clinic visit, but the ratings of importance had changed. Retention of information over time is also a concern. 21 This suggests that the focus of acute care education and follow-up education in clinics is a priority but may need to have different content. Outpatient settings may need to redirect their education to address new learning needs as perceptions of importance change with time. Czar et al23 found that an inpatient questionnaire was help169
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Table III Recommendations for future research Learning needs Develop and test tools to help determine patient learning needs in both the acute care and outpatient clinical settings. Examine emotional needs of spouse or significant other and develop education information needs directed to this population. Cardiac recovery behavior Replication studies to examine use of self-efficacy expectations as a predictor of health behavior. Determine when the patient and family is most receptive to education on lifestyle changes and develop programs to be presented at this time. Examine the best way to present information to this population: one-on-one, small group, 1 class session, or series of sessions. Outcomes research Determine if patient information and learning needs are met by individualizing cardiac health programs. Measure if restenosis rate is decreased in those patients instituting risk factor modification, and how many of these changes need to be made to make a difference.
ful in triggering discussion and questions by the patient. Because the components contributing to the development and management of cardiac disease are many and patients may be in different stages of understanding or have difficulty articulating their needs, a formalized tool may help in soliciting the most important concerns that can then be addressed by health care professionals. This completed tool can help tailor the education program to the needs of the individual and could be used to continue education in the outpatient clinic. Reinforcing and building on prior information encourages the concept of continuity of care between the inpatient and outpatient setting. A learning style assessment of the patient may also be beneficial in determining how people prefer to learn.20 Organized instruction with detailed information was determined to be most beneficial by Merritt.20 Paying attention to the patient’s perception of his or her ability to learn can also affect understanding. Few studies included family perceptions of their learning needs in their findings. This is unfortunate; it is an area in need of additional research because family learning needs may not be met because they have not been identified. The 2 studies11,24
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that did examine the spouses’ needs reported knowing how to deal with their emotions as important. Assisting spouses in managing their emotions and supporting their family member may improve overall health outcomes of the patient with heart disease. Nurses’ and patients’ perceptions of learning needs are not always the same.10,18 In addition, shortened hospital stays make it increasingly difficult to provide the necessary education for patients and families. The unfortunate outcome is unmet needs that can also translate into patient and family dissatisfaction.26 Nurses can better serve their clientele by recognizing and tailoring education to the needs of each individual.21 Perceptions surrounding the PTCA experience. The PTCA experience was viewed as mostly positive,9,15 with low levels of mood disturbance17 and mild to low levels of heart disease threat.14,15 Trust in competent staff members9 and care exceeding expectations9 were probable contributing factors to this view. This implies that the majority of patients’ acute, physical needs are being met in the hospital setting. There is room for improvement in the areas of controlling back and leg pain, lessening the feelings of dehumanization, and improving patient decision-making control.
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Because these subjects had such a low feeling of threat and thought the PTCA procedure was routine, perhaps health care professionals are not doing a good job in getting across the message to these patients that undergoing PTCA means they have heart disease. With most patients returning to their normal life routines in a very short time and often feeling better, this is a difficult message to get across. Additional research needs to be done on how best to elicit a better understanding of this concept. Cardiac recovery behavior. The majority of the studies focused on cardiac recovery behavior perhaps demonstrating the increased focus on the importance of preventing the progression of heart disease by making lifestyle changes.4,5 Making the suggested behavioral changes was reported to be more difficult for subjects than anticipated.25 This may have been reflected by other studies also in which subjects showed participation in only some lifestyle changes. Cardiac recovery behavior does not appear to be an “all or nothing” phenomenon. Incorporating some changes may imply that there is an understanding in this population of the correlation between cardiac disease and lifestyle. These studies present evidence that making more than one change at a time is unlikely and that sustaining the change over time is also very difficult. Educational efforts are needed to maintain knowledge levels after hospitalization.21 The measurement of a person’s self-efficacy expectation appears to be an accurate prediction of his ability to make behavior changes in the early recovery period after a PTCA.14,17 This has strong implications for use in the acute care and clinical setting. Being able to identify a patient’s self-efficacy expectation may enable health care professionals to personalize interventions needed to facilitate a positive health behavior outcome.
