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Early education and counselling of patients with acute coronary syndrome. A


pilot study for a randomized controlled trial

Article  in  European Journal of Cardiovascular Nursing · October 2014


DOI: 10.1177/1474515114556713 · Source: PubMed

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European Journal of Cardiovascular Nursing
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Early education and counselling of patients with acute coronary syndrome. A pilot study for a
randomized controlled trial
Lukas Weibel, Paola Massarotto, Hannele Hediger and Romy Mahrer-Imhof
Eur J Cardiovasc Nurs published online 23 October 2014
DOI: 10.1177/1474515114556713

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research-article2014
CNU0010.1177/1474515114556713European Journal of Cardiovascular NursingWeibel et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

Early education and counselling


1­–10
© The European Society of Cardiology 2014
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of patients with acute coronary sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1474515114556713

syndrome. A pilot study for a cnu.sagepub.com

randomized controlled trial

Lukas Weibel1,2, Paola Massarotto1, Hannele Hediger2 and Romy


Mahrer-Imhof2

Abstract
Background: At time of discharge, patients with acute coronary syndrome often have a knowledge deficit regarding
their disease, further treatment and necessary behavioural changes. It is well known that self-efficacy as a prerequisite for
behavioural changes can be influenced by patient education. This study investigated whether an individualized education
programme starting early in the cardiac care unit enhanced self-efficacy and rehabilitation programme attendance, and
was feasible and satisfying for patients.
Methods and design: In a pilot randomized controlled trial, 40 patients with acute coronary syndrome were enrolled.
The intervention group received in addition to standard care an early individual needs-oriented educational session in
the cardiac care unit and subsequently one on the ward addressing risk factors, medication and self-management as well
as referral to a rehabilitation programme by a nurse. Self-efficacy was assessed twice, at attendance in a rehabilitation
programme six weeks after discharge. The participants’ satisfaction with the intervention was assessed qualitatively.
Results: When controlling for anxiety and depression, the intervention group showed significant better self-efficacy
scores on the ability to control the symptoms (p=0.034). When controlling additionally for age, no significant differences
could be detected. The attendance of a rehabilitation programme was higher in the intervention group. The participants
in the intervention group reported high satisfaction with the early education.
Conclusion: Early education seems to benefit patients with acute coronary syndrome. In light of increased confidence
to control one’s symptoms and the higher attendance in rehabilitation programmes, as well as a high satisfaction with
the intervention, a full powered study will be pursued.

Keywords
Education, counselling, early, self-efficacy, patient-centredness, acute coronary syndrome

Date received: 24 May 2014; revised: 26 September 2014; accepted: 3 October 2014

Introduction
Cardiovascular disease remains, with almost 1.8 million deaths infarction (NSTEMI) and angina pectoris. Immediate medical
per year, the leading cause of mortality in Europe, and places a attention is necessary when symptoms are experienced.
substantial burden on the health care systems and economies
of Europe.1 According to the Federal Statistical Office,2 cardi- 1MedicalIntensive Care Unit, University Hospital Basel, Switzerland
ovascular disease is also the leading cause of death in 2Institute
of Nursing, Zurich University of Applied Sciences,
Switzerland. In 2010, 14.1% of deaths per 100,000 inhabitants Winterthur, Switzerland
were due to ischaemic heart disease. In Switzerland 36,353
Corresponding author:
persons were hospitalized with acute coronary syndrome Lukas Weibel, Coronary Care Unit, University Hospital Basel,
(ACS) in 2009. This umbrella diagnosis covers ST elevation Petersgraben 4, CH-4031 Basel, Switzerland.
myocardial infarction (STEMI), non-ST elevation myocardial Email: Lukas.Weibel@usb.ch

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2 European Journal of Cardiovascular Nursing

