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Patient and Staff Perspective of a Nurse-Led Support Programme for Patients Waiting for Cardiac Surgery: Participant Perspective of a Cardiac Support Programme

Patient and Staff Perspective of a Nurse-Led Support Programme for Patients Waiting for Cardiac... Abstract Background: A nurse-led support and education programme for patients waiting for coronary artery bypass surgery was evaluated in a randomised controlled trial of 188 patients at a tertiary centre in the UK. Aim: To add a qualitative perspective to the evaluation by exploring patients' experience while taking part in the trial and staff views of the patients' experience and the intervention. Methods: A purposive sample of 19 patients was interviewed and the transcriptions read to staff during focus groups. They discussed what they learned from the stories and their own experience of the programme. Results: The patients appreciated support from the nurses but felt communication and physical assessment could be improved. The patients varied in their understanding of the programme and their degree of motivation to improve their health. The staff varied in their approach to preparing patients for surgery. External factors influencing the intervention's impact were length of time on the waiting list and the increasing contribution of local rehabilitation services. Conclusion: Staff need to improve communication both between themselves and with the patients. Patients appreciate physical and psychological preparation for surgery, but the waiting period is not the optimal time to address their risk factors for coronary disease. Discovery Interviews, Focus groups, Qualitative research, Cardiac rehabilitation, Cardiovascular nursing, Patients' experience 1 Introduction In this paper we report a qualitative study using interviews and focus groups to explore the experience of patients and staff taking part in a randomised controlled trial evaluating a monthly home based nursing programme of education and support for patients waiting for cardiac surgery at two hospitals in south east England. Patients listed for coronary artery bypass surgery with at least one poorly controlled risk factor were randomised to standard care or the intervention which provided a cardiac risk assessment, lifestyle counselling according to motivational interviewing techniques [1] and physical and psychological preparation for surgery. Primary outcome measurements were anxiety, blood pressure, cholesterol, length of stay and body mass index. There was no significant reduction in risk factors in the parent study and this is the subject of a separate paper [2]. However, evaluation research suggests that studies should address not only whether an intervention worked but how and why it did or did not work [3] and that the context and process of the intervention being evaluated should be considered as well as the outcomes [4]. Previous randomised controlled trials of patient support and education programmes have focused on outcomes such as length of stay rather than the participant experience [5,6]. Others [7] have examined participant experience of nurse-led programmes following myocardial infraction to provide data about patients' perceptions of myocardial infarction and the nurses' knowledge base and competence. However, there are no published reports of a similar study with patients waiting for heart surgery. The aims of the qualitative study were to add to the evaluation of the programme by exploring patients' experience of waiting for coronary artery bypass surgery while taking part in the trial and explore staff views of both the intervention and the patients' descriptions. This data provided insight into the process and context of the programme while the trial provided detail on the outcomes [3]. The intended process, context and outcomes of the study are outlined in Fig. 1. Fig. 1 Open in new tabDownload slide Intended process, context and outcomes of the parent study An increasingly popular method of learning participants' views is the use of narrative or “story telling” [8,9]. Discovery Interviews are a narrative based tool developed by the Modernisation Agency (a national organisation in the United Kingdom promoting service improvement) to provide the patient viewpoint of their healthcare experience. Examples of changes made by staff after hearing these stories include one-stop clinics for chest pain, carer support groups and improved patient information [10]. Focus groups are formed to generate qualitative data from focused discussion [11]. They can be used to encourage dialogue between participants with different roles and remits and allows them to compare and debate ideas [12]. They have been found to be very useful for studying the impact of programmes in healthcare [11,13]. 2 Methods The rationale for using Discovery Interviews was that they provide a patient focused rather than professional led insight into the patients' experience and are therefore less likely to miss issues important to the patients [10]. A purposive sample of patients from both the experimental and control group were asked to take part in a Discovery Interview three months after discharge following their operation. A mix of intervention and control group, male and female patients from a variety of referring hospitals (Table 1) were selected throughout the course of the study. One patient refused to take part and one did not attend. Table 1 Patient details Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen M = male, F = female, Area = referring hospital. Open in new tab Table 1 Patient details Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen M = male, F = female, Area = referring hospital. Open in new tab The methodology does not specify how the data should be handled other than read back to interested parties but focus groups were deemed a valuable tool to ensure the feedback sessions had definite outcomes. The focus groups' composition is in Table 2. They were held during the regular staff meetings. No one refused to participate. Two cardiac surgeons whose patients had taken part in the programme also read the interview transcripts and were interviewed separately to gain their views on the programme. Table 2 Focus group participants in each focus group Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Open in new tab Table 2 Focus group participants in each focus group Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Open in new tab In terms of validity and reliability the goal of qualitative research is ‘meaning’ rather than ‘truth’ and the meaning is related to the context of the study [14,15]. The uniqueness of the narratives meant that the analysis was not generalisable but generated ideas for future research and development [16]. It is important that others can decide for themselves whether they accept the interpretation of the data [17,18] and so the analyses of the focus group transcripts were fed back to the staff for comment. 