DISCUSSION Several conclusions can be drawn from the existing research. Overall, patients perceived the PTCA experience as positive and beneficial, with a relatively low level of threat and mood disturbance.9,15,17 Meeting the acute care informational needs of the patient who had undergone a PTCA was identified by patients, spouses, and nurses as important,10,11 but proves to be a challenge because of the short hospital stay. Currently, nurses and patients ranked the importance of several learning categories differently.10,24 Streamlining education programs by determining what information is most important to the patient to learn may improve retention of that information and use of
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nursing time so that precious minutes are not wasted on facts the patient may already know. Organized visual and oral instruction that requires active participation by the patient may be more effective than reading material.20 Risk-reduction behaviors or the cardiac recovery behaviors a patient implements can positively or negatively affect his or her heart disease process.5 The majority of subjects made at least some behavior modifications, but adherence to the changes and newly acquired knowledge learned in the acute care setting lessened over time.12-14 Several studies indicate that the level of adherence to lifestyle changes may be a result of motivation, self-efficacy, social support, or levels of mood disturbance.14,15,17,22,25 It is evident that patients who have undergone a PTCA have a lesser tendency to make heart-healthful lifestyle changes than patients who have had either an MI or CABG surgery.22 There are indications that some type of continuing education program may increase the patient’s knowledge about his or her heart disease and provide added support needed to maintain the recommended lifestyle changes.21-23 Education in the acute care setting may need to focus on the shortterm learning needs of the patient and spouse, with additional education and resources provided after discharge. The same limitations are present in most of the studies reviewed for this integrative review. Small sample sizes and the inability to randomly assign individuals to programs weaken the studies. Selfreport bias may be present. Married white men made up the majority of the subjects, limiting the generalizability of the findings to other populations. Similarly, spouses’ needs were identified, but the findings may not be generalizable to men because most of the spouses were women. The PTCA population is relatively understudied, with few studies going beyond the 3-month period after the procedure, limiting the findings to a short time span. Future research opportunities are many (Table III). Simple, concise tools that can help identify patient learning needs in both the acute care and outpatient clinic settings need to be developed to aid the health professional in individualizing teaching sessions. Determining when the patient is most receptive to learning about lifestyle changes would enable nurses to address issues at the most opportune time. Does this population learn best when the information is presented one-on-one, or ingroup classes? Little has been studied about the effect the spouse and family has on recovery
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behaviors of the patient who has undergone a PTCA. Would education programs targeted to this population improve the outcomes of slowing the heart disease process? Individualized cardiac health programs are recommended, but long-term studies have yet to be conducted to determine if the overall outcome is improved. In addition, because it is so difficult for patients to adhere to many lifestyle changes, studies to determine how many changes need to be made to make a difference would be beneficial. Last, replication of the current studies would add to the knowledge presently available. REFERENCES 1. Kingsley CM, Gupta SC. How to reduce the risk of coronary artery disease. Postgrad Med 1992;91:147-60. 2. Levine GN, Chodos AP, Loscalzo J. Restenosis following coronary angioplasty: clinical presentations and therapeutic options. Clin Cardiol 1995;18:693-703. 3. Smith SC. Risk reduction therapies for patients with coronary artery disease: a call for increased implementation. Am J Med 1998;104(2A):23S-26S. 4. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. Circulation 1994;89:975-89. 5. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, et al. Can lifestyle changes reverse coronary heart disease? Lancet 1990;336:129-33. 6. Zerwic JJ, King KB, Wlasowicz GS. Perceptions of patients with cardiovascular disease about the causes of coronary artery disease. Heart Lung 1997;26:92-8. 7. Hanson V. Compliance with risk factor reduction among post coronary bypass and post coronary angioplasty patients. Appl Nurs Res 1988;1:94-8. 8. Jensen K, Banwart L, Venhaus R, Popkess-Vawter S, Perkins S. Advanced rehabilitation nursing care of coronary angioplasty patients using self-efficacy theory. J Adv Nurs 1993;18:926-31. 9. Gulanick M, Bliley A, Perino B, Keough V. Patients’ responses to the angioplasty experience: a qualitative study. Am J Crit Care 1997;6:25-32.
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Gentz 10. Brezynskie H, Pendon E, Lindsay P, Adam M. Identification of the perceived learning needs of balloon angioplasty patients. Can J Cardiovasc Nurs 1998;9:8-14. 11. Moser DK, Dracup KA, Marsden C. Needs of recovering cardiac patients and their spouses: compared views. Int J Nurs Stud 1993;30:105-14. 12. Gulanick M, Bliley M, Perino B, Keough V. Recovery patterns and lifestyle changes after coronary angioplasty: the patient’s perspective. Heart Lung 1998;27:253-62. 13. Bliley AV, Ferrans CE. Psychologic aspects of cardiovascular care: quality of life after coronary angioplasty. Heart Lung 1993;22:193-9. 14. Gulanick M, Naito A. Patients’ reactions to angioplasty: realistic or not? Am J Crit Care 1994;3:368-73. 15. Kimble LP. Cognitive appraisal and cardiac risk reduction behavior following coronary angioplasty. West J Nurs 1998;20:733-44. 16. Kimble LP, King KB. Perceived side effects and benefits of coronary angioplasty in the early recovery period. Heart Lung 1998;27:308-14. 17. Perkins S, Jenkins LS. Self-efficacy expectation, behavior performance, and mood status in early recovery from percutaneous transluminal coronary angioplasty. Heart Lung 1998;27:37-46. 18. Karlik BA, Yarcheski A, Braun J, Wu M. Learning needs of patients with angina: an extension study. J Cardiovasc Nurs 1990;4(2):70-82. 19. White RE, Frasure-Smith N. Uncertainty and psychologic stress after coronary angioplasty and coronary bypass surgery. Heart Lung 1995;24(1):19-27. 20. Merritt SL. Learning style preferences of coronary artery disease patients. Cardiovasc Nurs 1991;27(2):7-11. 21. Murphy MC, Fishman J, Shaw RE. Education of patients undergoing coronary angioplasty: factors affecting learning during a structured educational program. Heart Lung 1989;18(1): 36-45. 22. Gaw-Ens B, Laing GP. Risk factor reduction behaviours in coronary angioplasty and myocardial infarction patients. Can J Cardiovasc Nurs 1994;5(1):4-12. 23. Czar ML, Litt M, Engler MM. Perceived learning needs of patients with coronary artery disease using a questionnaire assessment tool. Heart Lung 1997;26:109-15. 24. Dickerson SS. Support needs of spouses of cardiac patients. J NY State Nurse Assoc 1993;24(2):17-21. 25. Gaw B. Motivation to change life-style following PTCA. DCCN 1992;11(2):68-74. 26. Hostutler JJ, Taft SH, Snyder C. Patient needs in the emergency department: nurses’ and patients’ perceptions. J Nurs Adm 1999;29:43-50.