However, in spite of symptoms such as excruciating patients with ACS.32 For various chronic conditions, it has
pain, patients with ACS often delay seeking hospital treat- been shown that increased self-efficacy is associated with
ment. Delays were also observed in patients who had pre- improved self-management.33-36
viously suffered myocardial infarction, which indicates In order to improve self-efficacy and eventually the will
that patients should be better prepared to respond to to attend rehabilitation and enhance self-management, indi-
another cardiac event.3 Studies have shown that patients vidualized education and counselling has been proven to be
with ACS often have a knowledge deficit regarding their essential.18,37 Patients’ needs are individual and subjective38
illness and treatment, risk factors and recommended life- and determined by sex,39 age and severity of disease.40
style changes at discharge.4-6 Dracup7 found that 46% of Timmins41 emphasized that the desire for information
patients had low levels of knowledge about ACS. Studies expressed by the patient is of major importance. Turton42
indicated that knowledge influences patients’ understand- developed the Cardiac Patients Learning Needs Inventory
ing and day-to-day behaviour.8-10 The ability to absorb (CPLNI), a standardized instrument to assess those patients’
information and to comply with behavioural changes has information needs.
been shown to be influenced by psychosocial factors and In light of expected reduction of hospital length of stay
peoples’ characteristics. For example depression has been due to fast symptom relief through coronary angioplasty as
shown not only to be associated with increased risk of inci- standard therapy, condensed but also very early interven-
dent coronary heart disease11,12 but also to be associated tion becomes pivotal. Patients might be ready to absorb
with poorer prognosis.13,14 information at an early stage of their hospital stay with the
Lack of knowledge may affect patients’ awareness of aim to prevent readmissions and to provide support for
risk factors, health behaviour and compliance with drug behavioural change. The goal of early education is to
therapy. Increasing evidence indicates that psychosocial improve patients’ knowledge of their disease and treat-
factors such as depression and anxiety can worsen the ment, but also to strengthen patients’ beliefs in their own
prognosis of coronary heart disease.15 capabilities to cope more effectively with ACS and plan
Patient education has been shown to be an important for their future after discharge from hospital.
component of treatment and care, addressing knowledge An early individualized patient education intervention
deficits and facilitating behavioural changes.16-18 that permitted shared decision making aiming to promote
Cardiac rehabilitation programmes were designed for patient self-efficacy and facilitate patient self-management
these patient groups and have been proven to help reduce has been developed.
overall mortality, risk of re-infarction19 and rates of rehos- The purpose of the study was to pilot test this early
pitalization within 12 months20 and thus represent an patient education intervention. It has been hypothesized
effective intervention for patients with coronary heart dis- that self-efficacy and hence participation in rehabilitation
ease. Heran et al.20 demonstrated that cardiac rehabilita- programmes would be increased in patients with ACS.
tion was associated with improved quality of life in seven Additionally, investigation has been made into whether
of 10 studies. Research on centre-based and home-based patients in the intervention group were satisfied with the
rehabilitation programmes focusing on diet and exercise21 intervention.
has demonstrated positive effects on desired behavioural
changes. The responsible mechanisms for the positive ben-
Methods
efits of cardiovascular rehabilitation are multifactorial and
include a reduction in cardiovascular disease risk factors, A randomized controlled trial was pilot tested at the
improved diastolic function, positive ventricular remodel- Coronary Care Unit (CCU) and medical wards of a Swiss
ling after heart attack, improvement of endothelial func- university hospital between October 2011 and April 2012.
tion and inflammatory status and improved electrical Patients diagnosed with ACS, hospitalized in the CCU and
stability of the myocardium.22-26 In spite of these encour- projected to stay in the university hospital throughout the
aging findings, studies in various countries have shown entire hospitalization were eligible to participate in this
that only 14–43% of eligible patients participate in cardiac study. They had to have adequate knowledge of written
rehabilitation programmes.27-29 and spoken German. Patients with cardiovascular instabil-
A study by Lau-Walker30 concluded that early interven- ity (systolic blood pressure<90 mmHg and >150 mmHg),
tions designed to address individuals’ sense of control severe arrhythmia, life-sustaining devices (Impella®,
could increase the attendance and effects of rehabilitation IABP), low oxygen saturation (<90%) increased New
programmes. York Heart Association (NYHA) class (> 1) or confused
Self-efficacy seems to be an important factor in pursu- patients, assessed with the Intensive Care Delirium
ing behavioural changes. The aim of patient education was Screening Checklist (ICDSC; ≥ 4), were excluded.
to enhance patients’ perceived self-efficacy, as self- On the basis of calculations with G*Power3,43 we
efficacy beliefs determined health behaviour.31 Higher assumed that a sample size of 40 allowed to show an effect
self-efficacy was associated with better health status in of 0.40 (Cohen’s f = 0.40) in a repeated measures analysis

