Nurse Training in Cardiac Procedures

Nurse Training in Cardiac Procedures

The effects of pre-operative nursing teaching on the stress/anxiety level of patients who will undergo heart surgeries and percutaneous interventions

Patients undergoing any heart-related procedure could expect to experience a certain amount of stress. Stresses go beyond the physical stresses associated with the procedure. Emotional responses before, during, and after the procedure have an impact on the ability of the patient to cope. Additional stress has an effect on the ability of the patient to recover and their willingness to make life changes to accommodate their condition. Stress has a negative impact on the lives of patients and families of patients who have undergone invasive heart-related interventions. This research will examine the effectiveness of nurse training on reducing the stress level of the patient post operative.

Research Problem

Background of the Problem

Stress has a negative impact on the body's ability to heal itself and on the recovery period from traumatic events such as surgery. Until recently, attention from the medical community has focused on the physical stress of the surgical procedure itself. However, the medical community is not beginning to attend to the emotional state of the patient, before and after the procedure. The impact of stress can haven an impact on how the events effect them for the rest of their lives. This research will examine ways to reduce anxiety in patients that must undergo invasive heart-related procedures.

Significance of the Problem

This study is important, as it will provide insight into an important aspect of the healing process and quality of life for the patient. Patients that are more knowledgeable about their disease and the effects of the surgery are more likely to take actions that result in long-term changes in lifestyle. Patients that are knowledgeable about their disease and about health related issues in general will be able to play a more active role in the recovery process.

This study will help to determine the role that patient education plays in the anxiety level of the patient prior to discharge. Reducing stress prior to discharge is expected to have a positive impact on the life of the patient and their caregivers once they arrive home. They will have a greater feeling of control over their circumstances and will be able to better assist in the recovery process than those that are not thoroughly trained in the management of their particular condition. This study will play a significant role in helping patients and families to adjust to the changes that will take place once they are discharged from the hospital. The goal of this research is to lower anxiety regarding their disease and the procedure that they have undergone in a permanent manner.

Theoretical Basis of the Study

The study is based on past evidence that indicates stress has a negative impact on the outcome of several medical procedures. Stress not only effects the emotional state of patients, stress produces chemical reactions in the body that are detrimental to health. Reducing stress before, during, and after a traumatic procedure has positive medical benefits and can dramatically improve a patient's quality of life. Heart surgery is a stressful prospect for most patients that must undergo procedures. This study will focus on finding a way to reduce stress in patients that must undergo a heart procedure.

This study will examine patients that are scheduled for one of several heart-related procedures. Any of these procedures could reasonably be expected to produce a certain level of stress for patients. Patients in this study will be scheduled to undergo CABG, valve surgeries, hear transplant, or have percutaneous interventions such as PTCA, stent placement, or AICD/pacemaker placement.

Education is one of the keys to reducing stress in situations that are unfamiliar. The premise of this study is that pre-operative teachings by the nursing staff will play a significant role in reducing stress in patients undergoing the above procedures. These teachings will be designed to give the patient knowledge regarding the disease process, the risks and benefits or specific surgeries, what to expect before the procedure, what to expect during the procedure, and what to expect after the surgery. It will address cardiac rehabilitation, discharge planning and what will happen in follow up visits.

Experimental Overview

The study will examine a group of patients that are scheduled to undergo any of the procedures previously mentioned. The patients will be divided into two groups. One group will be given a training course during their pre-operative hospital stay by one of the nursing staff. The training program will be designed to address the specific needs of the procedure that the patient will undergo.

The test group will receive the training, while the control group will receive no pre-operative training. After the patients undergo their procedure and spend the required time in the hospital, they will be administered the State-Trait Anxiety Inventory for Adults as part of their pre-discharge routine. This survey instrument is a standard instrument that is useful in addressing stress related to traumatic events such as medical procedures. There is a considerable amount of information available about this survey instrument and its reliability traits. It is expected that there will be significant differences between the control and test groups. The test group is expected to demonstrate reduced anxiety, as opposed to the control group.