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OBJECTIVE: This study presents, through an integrative review, a comprehensive account of the perceived concerns and learning needs of patients in the early recovery period after a coronary angioplasty. SCOPE: Nineteen studies involving the patient who has undergone coronary angioplasty were identified using CINAHL and MEDLINE. These studies were examined to compare samples, methods, findings, implications, and suggestions for future research. FINDINGS: Overall the subjects believed that undergoing coronary angioplasty was positive and beneficial, and they viewed it as a minimally invasive, routine procedure. Informational knowledge, such as risk factor education and survival management, were considered of high importance. The majority of subjects modified their behavior, and the most common modification was in diet. Both learned knowledge and lifestyle changes decreased over time. Self-efficacy expectations and levels of anxiety were predictors of behavior changes and knowledge retention in the early recovery period after the coronary angioplasty procedure. IMPLICATIONS: Health professionals must emphasize the seriousness and long-term outcomes of untreated heart disease. Education programs should be individualized and streamlined. Spouses and significant others have informational needs and should be included in education programs. Learning needs in the acute care setting differ from those in the outpatient setting. Continuing education and resources need to be available for patients who are recovering from percutaneous transluminal coronary angioplasty and their families, and should build upon knowledge obtained during hospitalization. (Heart Lung® 2000;29:161-72.)
T
he progression of coronary artery disease (CAD) is a significant health care problem. CAD, the leading cause of morbidity and mortality in the United States, affects 70% of the adult population to some extent and claims the lives of approximately 500,000 men and women each year.1 In addition, approximately 300,000 patients undergo percutaneous transluminal coronary angioplasty (PTCA) procedures yearly. Of these, approximately 40% will need additional treatment because of restenosis of the ballooned vessel(s).2 From the Graduate School of Nursing, Northern Illinois University, Rockford. Reprint requests: Catherine A. Gentz, RN, BSN, 1410 Geneva Ave, Rockford, IL 61108. Copyright © 2000 by Mosby, Inc. 0147-9563/2000/$12.00 + 0 2/1/106002 doi:10.1067/mhl.2000.106002
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Economically, the direct costs for treating patients with CAD are currently more than $150 billion a year and are expected to exceed $200 billion by the year 2000, with most medical costs occurring from hospitalizations. Although the treatment of cardiac disease symptoms has improved over the past decade with advances in diagnosis, interventional techniques, and medical therapy, this does little to treat the underlying causes of CAD.3 Evidence exists that the disease process can be slowed or reversed through the implementation of lifestyle changes and risk factor modifications.4,5 Improved patient quality of life and lessened financial burdens are likely outcomes of such lifestyle changes. Recognizing cardiac risk factors as causes of CAD is the first step for patients in reducing their risk by making lifestyle changes. Only then can the adop-
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tion of a healthful lifestyle follow.6 Past research suggests that this process of learning and changing, as well as other challenges, exists uniquely for the patient who has undergone a PTCA.7,8 A lesser tendency toward compliance, less favorable behavioral changes, and a decrease in healthful behaviors over time was seen in patients who had undergone PTCA versus those patients who had coronary artery bypass graft (CABG) surgery.7 An inaccurate perception of the seriousness of their disease among those who had a PTCA may be a result of the shorter hospital stay, shorter recovery period, and less discomfort when compared with those who had a CABG.8
PROBLEM The patient who has undergone a PTCA has a shorter hospital stay than the patient recovering from CABG surgery or a myocardial infarction (MI), creating a challenge for the health professional. Less time is allowed for nursing interventions that provide education to the patient and family; however, teaching patients in preparation for discharge from the hospital is the health professional’s responsibility. Because of the imposed time constraints, understanding what information the patient perceives as important aids in development of meaningful and effective nursing interventions to help the health professional meet patient needs.9-11 This article presents a literature review of a sample of studies on the perceived concerns and learning needs of patients in the early recovery period after PTCA to obtain a clearer understanding of areas that need to be addressed during this time. Patient education and valuable nursing time can be better focused to meet the goal of decreasing the progression of heart disease, thereby decreasing the likelihood of negative outcomes including restenosis and readmission.
SCOPE The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE databases were searched for studies by using the following subject headings: coronary angioplasty, perceived learning needs, coronary artery disease, and risk factor modification. The ancestry approach was also used to ensure that all potential studies were identified. Because the treatment regimen of patients who have undergone PTCA is continually changing, resulting in shorter hospital stays, and is increasingly being performed in the outpatient setting, the search was limited to studies completed between
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1989 and 1999 so that findings would be pertinent to current practices. Nineteen studies were included in this review (Table I). Two of the studies were written by the same authors and used the same subjects, but they had different objectives.9,12 Both articles offered valuable information regarding patient perceptions, so both were included in this review. Only studies that offered the perceived findings of patients who had undergone PTCA were included. The purpose of each study, the design, and data collection methods are included in Table I. The most frequent journal source was Heart & Lung: The Journal of Acute and Critical Care (42%). The remaining articles (58%) were published in 7 different nursing research journals. The majority of the articles were published between 1993 and 1998. All of the primary investigators were nurses. Quantitative research comprised the majority of the sample (74%)8,10,11,13-22 with more than half of these falling under the descriptive correlational design.8,11,15-17,19,20,22 The remaining research was qualitative.6,9,23,24 Of the 6 qualitative studies, 3 used focus groups,9,12,24 and the other 3 used semistructured interviews 6,23,25 to identify patient concerns and perspectives related to their PTCA experience. Nine studies identified a theoretical framework,6,8-9,13,15,17,18,20,24 and Bandura’s theory of self-efficacy was used in 2 of these.8,17