3 Data collection Nineteen patients were selected from the 188 patients who took part in the study. The participants told their own story during a taped interview in their home. The interviewers asked the patient to talk through key stages of their experience of the illness according to an interview spine which was written out on cards for the patients at the interview and comprised of the phrases, ‘Waiting for your heart surgery’, ‘Effect on your lifestyle’, ‘Being told you needed surgery’, ‘Support while waiting’, ‘Going into hospital’ and ‘Your recovery’. The interviewer only intervened to ask for clarification of particular points. The interviews lasted 45–60 min and were transcribed; interjections removed and the interviews read back as stories over the course of 10 focus groups. Focus groups generally have a topic guide but in this instance the focus was on the Discovery Interviews. The participants were asked to discuss what they had learned from the patients' experience related in the stories and what changes they would make to the service as a consequence. In the last four focus groups they were also asked to describe how the programme had worked from their perspective. They lasted approximately 60 min and with minimal intervention from the facilitator. The surgeons were asked to do the same as the focus groups but in individual taped interviews lasting 30–45 min. Ethical approval was granted by the local ethics committee [19]. 4 Data analysis The texts of the interviews and focus groups were analysed by the researcher using a thematic analysis focusing on the process and contexts of the intervention and the changes that could be made as a result of hearing about the patients' experience. The participants' own views of the programme and ideas of how the programme might be improved were then analysed. 5 Results The changes suggested by the staff in the focus groups are in Table 3. The analysis of the transcripts of both the interviews and focus groups is divided into those related to Process and Context (Fig. 2). Table 3 Changes suggested by staff after hearing the Discovery Interviews Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Open in new tab Table 3 Changes suggested by staff after hearing the Discovery Interviews Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Open in new tab Fig. 2 Open in new tabDownload slide Actual context, process and outcomes of intervention in the parent study 6 Process The main findings regarding the process of providing the programme were in relation to engagement, information and physical assessment. 7 Engaging patients Of particular concern in providing the intervention was that the stories showed failings to engage patients fully with the programme and raised doubts as to the degree patients had understood the aims of the programme. Many patients appeared to have understood they were taking part in research but not a programme to improve their fitness. In the intervention group Geraldine1 1 The patients have been given pseudonyms. said, “I think a nurse from the Brompton came a couple of times. To take my blood pressure and that” and Martin also failed to grasp the reasons for the visit saying, “(the homecare nurse) came and said would I do it (the research) and she came… but that was ancillary wasn't it? It wasn't to do with me having an op. It was to do with what you wanted to find out about me”. In contrast Jessica, in the Control group, seemed to see the research assistant visit as an intervention, “She came and took blood tests and checked me and had a chat and tells me what's going on — everything”. Patients spoke about the blood tests and having their blood pressure measured but few mentioned diet or exercise. One of the nurses suggested they had focused too much on what the hospital needed rather than what was important to the patients and that the patient might have understood the programme better if they had addressed the goals patients might have. 8 Information The stories highlighted limitations to information provision. As part of their intervention the homecare team explained what the patient's operation would involve. However, the stories showed that misunderstanding arose when the information was not tailored to the individual patient. Francis had been given information for a standard coronary bypass procedure but he had a minimally invasive approach which meant he had recovered much quicker than he had expected, “I think if I am typical of a single bypass, then everything needs to be adjusted… Tell people that they shouldn't expect this and this… in this period of time, because you can do better than that, because it's so less invasive”. The staff discussed how to improve information by ensuring they discuss the patient's specific procedure. However, they thought it important that in addition to providing accurate information, reinforcement was needed as the stories suggested that some patients had not absorbed what they were told. One focus group participant said, “reinforce, reinforce and go through it and say… ‘tell me what's going to happen, explain what you understand’, so that then you can correct any slight misinterpretations”. They concluded that the process of providing the intervention would be improved by checking patients' understanding and reiterating information when necessary. 9 Physical assessment Despite misunderstanding of the aims of the programme the patients appreciated the support of the nurses who were able to perform physical assessment, give medical advice or refer back to the medical team. Carol spoke of the assurance from knowing she could ask for advice about physical symptoms, “I could say to them (homecare team), ‘I've got an extra pain here or there. Is it all right?”. However, two patient stories described their operations being cancelled at the last minute because of medical problems. Henry described how he had been sent home while a scan of his carotid arteries was arranged, “Well, that surprised me a bit, that (the scan) hadn't been done prior to my operation, in fact prior to my even going in”. The nurses in the focus groups said this highlighted how the assessment could be improved if they assessed carotid bruits and ordered carotid Doppler scans prior to admission. 