Hypotheses/Research Questions

The purpose of this study is to examine the impact of nurse training on the anxiety level of patients following an invasive heart related procedure. The procedures will be considered in aggregate, rather than addressing a separate hypothesis regarding every different type of procedure. The anxiety produced by each procedure is difficult to differentiate and there are a number of external factors that could influence the perceived stress level of the patient. It is expected that the impending procedure will have an equal chance of producing stress in each of the patients and that the type of procedure will not be a variable in the study. All of the procedures will be assumed to have a similar chance of producing perceived stress in the patient.

The research will examine the following hypotheses.

H1: Patients that receive specific training regarding their particular condition and procedure prior to the procedure will have significantly lower anxiety scores prior to discharge from the hospital than those that did not receive the training prior to having the procedure performed.

H0: Patients that receive specific training regarding their particular condition and procedure prior to the procedure will not have significantly lower anxiety scores prior to discharge from the hospital than those that did not receive the training prior to having the procedure performed.

This research will address a single research hypothesis, but it will involve many facets of the research topic. Therefore, in addition to the hypothesis, the research will address the following research questions.

How does nurse training prior to the procedure affect a patient's anxiety level prior to the procedure?

What impact, if any, does nurse training prior to the procedure have on the patient's anxiety level during the procedure?

What impact, if any, does nurse training prior to the procedure have on the patient's anxiety level after the procedure?

How does nurse training prior to the procedure affect the patient's perceived quality of life?

What impact does nurse training prior to the procedure have on the patient's ability to cope with necessary changes in their life as a result of the procedure?

What impact does nurse training prior to the procedure have on the patient's willingness to adhere to necessary changes in their life as a result of the procedure?

What impact does nurse training prior to the procedure have on the patient's overall feelings of satisfaction with the outcome of the procedure?

Conclusion

This research will examine a side of surgical heart procedures that has only recently begun to be addressed by academic literature. The mind-body connection has only recently begun to achieve an importance that resembles that which is attributed to physiological responses to traumatic procedures. There are many aspects to heart surgery that have an impact on the outcome of the procedure from a physiological standpoint. However, the life of the patient and their loved ones does not end when the physiological illness has passed. The disease itself and the procedure to remedy it have a lasting emotional impact on the patient and those that are close to them.

After the procedure, the patient must adjust to many new ideas and changes. They may have an electronic device or other implant. This not only has an impact on their physical well-being, but has a significant emotional impact as well. They may not feel as if they are "whole" anymore. If the procedure means limiting certain activities to which they were accustomed, this may mean further adjustments and a sense of "grieving" for things that are no longer a part of their life.

Quality of life goes beyond the physical act of living and being able to care for one's physical needs. A patient's emotional well-being may have more to do with how they define their quality of life than physical limitations imposed by the procedure. The procedure itself and the hospital stay associated with it is only one small chapter in the patient's life. They will eventually go home and will have many years after the procedure. It is important for the nursing staff to make a positive impact on how they feel about the procedure. The procedure will represent a lasting memory to the patient. If the patient perceives this to be a time of strength and care from nurturing individuals then it will help them to be able to develop the coping mechanisms necessary to learn to live with the after-effects of the procedure.

If the patient sees this as a negative experience, then it could produce unwanted effects such as depression, post-traumatic stress disorder, or other emotional problems that could have an effect on their ability to cope with the life changes. Those that develop appropriate coping mechanisms will be more likely to have a successful recovery than those that have a negative experience. Fear is often the result of the unknown. We fear what we do not understand or hoave not experienced. The goal of this research is to develop a program that will provide the patient with a greater understanding of their disease and the procedure that they will undergo. It is hoped that this will relieve some anxiety on their part and that this will result in a more positive outlook on the procedure. This research will help the patient to develop effective coping strategies in dealing with their disease and the invasive procedure.