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Weibel et al. 3

Enrolment
Assessed for eligibility (n = 42)

Excluded (n = 2)
♦ Declined to participate (n = 2)

Randomized (n = 40)

Allocation
Allocated to intervention (n = 20) Allocated to control (n = 20)
♦ Received allocated intervention Part 1 (n = 20)
♦ Received allocated intervention (n = 20)
♦ Received allocated intervention Part 2 (n = 19) ♦ Did not receive allocated intervention (left
♦ One did not receive allocated intervention Part 2 hospital before second measurement) (n = 1)
(transfer to other hospital) (n = 1)

Analysis
Analysed (n = 19) Analysed (n = 19)

Figure 1.  CONSORT 2010 flow diagram.

of variance and an effect of 0.50 (Cohen’s d = 0.5) in a whether patients were participating or had participated in
dependent t-test, with a power of 0.8 and α = 0.05.44 an inpatient or outpatient rehabilitation programme.
The investigation conforms with the principles outlined
in the Declaration of Helsinki.45 The study was approved
Intervention
by the Ethics Committee Canton Basel, Switzerland (Ref.
Nr.EK:332/11). Control group. The participants in the control group
received standard care, consisting of information provided
during the attending physician’s daily rounds and through
Recruitment and data collection procedures an information booklet. The individual risk factors were
After patients gave informed consent, baseline data was highlighted to each patient.
collected in the CCU and patients were assigned to the
intervention or control group by block randomization (see Intervention group.  In addition to standard care, the inter-
Figure 1). Five blocks with eight mixed (control/interven- vention group (IG) received two individually-targeted
tion) envelopes were formed. educational sessions.
Baseline data collection covered a demographic ques-
tionnaire and case history data, self efficacy assessed First intervention. The first intervention was scheduled
with the Cardiac Self-Efficacy Scale (13 questions) and within 48 h after patients had completed the Cardiac
depression and anxiety with the HADS scale (14 ques- Patient Learning Needs Inventory (CPLNI) whilst in the
tions). After the randomization, patients were informed CCU, indicating their individual information needs.42
about their assignment to the intervention or the control The CPLNI consists of 37 questions and emphasizes
group. the following topics: anatomy and physiology (five items),
Prior to discharge, all the study participants completed psychological factors (four items), risk factors (three
the Cardiac Self-Efficacy and Hospital Anxiety and items), medication information (five items), diet informa-
Depression Scale–Deutsche (HADS-D) scales for a sec- tion (five items), physical activity (six items), symptom
ond time. Three weeks after discharge, the telephone fol- management (six items) and other pertinent information
low-up was conducted by a study nurse to determine (three items).

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4 European Journal of Cardiovascular Nursing