10 The context The stories provided insight into the context within which the programme was being delivered in two areas; sources of risk factor advice and understanding of healthcare. This provided other possible reasons for lack of engagement. 10.1 Sources of risk factor advice The stories showed that nurses needed to be aware of other sources of cardiac rehabilitation advice patients were receiving. Lillian had been attending a diabetic clinic, “I don't think I've altered anything else particularly, because being diabetic I've always had to watch my diet”. Although she did add, “I perhaps walk a bit more,… I would have jumped in the car, now I walk,” which suggests different sources of advice may have an accumulative affect. Whereas Edward had attended cardiac rehabilitation classes previously, “I was going to go to Rehab, but I've been through it twice,…. I know what I'm doing and what I should be doing” and so may have been less likely to want more advice from the homecare team despite having agreed to take part in the study. These patients may have had sufficient rehabilitation support from their local hospitals and specialist clinics without the help of the homecare team. This contrasts with the pilot study [20] prior to the parent study in which the nursing staff found the patients were receiving very little rehabilitation input or secondary prevention advice. 10.2 Understanding of healthcare As well as receiving previous advice, the stories showed the nurses the differences among patients in their understanding. Lillian's son had had heart surgery for a different condition several years previously and discovering and exploring this experience and how hers would be different could have helped prevent problems of anxiety, “… having been through it with my son, and he was far worse, you know,…, I've seen the worse side of it, so maybe that was why I was so anxious”. Patients perceived services very differently from health care providers and can have misconceptions about the health service. Kevin had been under the impression that all leg wounds became infected and Martin had misunderstood how the waiting list operated. He had started getting pain in 2000 but “it wasn't until the year 2003 that they actually came along and they said right now you need the operation”. He did not seem aware from 2000 to 2003 he was being treated medically but that his disease had subsequently progressed to the stage where he needed surgery. The nursing team could have discussed patients' previous experiences and expectations and helped them understand how the health service operated. 11 The nurses' perspective From their own perspective the nurses felt that a key factor influencing the success of the programme was the patients' attitudes towards their health and the research. 11.1 Attitudes towards heart disease The nurses felt that the operation was seen by some patients as a cure and that this affected patients' attitude towards the programme. Commenting on Robert's story one nurse said, “He was expecting that this was going to cure everything”. Robert mentions the fact that his cholesterol level was high but does not mention diet as a way of controlling it but rather that he was taking ‘pills and potions’. The nurses felt that patients preferred taking pills rather than changing their lifestyle. Caroline: “And the thing is with blood pressure, it is usually the GP who prescribes a tablet and patients find it easier to take a tablet to control blood pressure than to exercise for an hour a day”. Jane:“I think… patients… always want the quick fix. They want to do as little of it themselves… patients tend to think that (the operation) is their fix”. The nurses felt the patients who did make changes had a positive attitude and this was not dependent on the group they were in. Commenting on Edward who had attended cardiac rehabilitation classes, one nurse suggested, “Even though he was in the control group and didn't get the visits, he was positive enough to go through it all and still be positive at the end of it.” Whereas other patients receiving the intervention had been unmotivated to change and nurses made comments such as, “not interested in making any changes” and, “Very little advice given as patient not receptive”. 11.2 Dissonance in team approach The attitude of the medical staff towards preparing patients for their operation was also discussed by the nursing staff. The nurses felt some of the hospital doctors valued the pre-operative screening element of the programme but did not always act on problems raised, “We highlight a problem, let them know, they bring the patient in and they get cancelled”. Also they did not always allow time for an intervention to be carried out. One nurse spoke of a patient who had a letter in his medical notes saying he was advised to lose weight but was then admitted two weeks later. This was in contrast to previous studies where the medical staff had referred the patients to the nursing team [6]. The nurses felt some patients received contradictory advice from GPs in regard to diet and exercise, as Matthew states, “A lot of patients, it's the GPs who tell them not to do anything. ‘Oh the GP told me not to do anything’. It's very hard for a nurse to come in then and tell then otherwise.” Overall these comments suggested that mixed messages were being given to the patients and any future programme would need to be clear about what it wanted to achieve. 12 Surgeons' views The surgeons felt that the programme was very valuable in terms of the psychological support the nursing staff were able to provide the patients and the physical assessments and results that the nurses were able to provide for them. They felt that the patients were more likely to discuss their concerns and practical issues with the nursing staff in the relaxed environment of their own homes rather than the busy medical out-patient clinic. One surgeon said of the nursing staff, ‘(when you) get to see the patient in their environment, you pick up a lot of problems that I wouldn't (in the 15–20 min consultation) such as uncontrolled diabetes, badly controlled hypertension, and… the environment they will go back to'. They felt the nursing intervention was a more holistic approach. However, in terms of risk factors they felt while they might encourage weight loss and smoking cessation, the patient's clinical condition might mean they had to operate before they could wait for the patient to lose weight or stop smoking. They felt the patients who had shorter waits for their operations were in greater need of the psychological support in coming to terms with their operation, ‘the patients don't have time to assimilate the knowledge and experience that other patients have(who wait longer)’. They felt that the risk factors should have been addressed when they first came into contact with cardiac services and should not have to wait until the patient was put on a list for surgery which might explain why the nurses felt that the medical staff were less interested in the patients' lifestyle. 