Chapter 2: Literature Review

Research into how the emotional state of the patient and personality traits effect stress an the willingness to adhere to advice after discharge has only begun to appear in mass over the past two years. This research is built on concepts borrowed from other disciplines of psychology that relate to the influence of one's emotional state on their physiological ability to heal and cope with trauma. This represents a paradigm shift in the field from focusing primarily on the physical body to recognizing the role that a person's emotional state plays on their general health.

Currently, literature has been produced by an only a handful of researchers. However, they are beginning to develop the groundwork for clinical application of their theories. This new branch of mental health research will become more specific as the theories are developed. The current state of research in this new field is largely theoretical at this time, with a few instruments under development that may become useful in the future. This research study will take the current body of research one step further and will attempt to apply it in the patient setting.

In areas of research that are better developed, one often finds large groups of literature that address a certain facet of the topic. However, in areas that are just beginning to be recognized as a separate entity, such as this one, it is sometimes more necessary to provide more explanation as to how the new theories apply to the field than in a traditional literature review. This literature review will not only examine the literature in composite, but will provide a detailed discussion of how the research applies to this developing union between mental health and physiological health.

There are several factors that are borrowed from other areas of psychology that are useful in determining the likelihood that a patient will have a positive emotional outcome after the procedure. Early research indicates that identification of certain personality traits and attitudes might predispose certain patients to be at-risk for developing psychological disorders after a traumatic procedure. If clinicians can identify these risk factors, they may be able to take precautions to help the patient adjust to life after surgery. This concept forms the theoretical basis for this research study.

The purpose of nurse training is two fold. It is to inform the patient about the physical sensations, risks, and other factors that will effect them before, during, and after surgery. However, the goal is to reduce the amount of stress associated with the procedure and their disease. Several areas of literature will be useful in the development of the training program, patient assessment, and measurement of the training program. Many of these are borrowed from psychology and applied to the specific population addressed in this study. Literature into factors that influence the emotional states of patients and their relationships to achieving treatment objectives can be divided into several subtopics. The following will address the major categories of literature that exist within this newly emerging discipline.

Factors that Influence the Ability to Maintain Physical Activity

Goal intentions and implementation intentions play an important role in the exercise that rehabilitation patients performed independently (Ziegelmann et al., 2006). This study found that goal intentions were not predictive in whether the patient would follow the prescribe regime of exercise. However, implementation intentions were found to be associated with exercise 12 months after the rehabilitation program was complete. Implementation intentions, rather than goal intentions predicted behavior. Planning was found to be a significant factor in implementation intentions (Sniehotta, Scholz, & Schwarzer, 2006). This study provides an important factor in the recovery process and is easily extrapolated to the sample population of the current study.

Heart patients must make many changes in their lives in order to improve their health and maintain the benefits of the surgery. The study by Ziegelman and associates demonstrates that although the patient has goals, this alone does not predict whether they will be able to elicit permanent changes in their exercise level after discharge. This is an area where nurse training of patients could prove to be an important factor in creating permanent change in the patient that will lead to long-term exercise regimes. It is important for the patient to have a goal, but we now know that the plan and intention to stick with the plan are a key factor in the ability to cope with changes.

Intention is one of the most important predictors of behavior (Sniehotta, et al., 2006). In heart patients, it is important that patients develop a sense of proper intentions regarding their willingness to stick to necessary exercise and diet recommendations. This is perhaps the most important area where the nurse training program will be beneficial to patients. Training will enhance the need to stick to the routine in order to prevent the need for future surgery.

Ziegelmann, Lippke, and Schwarzer, (2006a) explored socio-cognitive predictors of physical exercise in patients released from rehabilitation. This study measured the effect of perceived remaining life expectancy and the willingness to exercise. The study examined those who felt their lifetime was expansive, versus those who felt their lifetime was limited. Individuals who felt their lifetime was limited were less likely to achieve their exercise goals than those who felt that they had many years remaining.