The questionnaire has content validity assessed by HADS German version (HADS-D).  HADS is a tool to assess
medical doctors and specialized nurses. The suitability of anxiety and depression. The questionnaire comprises 14
the CPLNI questionnaire for use in Switzerland has been questions.50 The HADS German version has been vali-
tested. The results showed that the patients could indicate dated in almost 6200 patients with cardiac as well as other
their information needs.46 internal or psychiatric conditions and often applied clini-
The CPLNI allows marking on a Likert scale (1–5) how cally. For the subscale anxiety, Cronbach’s α was 0.80, for
important the question is to the user at this point in time. the subscale depression, Cronbach’s α was 0.81.51,52
After having decided on the importance of each of the 37 In our study, the HADS-D scale had a Cronbach’s α of
questions, the participants in the IG subsequently received 0.85 at T0 and 0.84 at T1.
individual needs-based education from the first author on
every topic assessed with four or five points on the scale.
Attendance to rehabilitation
To ensure consistent quality of education, a manual was
prepared, containing the answers to the 37 questions. The Data collection of patients participating in a local rehabili-
manual included graphics, enabling participants to visual- tation programmes was supported by the rehabilitation
ize the disease process. team. The data were extracted from the medical records,
assessing attendance and completion of the programme.
Second intervention.  The second individual education inter- Data from two patients who attended another programme
vention was performed by the first author face to face on the were provided by themselves.
day before discharge on the medical ward. Individual risk
factors, current cardiac medication and personal disease
management barriers and facilitators were addressed. In
Data analysis
connection with personal disease management, the topics of Intervention and control group data were analysed descrip-
increasing physical activity and the appropriate response to tively (frequency, mean, median, standard deviation and
future chest pain were discussed. Concluding participation range). Various tests were used for group comparisons,
in a rehabilitation programme was recommended. depending on the data level (t-test, Mann–Whitney U test
The two education interventions each lasted about 30 and chi-square test). The significance level was set at
minutes. Due to the monitoring and given structures of the p<0.05. In view of the assumption (based on the literature)
CCU, privacy could not always be guaranteed in the first that self-efficacy is increased as a result of the educational
intervention. The second intervention, however, took place intervention, one-sided tests of significance were used.
on the ward in a specially reserved room. Power53 was calculated using the free program G*Power43
from Düsseldorf University. To answer the broader study
question, analysis of covariance was used – repeated meas-
Data collection ures ANCOVA, in which the HADS anxiety and depres-
Cardiac Self-Efficacy Scale.  The Cardiac Self-Efficacy Scale sion subscales were used as covariates.
measures self-efficacy and comprises two subscales: Attendance to the rehabilitation programme and patient
‘Control symptoms’ and ‘Maintain function’. ‘Control satisfaction were descriptively analysed. For categorizing
symptoms’ includes eight questions on a Likert scale of the participation we created four groups: ‘full outpatient
1–5 (score 8–40) with an emphasis on handling with pain rehabilitation’ (>90% attendance), ‘partial outpatient reha-
and shortness of breath, consulting the doctor, taking the bilitation’ (<60% attendance), ‘inpatient rehabilitation’
medicine and physical activity during hospitalization. A and ‘no rehabilitation’. IG patients were additionally asked
higher score means more confidence to manage the symp- to rate the quality of the intervention.
toms properly. The factor ‘Maintain function’ includes In the statistical analysis of the rehabilitation data using
five questions on a Likert scale of 1–5 (score 5–25) a contingency table, cell frequency was found to be too
addressing maintaining social activity, maintaining activ- low to permit detection of significant group differences.
ity at home and outside of the home, sexual activity and The data were therefore analysed in terms of frequencies.
exercise. A higher score indicates more confidence to per- The IBM Statistical Package for Social Sciences, ver-
form activities adequately. The internal consistency of the sion 19.0 (SPSS 19.0) was used for data analysis.
two factors is reported to be high – Cronbach’s α = 0.90 for
‘Control symptoms’ and 0.87 for ‘Maintain function’ –
Results
and validity is described as good.47 In our study the Ger-
man version of the Cardiac Self-Efficacy Scale had a Sociodemographic data
Cronbach’s α of 0.85 respectively 0.90.
Sullivan’s Cardiac Self-Efficacy Scale was translated Forty patients were enrolled in the study. Two persons
into German and back-translated by the first author48 were lost to follow-up due to unexpected discharge from
according to Brislin’s protocol.49 hospital. One person was unexpectedly transferred to a