SAMPLES AND SETTINGS Sample sizes in the studies ranged from 14 to 251 subjects.10,25 Ages of the subjects ranged from 26 to 84 years.10,25 Mean ages were between 56.8 and 64 years, with 42% of the subjects between 61 and 62 years of age.6,11,12,15-17,22,23 The majority of the subjects were married (84%) men (68%). One qualitative pilot project had equal numbers of men and women as subjects.25 Two studies examined patients with heart disease and their spouses, and the majority of the patients with heart disease were men and the majority of spouses were women.11,24 Only 7 studies mentioned race.6,13,15,16,20,21,23 Of these, the majority of the subjects were white. Twelve of the studies (63%) reported the education level of the subjects.6,11-13,15,20,22-24 All subjects had a high school education or higher, including college or trade school. Criteria for subject selection were identified in all of the research studies; the most common inclusion criteria were age (at least 18 to 21 years), English speaking, no psychiatric or cognitive problems, and had recently undergone a PTCA. In the majority of the studies (42%), subjects underwent PTCA for
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the first time.9,12,14,17,19,25,26 A history of cardiac illness among some of the subjects was evident in 3 of the studies.10,13,15 One study specifically stated no history was present,6 whereas in 6 others it is not mentioned.8,11,18,20,22,23 Eight studies included subjects other than those patients who had recently undergone a PTCA.6,9,12,19,20,22-24 Two included patients who, in addition to PTCA, may have had an MI.9,12 Two compared patients recovering from MI with patients who had an angioplasty.6,22 Another included patients with angina and MI.23 Subjects who had an MI, CABG, or PTCA were included in 2 other studies.11,24 Patients who had undergone CABG surgery were compared with patients who had undergone PTCA in another study,19 and 2 other studies were nonspecific, describing their subjects as having CAD and angina with catheterization.18,20 Settings for the studies spanned North America, with 4 studies in Canada,10,19,22,25 4 in New York or New Jersey,15,16,18,24 3 on the West Coast,11,21,23 6 in the Midwest,8,9,12-14,17 and one each in the Midwest and on the East Coast.20 All patients had received their health care at large medical centers. Table II illustrates the setting and collection times for each study. The majority of the studies (39%) began in the hospital setting and carried over to the outpatient setting. More than 1 collection time was most common (56%).
DEFINITIONS Three main categories were identified from the studies: perceived learning needs, perceptions surrounding the angioplasty experience, and cardiac recovery behaviors. Perception is the level of understanding and insight the involved person(s) has about a particular event, in this instance, the PTCA procedure and diagnosis of CAD. The patient uses his or her senses and knowledge to sum up how he or she views the experience. Learning needs are the identified skills or knowledge that are lacking because of the introduction of a new situation. A person’s learning needs are influenced by his or her perceptions. The angioplasty experience includes the time frame from when the patient is informed of the need for the procedure, during the procedure, during hospitalization after the procedure, and the recovery period at home as it relates to the angioplasty itself. Cardiac recovery behaviors are those lifestyle modifications that promote healthful outcomes by decreasing cardiovascular risk factors thus contributing to a decreased risk of CAD. These behav-
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iors include diet, exercise, smoking cessation, weight, and the management of hypertension, diabetes, cholesterol levels, and job and family stress.
FINDINGS Findings from the studies were categorized into 1 of 3 areas: perceived learning needs, perceptions surrounding the angioplasty experience, and cardiac recovery behaviors. Because the scope of the researchers’ studies often overlapped, findings from a particular study may be in more than 1 category.
Perceived learning needs Seven of the studies offered information from the patients on their perceived learning needs. 10-12,18,20,21,23 Ranking highest among the learning priorities of patients who had undergone a PTCA before discharge were informational needs and survival management. Informational needs included understanding the outcome of the procedure, 11,12 anatomy and physiology, risk factor management and lifestyle changes, and medications.10,11,18,23 Gaw25 reported that only 50% of the subjects were able to identify risk factors associated with their cardiac diagnosis. Survival management involved knowing how to manage cardiac symptoms should they return at home.10,11,23 Karlik et al18 found that patients have a greater preference to learn cardiac information from physicians rather than nurses in all categories. The needs of spouses’ of patients undergoing PTCA were examined in 2 separate studies by Dickerson24 and Moser et al.11 Informational needs were ranked as important in both studies. Providing information about emotions and feelings they would be experiencing during the recovery period of the patient,11 as well as information on available resources and firsthand sources, such as roommates and support groups the spouse could talk with, were recommended.24 Dickerson also found spouses preferred to be present when patient teaching was being done. Two studies compared nurses’ perceived rankings of patient learning needs with the rankings done by the patients.10,18 Both patients and nurses were in agreement that all the categories were important, ranking risk factor modifications and medications as the top 2 items, but considerable differences in the rankings appeared after this.10,18 Brezynskie et al10 found patients ranked knowing their test results and outcome considerably higher than the nurses did. Anatomy and physiology
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Table I Summary of studies Author and date
Purpose
Bliley & Ferrans13 (1993)
Explore effect of PTCA on perceived quality of life
Brezynskie et al10 (1998)
Identify perceived learning needs of patients who have under gone PTCA Compare with nurses’ perception of learning needs of patients who have undergone PTCA
Czar et al23 (1997)
Identify perceived learning needs and level of importance of patient with CAD at hospital and follow-up clinic visit
Dickerson24 (1993)
Determine the perceived support needs of cardiac patients’ spouses
Gaw25 (1992)
Identify patient’s concerns and perceptions of PTCA
Gaw-Ens and Laing22 (1994)
Compare and contrast lifestyle modifications of patients who have undergone PTCA with those of patients who have had an MI
Gulanick and Naito14 (1994)
Examine concerns and risk factor modification behavior in early recovery period of patients who have undergone PTCA
Gulanick et al12 (1998)
Describe the PTCA experience from the patient’s perspective
Gulanick et al9 (1997)
Identify: patient’s reactions to lifestyle changes, barriers and facilitators to risk reduction, sources of health information, and suggestions for nursing interventions
Jensen et al8 (1993)
Summary of Bandura’s self-efficacy theory and the Perkins study of patients who have undergone PTCA and cardiac recovery behavior
Karlik et al18 (1990)
Compare learning needs of patients with CAD and nurses who care for them and compare rankings of intended adherence to prescibed medical regimens with rankings of identified learning needs
Kimble15 (1998)
Explore relationships among identified variables in early recovery of PTCA
Kimble and King16 (1998)
Examine patient perceptions of side effects and treatment benefit of PTCA and determine if variables were associated with perceptions