12.1 Waiting time Much discussion in the focus groups expressed concern at how much could be achieved during the current waiting time of three months, “Addressing any lifestyle issues we will be very, very limited unless… we will take them off the waiting list until they have lost 6 stone, stopped smoking or whatever (nurse manager).” When the programme was originally planned there were waiting times for cardiac surgery of 6–18 months which would have given more time for the intervention. However previous research supports an effect on length of stay in a programme in only 10–11 weeks prior to the operation [6]. The nurses agree with the medical staff that there was an increasing role for them to help patients adjust to having heart disease when there was a short time between diagnosis and surgery. They felt that the patients who had a longer history of heart disease were more likely to be on the correct medication and to have come to terms with the limitations of their disease as discussed by homecare nurses Matthew and Megan. Matthew: “I have found people have had difficulty coming to terms with the fact they have coronary artery disease as well and I feel we have a big counselling role…” Megan: “I've had one quite recently who have been diagnosed very quickly but haven't got aspirin, haven't got GTN (glycerol trinitrate spray)…” The staff gave the evaluation a wider perspective than that of the patient because they were aware of physical and operational needs that, perhaps, the patient was not and they were able to use the discussion to make plans for the future. 13 Discussion The Discovery Interviews suggest the staff need to be clear about the aims of their visits. This does not appear to have been a problem in other similar studies [5,6] but results on a nurse-led programme of follow up after myocardial infarction showed perceptions about the nurse's role, knowledge, relationship with medical staff and communication were important factors in how patients received the programme [21]. A nurse-led secondary prevention programme in primary care found nurses failed to address issues of concern to the patients and focused on collecting factual information [22]. Future programmes might learn from this and ask patients what they want to discuss. Mooney et al. [23] reported experiences of patients taking part in a 12-week pre-operative programme while waiting for surgery. They appreciated the support and the chance to learn more about their operation and also address fears and emotional issues. In our study psychological preparation was seen as important by both staff and patients but information needed to be tailored to individual needs with due attention to the context of previous experience, and understanding of health. Mooney et al.'s study also showed that the information provided helped patients to see their operation as a treatment rather than a cure as it addressed misconceptions as well as risk factors [23] Previous studies following myocardial infarctions have described how patients have their own views of the course of coronary heart disease and that these need to be understood for health promotion messages to be effective [24,25]. Literature on general health beliefs [26] recommends that patients are asked what they believe about the origins of their illness and its effect on their life in terms of their family life and social position and that the health professional addresses a person's motivation to effectively encourage sustained lifestyle change. Also the health professional needs to address why people change before they will see sustained lifestyle change [27]. A limitation of the study is that due to the limited timescale available the researcher's analysis was not reported back to the patients and future programmes should ask patients' views on the content. Given the time available and the medical staff emphasis on the patient's clinical condition and psychological preparation for surgery the nurses' focus for the future might be to improve on their physical assessment skills and psychological support with more emphasis on addressing patients' understanding of their health and partner with local teams providing cardiac rehabilitation advice to provide support for lifestyle change after surgery. Acknowledgement The study would not have been possible without the support of the Cardiac Homecare team, and Rehabilitation Team and Cardiac Liaison Nurses at Royal Brompton and Harefield Hospitals. We are also grateful to all the participants of the Discovery Interviews. The study was funded by a research grant from the British Heart Foundation (PG02/116/14483) and by the Royal Brompton and Harefield Charitable Trustees. References [1] Rollnick S , Mason P, Butler C Health behaviour change 1999 Churchill Livingstone Edinburgh Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC [2] H. Goodman, A. Parsons, J. Davison, M. Preedy, E. Peters, C. Shuldham, et al. A randomised controlled trial to evaluate a nurse-led programme of support and lifestyle management for patients awaiting cardiac surgery. Eur J Cardiovasc Nurs 2007, 10.1016/j.ejcnurse.2007.11.001. 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Patient and Staff Perspective of a Nurse-Led Support Programme for Patients Waiting for Cardiac Surgery: Participant Perspective of a Cardiac Support Programme

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Oxford University Press
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Copyright © 2022 European Society of Cardiology
ISSN
1474-5151
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1873-1953
DOI
10.1016/j.ejcnurse.2008.03.001
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Abstract