How a person perceives their life expectancy has a significant impact on self-regulation of activities that will help to improve the quality of their life (Ziegelmann, Lippke, and Schwarzer, 2006a). If is expected that the educational process developed as a part of this research will have a positive impact on the patient's perception of their life expectancy. The most important factor in this equation is that education could make the patient realize that exercise and adherence to suggestions could help to improve their life expectancy. This factor will be an important element in the educational training program of the nurses.

Age is a factor in the type of intervention that will be most likely to result in prolonged maintenance of exercise programs after physical therapy (Ziegelmann, Lippke, and Schwarzer, 2006b). According to this study, middle aged and older patients benefited from a program where the interviewer assisted in planning. Whereas younger persons benefited from a plan that they developed independently. This study demonstrates that age will have to be considered in the type of training that the patient receives. Certain training styles may be more beneficial than others to certain age groups.

In some patients critical life events, such as cancer surgery were beneficial in improving the patient's sense of well-bring (Schwarzer et al., 2006). This study demonstrates the connection between mental state and one's overall health. The most marked improvement in attitude was in those that started out with a relatively low sense of well-being, as opposed to those that had a relatively high level before their surgery. Self-efficacy and social support also predicted benefit finding in patients who had undergone cancer surgery (Luszczynska, Mohamed, and Schwarzer, 2005). Benefit finding can be distinguished by personal growth, acceptance of life's imperfections, sensitivity to others, and improved family relationships.

Support Systems

Support is a critical factor in the success of heart patients in coping with their illness after discharge (Schulz & Schwarzer, 2004). Gender and age differences, as well as associations with mental health were considered in an assessment of support systems available. Support can be divided into four types, advice giving, assistance, reassurance, and empathic listening (Schwarzer & Gutierrez-Dona, 2005). Support came from four primary sources, friends, family, spouses and groups/organizations (Schwarzer & Gutierrez-Dona, 2005). It is not only the quantity of support that is important, but the quality of support as well. The personality qualities of partners played an important role in the coping ability of heart patients (Schroder & Schwarzer, 2001).

Older women received less suppoft from their spouses than did younger women (Schwarzer & Gutierrez-Dona, 2005). The association between spousal support and depression was significant for men, but not for women in the study (Schwarzer & Gutierrez-Dona, 2005). Understanding the types and sources of support available will be an important factor to determine in the training session. Helping the patient find the support that they need will play an important role in their ability to cope with stressful heart interventions.

Personality and Coping Skills

Personality plays an important role in the ability of the patient to cope with a mildly stressful medical procedure. Knoll, Rieckmann, & Scwarzer, (2005) identified two different types of coping skills: situation-specific coping and dispositional coping. Stress outcomes Dispositionally assessed coping did not account for various outcomes, once personality traits were controlled. Situation-specific coping mediated between personality traits and adaptational criteria.

Self-efficacy is the perception of being able to have a positive effect on the outcome of a situation. It is closely associated with self-confidence and a feeling of mental well-being. Self-efficacy is a factor in the ability to find beneficial outcomes from challenges. Those with a greater sense of self-efficacy tend to have a greater sense of benefit than those with low self-efficacy one year after cancer surgery (Luszczynska, Mohamed, & Schwarzer, 2005). These findings are consistent across multiple cultures and socioeconomic circumstances (Luszczynska, Scholz, & Schwarzer, 2005).

Exercise and changing behavior so that a patient engages in a healthy regime of exercise is a desired outcome of this research project. Predicting the level of participation in cardiac rehabilitation and identifying those at risk for failing to follow proper regimes is a key desired outcome of this proposed project. Scholz, Sniehotta, & Schwarzer (2005) examined phase-specific self-efficacy in cardiac rehabilitation patients. They examined task self-efficacy, maintenance self-efficacy, and recovery self-efficacy. This study recognized that recovery occurs in various phases. Persons in the maintenance phase benefited more from maintenance self-efficacy, while those who had to resume exercise after a break profited more from recovery self-efficacy (Scholz, Sniehotta, & Schwarzer, 2005). The most important implication of this research is that it recognized several different stages of recovery and how various interruptions in the routine can effect the ability to resume exercise.