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Design and theoretical framework
Sample
Data collection methods
One group pretest-posttest; Ferrans conceptual framework
n = 40 Convenience PTCA only
Ferrans and Powers quality of life index—cardiac version, structured interview and mailed questionnaire; medical record
Open, cross-sectional, onetime survey; no theoretical framework
n = 251 patients n = 45 nurses Convenience PTCA only
PTCA learning needs inventory; questionnaire
Longitudinal, exploratory; no theoretical framework
n = 28 male only Convenience Angina and/or MI
Everything You Ever Wanted To Know About Heart Disease (self-administered questionnaire); personal data sheet
Qualitative; grounded theory approach for analysis
n = 13 spouses Convenience PTCA, MI, CABG
Focus groups
Qualitative (investigative project); no theoretical frame work
n = 14 Convenience PTCA only
Semistructured interview
Descriptive, correlational; no theoretical framework
n = 210 PTCA n = 258 MI Convenience
Prediction of habits or lifestyle modification questionnaire
Descriptive; no theoretical framework
n = 54 Convenience PTCA and MI, or PTCA only
Profile of mood states; selfreport of recovery
Qualitative; no theoretical framework
n = 45 Convenience PTCA, stent, atherectomy
Focus groups
Qualitative; Cox interaction model of client health behavior
n = 45 Convenience PTCA, stent, atherectomy
Focus groups
Descriptive, correlational; Bandura self-efficacy theory
n = 90 Convenience PTCA
Profile of mood states; selfefficacy scale
Correlational; model of reasoned action
n = 30 patients n = 15 nurses Convenience Angina with catheterization
Cardiac patient learning need inventory; educator preference tool; health intention scale; health behavior scale
Prospective, correlational; cognitive appraisal theory
n = 58 Convenience Elective PTCA
Life orientation test; treatment appraisal scale; heart disease threat scale; bipolar profile of mood states
Descriptive, correlational; no theoretical framework
n = 62 Convenience PTCA
Interview questionnaire by semistructured telephone interview Continued.
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Table I (Cont’d) Author and date
Purpose
Merritt20 (1991)
Determine learning style preferences of CAD patients and if the differences are related to demographic differences
Moser et al11 (1993)
Identify and compare the needs of patients and spouses during months after a cardiac event
Murphy et al21 (1989)
Evaluate an educational program designed for patients undergoing PTCA
Perkins and Jenkins17 (1998)
Develop knowledge about patient decision making in selected cardiac recovery behaviors and psychologic factors in patients having PTCA
White and Frasure-Smith19 (1995)
Explore psychosocial differences between patients who have undergone PTCA and patients who have undergone CABG
Zerwic et al6 (1997)
Examine patient perceptions about causes and timeline of CAD and the accuracy of the perceptions
knowledge was ranked higher by patients and lower by the nurses in both studies.10,18 Psychologic needs were ranked low in both studies by the patient, but Karlik et al18 found that nurses rated this need higher than patients did. Merritt20 and Murphy et al21 examined learning preference styles of the patient who had undergone a PTCA. Merritt found a low preference for reading; instead, active participation of the patient with visual and oral instruction was found to be important. Murphy et al reported the need to tailor education programs to the specific coping style of the patient. In addition, knowledge gained from education programs was not retained past 6 months after having a PTCA.21 Gaw25 found that patients between the ages of 61 and 82 years felt less informed about their disease condition and the reasons for having a PTCA. Once discharged, subjects in one study reported feeling “cut off” after leaving the hospital.12 Sug-
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gestions to help meet the educational needs of patients and families at this recovery stage included a video library, newsletters providing the latest information, and a nurse hot line.
Perceptions surrounding the PTCA experience Four of the studies evaluated the feelings of patients regarding the PTCA and found them to be positive; patients described the experience as beneficial and, overall, were satisfied with the experience.9,14-16 Care was characterized as meeting or exceeding their expectations. Positive feedback included contentment with comfort measures and trust in team competence,9 as well as feeling adequately prepared for the PTCA procedure from educational videotapes.25 Negative feedback included patients who expressed feelings of dehumanization and frustration with their lack of control in decision making.9
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Design and theoretical framework
Sample
Data collection methods
Ex post facto test only with a descriptive survey method; Canfield model of learning style
n = 125 Convenience
Patient learning style questionnaire
Descriptive, correlational; no theoretical framework
n = 49 couples Convenience PTCA, MI, CABG
Needs assessment instrument developed by investigator; sociodemographic questionnaire
Quasi-experimental, onegroup pretest-posttest; no theoretical framework
n = 97 Convenience First PTCA
Coronary angioplasty risk factor inventory; Taylor manifest anxiety scale; Spielberger state-trait anxiety inventory; health locus of control scale; Wechsler adult intelligence scale; Norbeck social support question
Descriptive, correlational; Bandura’s self-efficacy theory
n = 90 Convenience PTCA
Jenkins’ self-efficacy expectation scales; Jenkins’ activity checklist; Profile of mood states inventory
Descriptive, correlational; no theoretical framework
n = 22 PTCA n = 25 CABG Convenience
Mishel uncertainty in illness; general health questionnaire; perceived social support scale
Qualitative; common sense model of illness
n = 105 Convenience PTCA or MI
Semistructured interview
Gulanick et al9 and Kimble15 found that patients perceived the PTCA to be minimally invasive, nonthreatening, and routine. Low tension and anxiety were reported in the Gulanick and Naito study.14 The potential for restenosis was not a concern for patients in the 2 studies that examined this issue.14,16 Perkins and Jenkins17 reported the level of mood disturbance among the subjects was low after the procedure and at 2 weeks after discharge. The degree of threat from heart disease was determined to be mild to moderate by Kimble,15 and the study showed that positive moods predominated and psychologic distress was low. A notable finding of this latter study15 was that as patients’ heart disease threat increased, their psychologic well-being decreased. Gaw25 included family perceptions of the PTCA experience, with the predominant feeling of worry before the procedure and the predominant concern of recurrence of cardiac symptoms after hos-
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pital discharge. Concerns after hospitalization included the complaint of groin discomfort and unusual sensations in the chest.16 Two studies reported contradictory findings on medication.14,16 Kimble and King16 found that medication reactions were a posthospitalization concern for patients but were not considered an issue by Gulanick and Naito.14 Quality of life was the focus of a study by Bliley and Ferrans.13 A significant increase in scores that reflected patient perceptions of improved quality of life after PTCA was reported. This same study reported fatigue as the the major symptom negatively affecting quality of life.