Abstract Background: A nurse-led support and education programme for patients waiting for coronary artery bypass surgery was evaluated in a randomised controlled trial of 188 patients at a tertiary centre in the UK. Aim: To add a qualitative perspective to the evaluation by exploring patients' experience while taking part in the trial and staff views of the patients' experience and the intervention. Methods: A purposive sample of 19 patients was interviewed and the transcriptions read to staff during focus groups. They discussed what they learned from the stories and their own experience of the programme. Results: The patients appreciated support from the nurses but felt communication and physical assessment could be improved. The patients varied in their understanding of the programme and their degree of motivation to improve their health. The staff varied in their approach to preparing patients for surgery. External factors influencing the intervention's impact were length of time on the waiting list and the increasing contribution of local rehabilitation services. Conclusion: Staff need to improve communication both between themselves and with the patients. Patients appreciate physical and psychological preparation for surgery, but the waiting period is not the optimal time to address their risk factors for coronary disease. Discovery Interviews, Focus groups, Qualitative research, Cardiac rehabilitation, Cardiovascular nursing, Patients' experience 1 Introduction In this paper we report a qualitative study using interviews and focus groups to explore the experience of patients and staff taking part in a randomised controlled trial evaluating a monthly home based nursing programme of education and support for patients waiting for cardiac surgery at two hospitals in south east England. Patients listed for coronary artery bypass surgery with at least one poorly controlled risk factor were randomised to standard care or the intervention which provided a cardiac risk assessment, lifestyle counselling according to motivational interviewing techniques [1] and physical and psychological preparation for surgery. Primary outcome measurements were anxiety, blood pressure, cholesterol, length of stay and body mass index. There was no significant reduction in risk factors in the parent study and this is the subject of a separate paper [2]. However, evaluation research suggests that studies should address not only whether an intervention worked but how and why it did or did not work [3] and that the context and process of the intervention being evaluated should be considered as well as the outcomes [4]. Previous randomised controlled trials of patient support and education programmes have focused on outcomes such as length of stay rather than the participant experience [5,6]. Others [7] have examined participant experience of nurse-led programmes following myocardial infraction to provide data about patients' perceptions of myocardial infarction and the nurses' knowledge base and competence. However, there are no published reports of a similar study with patients waiting for heart surgery. The aims of the qualitative study were to add to the evaluation of the programme by exploring patients' experience of waiting for coronary artery bypass surgery while taking part in the trial and explore staff views of both the intervention and the patients' descriptions. This data provided insight into the process and context of the programme while the trial provided detail on the outcomes [3]. The intended process, context and outcomes of the study are outlined in Fig. 1. Fig. 1 Open in new tabDownload slide Intended process, context and outcomes of the parent study An increasingly popular method of learning participants' views is the use of narrative or “story telling” [8,9]. Discovery Interviews are a narrative based tool developed by the Modernisation Agency (a national organisation in the United Kingdom promoting service improvement) to provide the patient viewpoint of their healthcare experience. Examples of changes made by staff after hearing these stories include one-stop clinics for chest pain, carer support groups and improved patient information [10]. Focus groups are formed to generate qualitative data from focused discussion [11]. They can be used to encourage dialogue between participants with different roles and remits and allows them to compare and debate ideas [12]. They have been found to be very useful for studying the impact of programmes in healthcare [11,13]. 2 Methods The rationale for using Discovery Interviews was that they provide a patient focused rather than professional led insight into the patients' experience and are therefore less likely to miss issues important to the patients [10]. A purposive sample of patients from both the experimental and control group were asked to take part in a Discovery Interview three months after discharge following their operation. A mix of intervention and control group, male and female patients from a variety of referring hospitals (Table 1) were selected throughout the course of the study. One patient refused to take part and one did not attend. Table 1 Patient details Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen M = male, F = female, Area = referring hospital. Open in new tab Table 1 Patient details Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen Hospital Sex Area Group Age Pseudonym 1 M 1 C 76 Alfred 1 M 2 C 62 Barry 1 F 3 E 70 Carol 1 M 1 E 51 David 2 M 4 C 66 Edward 2 M 5 E 67 Francis 1 F 3 E 76 Geraldine 1 M 3 E 66 Henry 1 M 2 C 66 Ian 1 F 2 C 66 Jessica 1 M 3 C 69 Kevin 2 F 4 E 56 Lillian 2 M 6 E 72 Martin 1 M 3 C 74 Neil 1 M 3 E 56 Oliver 2 M 4 C 67 Phillip 1 M 3 E 72 Quentin 1 M 7 C 42 Robert 1 M 2 E 52 Stephen M = male, F = female, Area = referring hospital. Open in new tab The methodology does not specify how the data should be handled other than read back to interested parties but focus groups were deemed a valuable tool to ensure the feedback sessions had definite outcomes. The focus groups' composition is in Table 2. They were held during the regular staff meetings. No one refused to participate. Two cardiac surgeons whose patients had taken part in the programme also read the interview transcripts and were interviewed separately to gain their views on the programme. Table 2 Focus group participants in each focus group Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Open in new tab Table 2 Focus group participants in each focus group Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Pseudonym Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Focus group Role 1 2 3 4 5 6 7 8 9 10 Abigail • Sister Alison • • Senior staff nurse Caroline • • Sister Dawn • Administrator Edith • • Researcher Elspeth • Homecare nurse Heather • • Sister Gill • • Sister Jane • • • • Homecare nurse Joanne • Sister John • • Researcher Karen • Senior staff nurse Louise • • • Sister Lucy • • • • Sister Matthew • • • • • Homecare nurse Megan • • • • Homecare nurse Michelle • • • Modern matron Naomi • • Senior staff nurse Penny • • • • Modern matron Ruth • Senior staff nurse Victoria • • • Administrator Open in new tab In terms of validity and reliability the goal of qualitative research is ‘meaning’ rather than ‘truth’ and the meaning is related to the context of the study [14,15]. The uniqueness of the narratives meant that the analysis was not generalisable but generated ideas for future research and development [16]. It is important that others can decide for themselves whether they accept the interpretation of the data [17,18] and so the analyses of the focus group transcripts were fed back to the staff for comment. 