Multidimensionl Health Locus of control (MHLC) is a concept that is similar to self-efficacy. MHLC is a relatively new concept that is closely related to health outcomes and behaviors. Self-efficacy is a generalized term that encompasses many disciplines. MHLC is culturally sensitive (Luszczynska & Schwarzer, 2005). The key to understanding MHLC is that the more a person feels they are in control of their own health, the more likely they will take positive action to change their own circumstances in a positive manner. However, because this instrument is so new, more refinement is needed in order to be beneficial from a clinical standpoint. This instrument may be useful in the future for assessing the likelihood that a patient will have a positive emotional outcome after a procedure. It may also be useful in identification of at-risk patients for poor emotional outcomes.

Habitual self-control is another concept that is related to the self-efficacy and MHLC. This term was coined by Schroder & Schwarzer (2005) as it related to heart patients. The results of this study directly relate to the training program that is being developed as a part of the proposed research study. Habitual self-control regarding health behaviors was assessed among several other trait predictors such as dispositional optimism, generalized self-efficacy beliefs, and health locus of control. This study examined outcomes such as dieting, physical exercise, and smoking in relation to the personality traits addressed. Habitual self-control was found to be a reliable predictor of the behavioral outcomes of the patient (Schroder & Schwarzer, 2005). Habitual self-control strengthens the bond between a person's intentions and actual behavioral outcomes (Schroder & Schwarzer, 2005). With long-term behavioral change as the goal of health management practices, such as the nurse training examined in this research, intention and habitual self-control will prove to be a useful tool in the future. However, as of yet, the instrument for assessment of this factor is still in development.

Perceived general self-efficacy may help a person combat stress by serving as a dispositional coping resource (Schwarzer et al., 2005). Coping appeared in the forms of planning, humor, acceptance, and accommodation to the changes after traumatic tumor surgery. Self-efficacy emerged as a personal resource factor. Although some people may have the intention to change health behaviors this is still no guarantee that they will. This is perhaps one of the most confounding occurrences in the health profession from a motivational standpoint. It would make sense to take actions to improve one's health. Yet, a person may know the risks of inaction, yet still continue to remain sedentary. There is an apparent gap between one's intentions and their behaviors. Planning, self-efficacy, and action control served as the mediators between intention to exercise and actual physical activity (Sniehotta, Scholz, & Schwarzer, 2005).

Now we understand the theories behind what factors influence a person's achievement of physical activity and other actions that will have a positive effect on their recovery. Theories regarding self-efficacy, locus of control, and motivation are not new. However, they are now beginning to gain a wider application in the field of medicine than they did in the past. Clinicians are now beginning to see the benefits of borrowing certain therapeutic techniques from the field of psychology to achieve positive motivational outcomes that will effect their patient's behavior in regards to their cardiac rehabilitation. Helping the patient to understand the importance of exercise, diet, and the need to quit smoking will give them the basic knowledge to change their behaviors. However, as this literature review points out, this is often not enough and certain techniques may be needed to help the patient achieve their behavioral goals.

Interventions to Effect Behavioral Change in Cardiac Patients key to successful cardiac rehabilitation is teaching patients how to engage in strenuous physical activity. Many patients start out with good intentions, but as time passes, their motivation to continue with the program diminishes and they no longer exercise (Sniehotta et al., 2005a). The goal of behavioral techniques is to effect a change in exercise that continues for the rest of the patient's life. The challenges and mental barriers that effect cardiac patients are similar to those experienced by athletes in their training schedule. Activities that target self-regulatory actions, such as keeping an exercise diary, are beneficial in the long-term maintenance of an exercise program (Sniehotta et al., 2005a).