Cardiac recovery behavior Nine studies focused on aspects of cardiac recovery behavior.12-15,17-19,22,25 The majority of the studies were conducted at 12 weeks or less after the procedure.13-15,17-19,25 Of these, 5 studies
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Table II Summary of study setting and data collection times Study
Collection times
Studies in a hospital setting Zerwic et al6 Brezynskie et
Not specified al10
Patients: evening before or morning after PTCA Nurses: while employed and caring for patients who have undergone PTCA
Studies beginning in the hospital setting and carrying over to the outpatient setting Bliley and Ferrans13
(1) Night before PTCA (2) 4-6 wk after
Czar et
al23
(1) Before discharge (2) First clinic time
Gaw25
(1) Night before PTCA (2) 2-8 h after procedure (3) 2-3 wk after
Jensen et
al8
(1) Before discharge after PTCA (2) 2 wk after
Kimble15
(1) 24 h before procedure (2) Before discharge (3) 2 wk after
Perkins and
Jenkins17
(1) Before discharge (2) 2 wk after
Murphy et
al21
(1) Before and after PTCA (2) 6 mo after (3) 2 y later
Studies conducted in the outpatient setting Gulanick et al12 Gulanick and
Naito14
3-18 mo after procedure (1) 1 wk after PTCA (2) 6 wk after (3) 12 wk after
Kimble and Moser et
King16
al11
Dickerson24 White and
Frasure-Smith19
2 wk after 3-6 mo after 2-4 wk after cardiac event (1) 1 mo after PTCA or CABG (2) 3 mo after
Continued.
PTCA patients: as outpatients (one time). *This is a subgroup under the Gaw-Ens and Laing22 study.
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Table II (Cont’d) Study
Studies conducted in both inpatient and outpatient setting Karlik et al18 Merritt20 Gaw-Ens and Laing22
Collection times
15 inpatients and 15 outpatients Both inpatients and outpatients Patients with MI (subgroup)*: (1) as inpatient (2) at 3 mo after (3) at 6 mo after
reported the majority of subjects made at least some lifestyle changes.12,13-15,22 Most frequently considered behavior modifications concerned diet, smoking, and physical activity. Changes in diet were reported in 4 studies as being the most successful lifestyle modification made.12,14,15,22 Bliley and Ferrans13 reported the changes included “cheating” by the subjects. Of 3 studies examining smoking behaviors,13-15 the majority of subjects reported positive changes.13,14 Stress management was a problem for the subjects in 3 studies12,14,19; Gulanick and Naito14 reported that participants felt less confident in their ability to manage stress, and Gulanick et al12 identified coping with stress as a barrier to making lifestyle changes. Subjects’ feelings about their success with lifestyle changes varied among the studies. Gaw25 reported that on hospital discharge, less than half of the participants had planned lifestyle behavior changes. Subjects in this same study thought that making lifestyle modifications to reduce cardiac risk was more difficult to carry out than they had anticipated. Gaw-Ens and Laing11 found patients who had undergone a PTCA were knowledgeable about risk factors but were less compelled to make changes. Bliley and Ferrans13 reported slight satisfaction among their subjects with regard to the changes they had made. Feeling frustrated because of a lack of family support for healthpromoting activities was reported. In addition, patients felt a sense of powerlessness to stop the progression of CAD, even if health-promoting activities were instituted.10 Dickerson19 found that those patients with high levels of perceived social support had significantly less psychologic stress and uncertainty than those with low levels of support. Facilitators in making behavior changes included participation in cardiac rehabilitation programs, tailored diet instructions, and permission to cheat. HEART & LUNG
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Five studies investigated mood status, motivation, or self-efficacy expectation of the subjects in relation to behavior modification performance.14,15,17,22,25 Self-efficacy, which is the “individual’s perceptions that they will be capable of carrying out a given behavior in a set of circumstances,”8 was found to relate directly to the behavior changes made by the subject in the 2 studies examining this concept in the early recovery period after the PTCA.14,17 Those with higher self-efficacy scores tended to have higher behavior performance scores. Lower levels of mood disturbances were noted in the study by Perkins and Jenkins17 also. Similarly, Kimble15 reported that a more positive mood increased the likelihood of high selfefficacy expectations resulting in behavior changes. Gaw-Ens and Laing22 and Kimble15 found that motivational tendencies to initiate and maintain lifestyle changes were low.