3 Data collection Nineteen patients were selected from the 188 patients who took part in the study. The participants told their own story during a taped interview in their home. The interviewers asked the patient to talk through key stages of their experience of the illness according to an interview spine which was written out on cards for the patients at the interview and comprised of the phrases, ‘Waiting for your heart surgery’, ‘Effect on your lifestyle’, ‘Being told you needed surgery’, ‘Support while waiting’, ‘Going into hospital’ and ‘Your recovery’. The interviewer only intervened to ask for clarification of particular points. The interviews lasted 45–60 min and were transcribed; interjections removed and the interviews read back as stories over the course of 10 focus groups. Focus groups generally have a topic guide but in this instance the focus was on the Discovery Interviews. The participants were asked to discuss what they had learned from the patients' experience related in the stories and what changes they would make to the service as a consequence. In the last four focus groups they were also asked to describe how the programme had worked from their perspective. They lasted approximately 60 min and with minimal intervention from the facilitator. The surgeons were asked to do the same as the focus groups but in individual taped interviews lasting 30–45 min. Ethical approval was granted by the local ethics committee [19]. 4 Data analysis The texts of the interviews and focus groups were analysed by the researcher using a thematic analysis focusing on the process and contexts of the intervention and the changes that could be made as a result of hearing about the patients' experience. The participants' own views of the programme and ideas of how the programme might be improved were then analysed. 5 Results The changes suggested by the staff in the focus groups are in Table 3. The analysis of the transcripts of both the interviews and focus groups is divided into those related to Process and Context (Fig. 2). Table 3 Changes suggested by staff after hearing the Discovery Interviews Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Open in new tab Table 3 Changes suggested by staff after hearing the Discovery Interviews Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Changes in relation to the ‘Process’ of providing the intervention Changes in relation to the ‘Context’ in which the intervention was provided Tailor information to the individual Clarify the main aims of the programme in the timescale available Reinforce information Assess patients' health beliefs Listen to the individual concerns of patients Assess patients' prior knowledge Follow up on consultations fully Assess patients' cardiac rehabilitation advice needs Establish good rapport with patients Address patients' preconceptions and expectations Improve physical assessment skills Agree approach with all healthcare professionals involved in seeing patients Inform patients about the possibility of cancellations Review theoretical approach to health promotion and own health beliefs Explore better tools for assessing psychological needs Review use of current literature and protocols Ensure accurate information is given regarding waiting times Open in new tab Fig. 2 Open in new tabDownload slide Actual context, process and outcomes of intervention in the parent study 6 Process The main findings regarding the process of providing the programme were in relation to engagement, information and physical assessment. 7 Engaging patients Of particular concern in providing the intervention was that the stories showed failings to engage patients fully with the programme and raised doubts as to the degree patients had understood the aims of the programme. Many patients appeared to have understood they were taking part in research but not a programme to improve their fitness. In the intervention group Geraldine1 1 The patients have been given pseudonyms. said, “I think a nurse from the Brompton came a couple of times. To take my blood pressure and that” and Martin also failed to grasp the reasons for the visit saying, “(the homecare nurse) came and said would I do it (the research) and she came… but that was ancillary wasn't it? It wasn't to do with me having an op. It was to do with what you wanted to find out about me”. In contrast Jessica, in the Control group, seemed to see the research assistant visit as an intervention, “She came and took blood tests and checked me and had a chat and tells me what's going on — everything”. Patients spoke about the blood tests and having their blood pressure measured but few mentioned diet or exercise. One of the nurses suggested they had focused too much on what the hospital needed rather than what was important to the patients and that the patient might have understood the programme better if they had addressed the goals patients might have. 8 Information The stories highlighted limitations to information provision. As part of their intervention the homecare team explained what the patient's operation would involve. However, the stories showed that misunderstanding arose when the information was not tailored to the individual patient. Francis had been given information for a standard coronary bypass procedure but he had a minimally invasive approach which meant he had recovered much quicker than he had expected, “I think if I am typical of a single bypass, then everything needs to be adjusted… Tell people that they shouldn't expect this and this… in this period of time, because you can do better than that, because it's so less invasive”. The staff discussed how to improve information by ensuring they discuss the patient's specific procedure. However, they thought it important that in addition to providing accurate information, reinforcement was needed as the stories suggested that some patients had not absorbed what they were told. One focus group participant said, “reinforce, reinforce and go through it and say… ‘tell me what's going to happen, explain what you understand’, so that then you can correct any slight misinterpretations”. They concluded that the process of providing the intervention would be improved by checking patients' understanding and reiterating information when necessary. 