Action planning and coping planning are an important part of planning for a permanent life-style change (Lippke, Zieglemann, & Schwarzer, 2004; Sniehotta et al., 2005b). Planning and Self-efficacy were found to be an important factor in the adoption and maintenance of many health behaviors, including breast self-exam (Luszcynska & Schwarzer, 2003). Coping planning refers to the mental process of overcoming barriers to action. Action plans and coping plans acted differently in effecting behavioral change. Action plans are important in the early phases of recovery after discharge, but coping plans became important in effecting change in the long-term. Patients with higher levels of coping planning were more likely to continue to follow exercise plans for a longer period of time after discharge than those with lower levels of coping planning. Obstacles are a part of any behavioral change. Coping planning plays an important role in the ability to overcome obstacles in the process (Sniehotta et al., 2005b).

It is now accepted the recovery occurs in several different stages. It is also accepted that behavioral change too, must occur in stages in order to represent a permanent behavioral change. Designign stage-specific interventions may prove to be beneficial in the intiation and maintenance of exercise programs (Lippke, Zieglemann, & Schwarzer, 2004). Lippke, Ziegelmann, & Schwarzer, (2005) introduced the three-stage model of health behavior change. This study examined the differences between intenders, non-intenders, and actors in terms of physical activity. Intenders are those that have a real intention to carry out their physical exercise routines. Non-intenders are those that have no intention of changing their behavior. Actors are those that pretend they are intenders, but in reality take actions to try to "fool" the health care professional into believing that they are following the prescribed regime.

This model measures the level of commitment to behavioral change, although it was not stated in this manner in the research. One of the most important findings in this study in relation to the proposed research is that risk awareness was an important factor in intention formation. This was true especially for those that had no intention of exercising prior to becoming aware of the risks. This is where nurse training could have the greatest impact on the patient outcome. By educating the patients about the risks of non-exercise, they could change a non-intender into an intender. This would help to improve patient outcomes and help to reduce the risk of further disease.

Health behaviors are determined by intention. Health beliefs, risk perception, expected outcomes, and self-belief play an important role in forming these intentions (Renner & Schwarzer, 2005). Intention was the mediator between self-efficacy, outcome expectations, and risk perception regarding adherence to a healthier diet. Health behavior has two distinct components; intention and action (Schwarzer, 2001).

Intention is necessary for the beginning of a behavior, but as previous research has demonstrated, those with good intentions often allow their good behaviors to fall away over time. Luazczynska et al., (2004) examined the ability of the patient to maintain attention control in pursuit of the goal. People tend to lose focus of the desired outcome, resulting in the inability to control their behaviors. The seven-item Self-Regulation Scale (SRS) was an outcome of this study. It was designed to measure attention control in the pursuit of a goal. The intention of the authors was to validate this measure as a legitimate measure. One of the key criticisms of the scale is its brevity and inability to identify specific items. It is important to gain an understanding of the instruments available, but it is also cautious to examine their merits before using them in a research project. This instrument may become useful in the future as more data becomes available on its usage.

Training and Coping Skills

The theoretical basis for the training system stems from related concepts from the field of psychology. Heart surgery patients who are trained in coping skills have lower blood pressure (National University of Singapore, 2005). Depression, anger and a lack of social support have been found to predict increased mortality in patients with heart disease (National University of Singapore, 2005). Patients with adequate coping skills demonstrated reduced psychosocial risk factors (National University of Singapore, 2005).

In a medical study conducted by the national Heart Centre in Singapore developed a program designed to help patients undergoing heart-surgery. The purpose of the study was to find a way to help them lower blood pressure and stress, thus decreasing their risk for high blood pressure. The program was called Lifeskills Workshop and focused on teaching patients appropriate coping skills. The program has demonstrated the ability to lower blood pressure and help patients deal with the stress associated with their surgery.

Heart-surgery patients and their spouses demonstrate information seeking when they have a feeling of self-sufficiency (Tuominen, 2004). Those patients that sought information about their illness demonstrated lower levels of stress than those who did not seek knowledge regarding their condition. This research supports the currently proposed research. However, the proposed research will expand on this study and will use a standardized teaching curriculum.

Theoretical / conceptual framework

The theoretical framework for this study stems from several relevant psychological concepts. The purpose of nurse training proposed in this study is to reduce anxiety levels in patient undergoing any number of invasive heart procedures. Several studies have been found that directly support the idea that information seeking in patients decreased their stress levels.