IMPLICATIONS DERIVED FROM INTEGRATIVE SUMMARY Perceived learning needs Patients who had undergone PTCA in these studies and spouses from 2 studies11,24 reported informational needs on risk factors and feeling prepared for a future cardiac emergency as their most important needs. Czar et al23 reported no difference in perceived learning needs between hospitalization and the first clinic visit, but the ratings of importance had changed. Retention of information over time is also a concern. 21 This suggests that the focus of acute care education and follow-up education in clinics is a priority but may need to have different content. Outpatient settings may need to redirect their education to address new learning needs as perceptions of importance change with time. Czar et al23 found that an inpatient questionnaire was help169
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Table III Recommendations for future research Learning needs Develop and test tools to help determine patient learning needs in both the acute care and outpatient clinical settings. Examine emotional needs of spouse or significant other and develop education information needs directed to this population. Cardiac recovery behavior Replication studies to examine use of self-efficacy expectations as a predictor of health behavior. Determine when the patient and family is most receptive to education on lifestyle changes and develop programs to be presented at this time. Examine the best way to present information to this population: one-on-one, small group, 1 class session, or series of sessions. Outcomes research Determine if patient information and learning needs are met by individualizing cardiac health programs. Measure if restenosis rate is decreased in those patients instituting risk factor modification, and how many of these changes need to be made to make a difference.
ful in triggering discussion and questions by the patient. Because the components contributing to the development and management of cardiac disease are many and patients may be in different stages of understanding or have difficulty articulating their needs, a formalized tool may help in soliciting the most important concerns that can then be addressed by health care professionals. This completed tool can help tailor the education program to the needs of the individual and could be used to continue education in the outpatient clinic. Reinforcing and building on prior information encourages the concept of continuity of care between the inpatient and outpatient setting. A learning style assessment of the patient may also be beneficial in determining how people prefer to learn.20 Organized instruction with detailed information was determined to be most beneficial by Merritt.20 Paying attention to the patient’s perception of his or her ability to learn can also affect understanding. Few studies included family perceptions of their learning needs in their findings. This is unfortunate; it is an area in need of additional research because family learning needs may not be met because they have not been identified. The 2 studies11,24
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that did examine the spouses’ needs reported knowing how to deal with their emotions as important. Assisting spouses in managing their emotions and supporting their family member may improve overall health outcomes of the patient with heart disease. Nurses’ and patients’ perceptions of learning needs are not always the same.10,18 In addition, shortened hospital stays make it increasingly difficult to provide the necessary education for patients and families. The unfortunate outcome is unmet needs that can also translate into patient and family dissatisfaction.26 Nurses can better serve their clientele by recognizing and tailoring education to the needs of each individual.21 Perceptions surrounding the PTCA experience. The PTCA experience was viewed as mostly positive,9,15 with low levels of mood disturbance17 and mild to low levels of heart disease threat.14,15 Trust in competent staff members9 and care exceeding expectations9 were probable contributing factors to this view. This implies that the majority of patients’ acute, physical needs are being met in the hospital setting. There is room for improvement in the areas of controlling back and leg pain, lessening the feelings of dehumanization, and improving patient decision-making control.
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Because these subjects had such a low feeling of threat and thought the PTCA procedure was routine, perhaps health care professionals are not doing a good job in getting across the message to these patients that undergoing PTCA means they have heart disease. With most patients returning to their normal life routines in a very short time and often feeling better, this is a difficult message to get across. Additional research needs to be done on how best to elicit a better understanding of this concept. Cardiac recovery behavior. The majority of the studies focused on cardiac recovery behavior perhaps demonstrating the increased focus on the importance of preventing the progression of heart disease by making lifestyle changes.4,5 Making the suggested behavioral changes was reported to be more difficult for subjects than anticipated.25 This may have been reflected by other studies also in which subjects showed participation in only some lifestyle changes. Cardiac recovery behavior does not appear to be an “all or nothing” phenomenon. Incorporating some changes may imply that there is an understanding in this population of the correlation between cardiac disease and lifestyle. These studies present evidence that making more than one change at a time is unlikely and that sustaining the change over time is also very difficult. Educational efforts are needed to maintain knowledge levels after hospitalization.21 The measurement of a person’s self-efficacy expectation appears to be an accurate prediction of his ability to make behavior changes in the early recovery period after a PTCA.14,17 This has strong implications for use in the acute care and clinical setting. Being able to identify a patient’s self-efficacy expectation may enable health care professionals to personalize interventions needed to facilitate a positive health behavior outcome.