9 Physical assessment Despite misunderstanding of the aims of the programme the patients appreciated the support of the nurses who were able to perform physical assessment, give medical advice or refer back to the medical team. Carol spoke of the assurance from knowing she could ask for advice about physical symptoms, “I could say to them (homecare team), ‘I've got an extra pain here or there. Is it all right?”. However, two patient stories described their operations being cancelled at the last minute because of medical problems. Henry described how he had been sent home while a scan of his carotid arteries was arranged, “Well, that surprised me a bit, that (the scan) hadn't been done prior to my operation, in fact prior to my even going in”. The nurses in the focus groups said this highlighted how the assessment could be improved if they assessed carotid bruits and ordered carotid Doppler scans prior to admission. 10 The context The stories provided insight into the context within which the programme was being delivered in two areas; sources of risk factor advice and understanding of healthcare. This provided other possible reasons for lack of engagement. 10.1 Sources of risk factor advice The stories showed that nurses needed to be aware of other sources of cardiac rehabilitation advice patients were receiving. Lillian had been attending a diabetic clinic, “I don't think I've altered anything else particularly, because being diabetic I've always had to watch my diet”. Although she did add, “I perhaps walk a bit more,… I would have jumped in the car, now I walk,” which suggests different sources of advice may have an accumulative affect. Whereas Edward had attended cardiac rehabilitation classes previously, “I was going to go to Rehab, but I've been through it twice,…. I know what I'm doing and what I should be doing” and so may have been less likely to want more advice from the homecare team despite having agreed to take part in the study. These patients may have had sufficient rehabilitation support from their local hospitals and specialist clinics without the help of the homecare team. This contrasts with the pilot study [20] prior to the parent study in which the nursing staff found the patients were receiving very little rehabilitation input or secondary prevention advice. 10.2 Understanding of healthcare As well as receiving previous advice, the stories showed the nurses the differences among patients in their understanding. Lillian's son had had heart surgery for a different condition several years previously and discovering and exploring this experience and how hers would be different could have helped prevent problems of anxiety, “… having been through it with my son, and he was far worse, you know,…, I've seen the worse side of it, so maybe that was why I was so anxious”. Patients perceived services very differently from health care providers and can have misconceptions about the health service. Kevin had been under the impression that all leg wounds became infected and Martin had misunderstood how the waiting list operated. He had started getting pain in 2000 but “it wasn't until the year 2003 that they actually came along and they said right now you need the operation”. He did not seem aware from 2000 to 2003 he was being treated medically but that his disease had subsequently progressed to the stage where he needed surgery. The nursing team could have discussed patients' previous experiences and expectations and helped them understand how the health service operated. 11 The nurses' perspective From their own perspective the nurses felt that a key factor influencing the success of the programme was the patients' attitudes towards their health and the research. 11.1 Attitudes towards heart disease The nurses felt that the operation was seen by some patients as a cure and that this affected patients' attitude towards the programme. Commenting on Robert's story one nurse said, “He was expecting that this was going to cure everything”. Robert mentions the fact that his cholesterol level was high but does not mention diet as a way of controlling it but rather that he was taking ‘pills and potions’. The nurses felt that patients preferred taking pills rather than changing their lifestyle. Caroline: “And the thing is with blood pressure, it is usually the GP who prescribes a tablet and patients find it easier to take a tablet to control blood pressure than to exercise for an hour a day”. Jane:“I think… patients… always want the quick fix. They want to do as little of it themselves… patients tend to think that (the operation) is their fix”. The nurses felt the patients who did make changes had a positive attitude and this was not dependent on the group they were in. Commenting on Edward who had attended cardiac rehabilitation classes, one nurse suggested, “Even though he was in the control group and didn't get the visits, he was positive enough to go through it all and still be positive at the end of it.” Whereas other patients receiving the intervention had been unmotivated to change and nurses made comments such as, “not interested in making any changes” and, “Very little advice given as patient not receptive”. 11.2 Dissonance in team approach The attitude of the medical staff towards preparing patients for their operation was also discussed by the nursing staff. The nurses felt some of the hospital doctors valued the pre-operative screening element of the programme but did not always act on problems raised, “We highlight a problem, let them know, they bring the patient in and they get cancelled”. Also they did not always allow time for an intervention to be carried out. One nurse spoke of a patient who had a letter in his medical notes saying he was advised to lose weight but was then admitted two weeks later. This was in contrast to previous studies where the medical staff had referred the patients to the nursing team [6]. The nurses felt some patients received contradictory advice from GPs in regard to diet and exercise, as Matthew states, “A lot of patients, it's the GPs who tell them not to do anything. ‘Oh the GP told me not to do anything’. It's very hard for a nurse to come in then and tell then otherwise.” Overall these comments suggested that mixed messages were being given to the patients and any future programme would need to be clear about what it wanted to achieve. 