Support is an important factor in the ability to cope with the stresses associated with heart surgery. The nurse is an important part of the support team.

Stress has a negative impact on the healing process. We found that self-efficacy and an internal locus of control were important factors in the willingness to make life changes after surgery. The nurse training program is expected to reduce stress in patients. This will have a positive effect on their ability to cope with the changes that they must make after surgery.

The literature review revealed that there are several factors that could influence the willingness of the person to adhere to advice regarding exercise and diet. Research into this area is relatively new and many researchers are just beginning to develop definitions and conceptual framework to describe the mind-body connection as it applies to clinical practice. People that have undergone heart surgery or another traumatic procedure are divided into those that intend to follow the regimen and those that do not intend to follow the prescribed regimen. Education was found to be a factor in turning non-intenders into intenders.

Education plays an important role in many factors regarding the willingness to stick with changes in diet and exercise after heart surgery. Those that do not stick with the prescribed changes significantly decrease their chances of the disease continuing to progress, thus shortening their life span. Education plays an important role in informing patients about the risks of non-compliance with the post surgical recommendations.

There were several personality traits that could help to predict whether a patient would stick to the prescribed regime of exercise and diet or whether they would refuse to change. Those who felt a high degree of self-efficacy and internal locus of control were more likely to stick to changes in exercise levels and diet than those who did not feel that they has as much control. Education may help to change a person's mind about how much they can control in their own disease progress.

Education is a key factor in the success of patients in adjusting to the new routines that are necessary after heart surgery. Nurse training of patients has a sound basis, both in academic research and in the medical community. The role of education in reducing stress among patients that have undergone traumatic surgical procedures has its basis in academic research. The benefits of reducing stress and informing patients of actions that they can take to help improve the outcome of their condition are also strongly rooted in academic studies. This research has a sound theoretical basis.

This research will take the information gained in the research examined as part of the literature review and will use it in the development of a nurse training program for each of the procedures that will be used to define the sample population. The study will operationalize the information gained from the theoretical work accomplished thus far., it will put the theories that are being developed into practice. This research will expand on the existing research and help to fill in the gap represented in the literature in how to operationalize the information.

This study will integrate several related fields of study in order to develop a training program that will help to integrate this knowledge base into a technique that will help to reduce the immediate and long-term stress of heart-surgery patients. This program will attempt to change their attitudes towards the necessity to stick to prescribed diet and exercise plans. It will inform them of the risks and give them support in attaining positive goals post operatively. The training program that will be developed as a part of this research will serve as the basis for expanding other programs to help patients achieve their surgical goals.

Chapter 3: Methodology

Overview

This research focuses on the effectiveness of a nurse training program designed to reduce the stress level of patients undergoing heart surgery. The study will use a quantitative study method that uses two study groups. One will receive nurse administered training prior to their procedure. The other group will not. Prior to their discharge from the hospital, the two groups will given a survey that assesses the stress level associated with the procedure and the changes in their life after the procedure. The differences in stress level will be assessed using the State-Trait Anxiety Inventory for Adults (STAI), an instrument that has been used in the past and for which the reliability and validity are well-documented.

The research method chosen for this study was a survey designed to quantitatively compare two groups of heart surgery patients. In this case, the groups of patients that will not receive nurse training will serve as the control group. The independent variable in this study will be stress associated with the procedure or treatment that they will receive. The most important factor in the procedure is not the procedure itself, but the stress associated with it. There are many factors that could effect the stress level of patients undergoing these types of procedures. Therefore, the individual procedures will not be treated as separate, but will be analyzed in aggregate. The type of procedure will be noted, and cross tabular analysis will be performed to check for bias between the various procedures. However, it is suspected that all of the procedures will display similar characteristics as far as stress is concerned.

The dependent variable will be the nursing training that the test group receives prior to performance of the procedure. One group will receive the treatment and will serve as the test group. The group that does not receive treatment will serve as the control group. Effectiveness of the treatment procedure will be determined by the difference between the control and test groups.