DISCUSSION Several conclusions can be drawn from the existing research. Overall, patients perceived the PTCA experience as positive and beneficial, with a relatively low level of threat and mood disturbance.9,15,17 Meeting the acute care informational needs of the patient who had undergone a PTCA was identified by patients, spouses, and nurses as important,10,11 but proves to be a challenge because of the short hospital stay. Currently, nurses and patients ranked the importance of several learning categories differently.10,24 Streamlining education programs by determining what information is most important to the patient to learn may improve retention of that information and use of
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nursing time so that precious minutes are not wasted on facts the patient may already know. Organized visual and oral instruction that requires active participation by the patient may be more effective than reading material.20 Risk-reduction behaviors or the cardiac recovery behaviors a patient implements can positively or negatively affect his or her heart disease process.5 The majority of subjects made at least some behavior modifications, but adherence to the changes and newly acquired knowledge learned in the acute care setting lessened over time.12-14 Several studies indicate that the level of adherence to lifestyle changes may be a result of motivation, self-efficacy, social support, or levels of mood disturbance.14,15,17,22,25 It is evident that patients who have undergone a PTCA have a lesser tendency to make heart-healthful lifestyle changes than patients who have had either an MI or CABG surgery.22 There are indications that some type of continuing education program may increase the patient’s knowledge about his or her heart disease and provide added support needed to maintain the recommended lifestyle changes.21-23 Education in the acute care setting may need to focus on the shortterm learning needs of the patient and spouse, with additional education and resources provided after discharge. The same limitations are present in most of the studies reviewed for this integrative review. Small sample sizes and the inability to randomly assign individuals to programs weaken the studies. Selfreport bias may be present. Married white men made up the majority of the subjects, limiting the generalizability of the findings to other populations. Similarly, spouses’ needs were identified, but the findings may not be generalizable to men because most of the spouses were women. The PTCA population is relatively understudied, with few studies going beyond the 3-month period after the procedure, limiting the findings to a short time span. Future research opportunities are many (Table III). Simple, concise tools that can help identify patient learning needs in both the acute care and outpatient clinic settings need to be developed to aid the health professional in individualizing teaching sessions. Determining when the patient is most receptive to learning about lifestyle changes would enable nurses to address issues at the most opportune time. Does this population learn best when the information is presented one-on-one, or ingroup classes? Little has been studied about the effect the spouse and family has on recovery
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behaviors of the patient who has undergone a PTCA. Would education programs targeted to this population improve the outcomes of slowing the heart disease process? Individualized cardiac health programs are recommended, but long-term studies have yet to be conducted to determine if the overall outcome is improved. In addition, because it is so difficult for patients to adhere to many lifestyle changes, studies to determine how many changes need to be made to make a difference would be beneficial. Last, replication of the current studies would add to the knowledge presently available. REFERENCES 1. Kingsley CM, Gupta SC. How to reduce the risk of coronary artery disease. Postgrad Med 1992;91:147-60. 2. Levine GN, Chodos AP, Loscalzo J. Restenosis following coronary angioplasty: clinical presentations and therapeutic options. Clin Cardiol 1995;18:693-703. 3. Smith SC. Risk reduction therapies for patients with coronary artery disease: a call for increased implementation. Am J Med 1998;104(2A):23S-26S. 4. Haskell WL, Alderman EL, Fair JM, Maron DJ, Mackey SF, Superko HR, et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. Circulation 1994;89:975-89. 5. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, et al. Can lifestyle changes reverse coronary heart disease? Lancet 1990;336:129-33. 6. Zerwic JJ, King KB, Wlasowicz GS. Perceptions of patients with cardiovascular disease about the causes of coronary artery disease. Heart Lung 1997;26:92-8. 7. Hanson V. Compliance with risk factor reduction among post coronary bypass and post coronary angioplasty patients. Appl Nurs Res 1988;1:94-8. 8. Jensen K, Banwart L, Venhaus R, Popkess-Vawter S, Perkins S. Advanced rehabilitation nursing care of coronary angioplasty patients using self-efficacy theory. J Adv Nurs 1993;18:926-31. 9. Gulanick M, Bliley A, Perino B, Keough V. Patients’ responses to the angioplasty experience: a qualitative study. Am J Crit Care 1997;6:25-32.
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Gentz 10. Brezynskie H, Pendon E, Lindsay P, Adam M. Identification of the perceived learning needs of balloon angioplasty patients. Can J Cardiovasc Nurs 1998;9:8-14. 11. Moser DK, Dracup KA, Marsden C. Needs of recovering cardiac patients and their spouses: compared views. Int J Nurs Stud 1993;30:105-14. 12. Gulanick M, Bliley M, Perino B, Keough V. Recovery patterns and lifestyle changes after coronary angioplasty: the patient’s perspective. Heart Lung 1998;27:253-62. 13. Bliley AV, Ferrans CE. Psychologic aspects of cardiovascular care: quality of life after coronary angioplasty. Heart Lung 1993;22:193-9. 14. Gulanick M, Naito A. Patients’ reactions to angioplasty: realistic or not? Am J Crit Care 1994;3:368-73. 15. Kimble LP. Cognitive appraisal and cardiac risk reduction behavior following coronary angioplasty. West J Nurs 1998;20:733-44. 16. Kimble LP, King KB. Perceived side effects and benefits of coronary angioplasty in the early recovery period. Heart Lung 1998;27:308-14. 17. Perkins S, Jenkins LS. Self-efficacy expectation, behavior performance, and mood status in early recovery from percutaneous transluminal coronary angioplasty. Heart Lung 1998;27:37-46. 18. Karlik BA, Yarcheski A, Braun J, Wu M. Learning needs of patients with angina: an extension study. J Cardiovasc Nurs 1990;4(2):70-82. 19. White RE, Frasure-Smith N. Uncertainty and psychologic stress after coronary angioplasty and coronary bypass surgery. Heart Lung 1995;24(1):19-27. 20. Merritt SL. Learning style preferences of coronary artery disease patients. Cardiovasc Nurs 1991;27(2):7-11. 21. Murphy MC, Fishman J, Shaw RE. Education of patients undergoing coronary angioplasty: factors affecting learning during a structured educational program. Heart Lung 1989;18(1): 36-45. 22. Gaw-Ens B, Laing GP. Risk factor reduction behaviours in coronary angioplasty and myocardial infarction patients. Can J Cardiovasc Nurs 1994;5(1):4-12. 23. Czar ML, Litt M, Engler MM. Perceived learning needs of patients with coronary artery disease using a questionnaire assessment tool. Heart Lung 1997;26:109-15. 24. Dickerson SS. Support needs of spouses of cardiac patients. J NY State Nurse Assoc 1993;24(2):17-21. 25. Gaw B. Motivation to change life-style following PTCA. DCCN 1992;11(2):68-74. 26. Hostutler JJ, Taft SH, Snyder C. Patient needs in the emergency department: nurses’ and patients’ perceptions. J Nurs Adm 1999;29:43-50.
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