12 Surgeons' views The surgeons felt that the programme was very valuable in terms of the psychological support the nursing staff were able to provide the patients and the physical assessments and results that the nurses were able to provide for them. They felt that the patients were more likely to discuss their concerns and practical issues with the nursing staff in the relaxed environment of their own homes rather than the busy medical out-patient clinic. One surgeon said of the nursing staff, ‘(when you) get to see the patient in their environment, you pick up a lot of problems that I wouldn't (in the 15–20 min consultation) such as uncontrolled diabetes, badly controlled hypertension, and… the environment they will go back to'. They felt the nursing intervention was a more holistic approach. However, in terms of risk factors they felt while they might encourage weight loss and smoking cessation, the patient's clinical condition might mean they had to operate before they could wait for the patient to lose weight or stop smoking. They felt the patients who had shorter waits for their operations were in greater need of the psychological support in coming to terms with their operation, ‘the patients don't have time to assimilate the knowledge and experience that other patients have(who wait longer)’. They felt that the risk factors should have been addressed when they first came into contact with cardiac services and should not have to wait until the patient was put on a list for surgery which might explain why the nurses felt that the medical staff were less interested in the patients' lifestyle. 12.1 Waiting time Much discussion in the focus groups expressed concern at how much could be achieved during the current waiting time of three months, “Addressing any lifestyle issues we will be very, very limited unless… we will take them off the waiting list until they have lost 6 stone, stopped smoking or whatever (nurse manager).” When the programme was originally planned there were waiting times for cardiac surgery of 6–18 months which would have given more time for the intervention. However previous research supports an effect on length of stay in a programme in only 10–11 weeks prior to the operation [6]. The nurses agree with the medical staff that there was an increasing role for them to help patients adjust to having heart disease when there was a short time between diagnosis and surgery. They felt that the patients who had a longer history of heart disease were more likely to be on the correct medication and to have come to terms with the limitations of their disease as discussed by homecare nurses Matthew and Megan. Matthew: “I have found people have had difficulty coming to terms with the fact they have coronary artery disease as well and I feel we have a big counselling role…” Megan: “I've had one quite recently who have been diagnosed very quickly but haven't got aspirin, haven't got GTN (glycerol trinitrate spray)…” The staff gave the evaluation a wider perspective than that of the patient because they were aware of physical and operational needs that, perhaps, the patient was not and they were able to use the discussion to make plans for the future. 13 Discussion The Discovery Interviews suggest the staff need to be clear about the aims of their visits. This does not appear to have been a problem in other similar studies [5,6] but results on a nurse-led programme of follow up after myocardial infarction showed perceptions about the nurse's role, knowledge, relationship with medical staff and communication were important factors in how patients received the programme [21]. A nurse-led secondary prevention programme in primary care found nurses failed to address issues of concern to the patients and focused on collecting factual information [22]. Future programmes might learn from this and ask patients what they want to discuss. Mooney et al. [23] reported experiences of patients taking part in a 12-week pre-operative programme while waiting for surgery. They appreciated the support and the chance to learn more about their operation and also address fears and emotional issues. In our study psychological preparation was seen as important by both staff and patients but information needed to be tailored to individual needs with due attention to the context of previous experience, and understanding of health. Mooney et al.'s study also showed that the information provided helped patients to see their operation as a treatment rather than a cure as it addressed misconceptions as well as risk factors [23] Previous studies following myocardial infarctions have described how patients have their own views of the course of coronary heart disease and that these need to be understood for health promotion messages to be effective [24,25]. Literature on general health beliefs [26] recommends that patients are asked what they believe about the origins of their illness and its effect on their life in terms of their family life and social position and that the health professional addresses a person's motivation to effectively encourage sustained lifestyle change. Also the health professional needs to address why people change before they will see sustained lifestyle change [27]. A limitation of the study is that due to the limited timescale available the researcher's analysis was not reported back to the patients and future programmes should ask patients' views on the content. Given the time available and the medical staff emphasis on the patient's clinical condition and psychological preparation for surgery the nurses' focus for the future might be to improve on their physical assessment skills and psychological support with more emphasis on addressing patients' understanding of their health and partner with local teams providing cardiac rehabilitation advice to provide support for lifestyle change after surgery. Acknowledgement The study would not have been possible without the support of the Cardiac Homecare team, and Rehabilitation Team and Cardiac Liaison Nurses at Royal Brompton and Harefield Hospitals. We are also grateful to all the participants of the Discovery Interviews. 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Journal

European Journal of Cardiovascular Nursing – Oxford University Press

Published: Mar 1, 2009

Keywords: nurses; heart; cardiac surgery procedures; physical examination; surgery specialty; surgical procedures, operative; cardiac rehabilitation; coronary artery bypass surgery

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