If the nurse training is successful, the test group will demonstrate lower stress levels on the SAIT than the control group.

Sample Population

The sample population for this study will consist of patients that are scheduled for one or more of the following procedures at an area hospital: CABG, valve surgeries, heart transplant, PTCA, stent placement, AICD/pacemaker placement. The patients will be between 40-70 years old and will be either male or female. They will not be selected for socioeconomic status, race, or for other demographic criteria. However, this information will be gathered so that inter-group analyses can be performed in order to determine if there are differences between groups that may account for differences found in the course of the experiment. They will be eligible for in-patient procedures requiring at least a 48-hour hospital stay at the minimum. The sample population will consist of a total of 50 patients scheduled to undergo a listed procedure. Fifty patients will serve as the control group and fifty patients will serve as the test group.

Only patients who have never undergone these procedures in the past will be selected to take place in the study. Familiarity with the procedure can help to reduce anxiety, therefore patients who have experienced the procedure would be expected to have a lower stress level than those for whom this is a new experience. Using patients that have been through the experience one or more times in the past could add a source of bias to the sample population that could effect the ability to draw valid conclusions.

The sampling method can have a dramatic effect on the accuracy of the findings. Sample participants will be randomly selected and assigned to either the test or control group using random methods. The research will only select for those patients that meet the inclusion criteria. However, after the population of eligible sample participants has been identified, the participants finally chosen to participate in the study will be randomly chose. Assignment to either test or control group will be random as well. The test and control groups will be of equal size in this case.

The sample selection techniques will be what is known as probability-based sampling (Simpser, et al., 2005). Using this sampling technique, participants are pre-screened to make certain that they meet a number of eligibility requirements. This differs from non-probabiliy, or convenience samples, in that the researcher creates a pool of eligible participants, as opposed to a sampling technique where the researcher has no control over the sample population. In this study, the researcher already knows some of the characteristics of the sample population. In this case, the patients are going to undergo a surgical procedure on their heart in a hospital setting.

The sample population will have a varied knowledge level regarding the procedure that they will undergo. Some may have obtained information prior to admittance into the hospital. The sources of this information may be from friends, doctors, or the internet. The level of information that patients have prior to the procedure could effect the results of the test. However, it is also recognized that some of the information that patients receive from other sources may add to the anxiety of the patient, as they do not have thorough understanding from a person to whom they can direct questions. Some sources of information may be incorrect or incomplete, which could effect the anxiety of the patient. There is also a chance that the information that patients received prior to the procedure reduces anxiety by giving the patient a false sense of security.

There is no way to control for the prior level of knowledge of the patient. Therefore, this issue will have to be addressed as a part of the study design. In order to control for the effects of prior knowledge, all patients will be treated as if they have no prior knowledge. They will be provided correct and complete information from the nursing staff. This will help to correct for missing or incorrect knowledge obtained from other sources. The nurse will be able to address any concerns from prior knowledge and make certain that the patient has correct knowledge regarding the procedure. This will reduce the effects of prior knowledge so that the sample population has the same level of knowledge regarding their procedure.

Study Procedure

This study will take place over a period of time sufficient for all of the patients to have their procedures and arrive at the day of hospital discharge. As a part of the final research, a nurse training program will be designed for each of the procedures considered in the sample population. Each of the programs will contain the same elements. However, the information within those elements will be specific to that particular disease or procedure. The training programs will contain the following information and sections: explaining the disease process, risk/benefits of specific surgeries, what to expect before, during & after surgery, cardiac rehab, discharge planning & follow up. The training program is designed to provide the patient with complete and accurate information about their particular condition.

After an adequate sample population is identified from patients scheduled for one of the listed procedures, and the population is divided into the test and control groups, the nursing staff will receive training as to how to administer the nursing training. They will be provided with a manual and training procedure that gives them step-by-step instructions, scripts to follow, and visuals to help in the training process.