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Weibel et al. 5

hospital close to his place of residence, which made con- differences were found when we controlled for anxiety and
tinued participation impossible. The other person left hos- depression.
pital early and thus missed the second intervention and the When we controlled for age, the effect of the interven-
pre-discharge data collection. Ultimately, the analyses tion was no longer significant, neither in ‘Control symp-
were performed with a total of 38 complete datasets (19 toms’ (p=0.178) nor ‘Maintain function’ (p=0.642) nor
per group; see Table 1). ‘Total self-efficacy’ (p=0.262).
Nine women and 29 men participated. NSTEMI was
diagnosed in 20 and STEMI in 18 patients, and these diag-
Rehabilitation
noses were identically represented in both groups. All
characteristics were evenly distributed between both More participants of the IG participated in a rehabilitation
groups; they differ significantly only in age. programme. ‘No rehabilitation’ was reported by 26.3% in
Self-efficacy ratings were analysed for the two sub- the CG group and 5.3% in the IG. ‘Inpatient rehabilitation’
scales ‘Control symptoms’ and ‘Maintain function’ (see was undergone by 31.5% in the CG vs. 21.1% in the IG.
Table 2). At baseline the mean scores did not differ signifi- ‘Partial outpatient rehabilitation’ was reported by 21.1% in
cantly between groups although the mean score on the CG and 26.3% in the IG, while 21.1% in the CG vs.
‘Maintain function’ was slightly higher in the intervention 47.3% in the IG completed an outpatient rehabilitation
group (14.74 (SD ±1.66) IG vs. 12.53 (SD ±4.01) control programme (see Figure 2).
group (CG)).
At follow-up the mean score on the subscale ‘Control
Patient satisfaction
symptoms’ increased in both groups (26.0 (SD ±4.59) in
the CG, and 28.0 (SD ±2.78) in the IG) indicating higher In general, immediately after the intervention, patients
self-efficacy. On the subscale ‘Maintain function’ the expressed their gratitude for the individual attention and
scores were practically unchanged in the CG (12.95 the large amount of helpful information they had received
(SD±3.74) vs. 12.53 (SD±4.01)) whereas they increased in directly from the first author. In the telephone interviews
the IG (14.74 (SD±1.66) vs. 16.42 (SD ±2.43)), indicating 16 participants of the IG described to the independent
higher self-efficacy. interviewer the intervention as timely and thus not too
The scores for anxiety were lower in the CG compared early. In these interviews, the comprehensiveness and
with the IG (5.79 (SD ±3.91) vs. 6.16 (SD ±4.22) and quality of the education were also very highly evaluated.
depression was slightly higher in the CG compared with
the IG (4.16±2.58 vs. 3.79±2.84). For the depression sub-
Discussion
scale, the mean value T1 was 4.16 (SD ±2.83) in the CG,
compared with 2.84 (SD ±2.14) in the IG. The pilot study examined whether early education and
According to the Shapiro–Wilk test, the intervention counselling of patients with ACS could lead to an increase
and control groups were normally distributed regarding in self-efficacy and could promote better participation in
Self-Efficacy Scale ‘Control symptoms’, ‘Maintain func- rehabilitation programmes and whether such an early
tion’ and ‘Total’ and the HADS depression subscale. Only intervention finds acceptance by the patients. Since we
the HADS anxiety subscale failed to show a normal distri- assumed that an acute event of ACS could lead to anxiety
bution. Given the equally sized groups, the homogenous and depression, we controlled for these factors. According
regression slopes within and between groups and over to Bandura55 an increase in self-efficacy is the basis for
time, the normal distribution of residuals and the fact that future behavioural changes. Sol et al.56 successfully dem-
analysis of covariance is an extremely robust method,54 onstrated that improved self-efficacy had an impact on
repeated measures analysis of covariance were used with- patients’ health behaviour, namely that it led to more exer-
out any reservations. cise and better food choices. The preliminary data of this
Repeated measures analysis of variance (see Table 3) pilot study revealed that the intervention had an effect on
showed a significant difference (p= 0.034) between the CG self-efficacy even in such a small sample of 19 partici-
and the IG on the subscale for self-efficacy ‘Control symp- pants in each group. As we pointed out in the IG, a signifi-
toms’ (T0 24.74±5.43/T1 26.00± 4.59 vs. T0 24.32±2.70/ cant increase, compared with the CG, was observed for
T1 28.0±2.78) but no difference could be detected on the ‘Control symptoms’, one of the two self-efficacy sub-
subscale for self-efficacy ‘Maintain function’ (p= 0.164). scales. This positive effect was still significant when the
The significant difference between the CG and IG was two factors anxiety and depression were used as covari-
stable for the self-efficacy ‘Control symptoms’ subscale ates. For ‘Maintain function’ – the second self-efficacy
when we controlled for anxiety (p= 0.036) and depression subscale – no significant difference was seen between the
(p= 0.041). Even when the anxiety and depression were control and intervention groups. These contrasting find-
simultaneously taken into account a significant difference ings can be explained by the content of the two subscales
was found (p= 0.036). For the ‘Maintain function’ scale no and the nature of the intervention. The education covered

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6 European Journal of Cardiovascular Nursing

Table 1.  Baseline characteristics of the study population.

Control group n=19 Intervention group n=19 p-value


Age, years 72.11 44–85 (R) 59.68 35–77 (R) 0.001*a
Sex 0.056b
 Women 7 36.8% 2 10.5%  
 Men 12 63.2% 17 89.5%  
Living 0.457b
arrangements
 Alone 6 31.6% 4 21.1% Alone
  Not alone 12 63.2% 14 73.7% Not alone
Education 0.751c
 No school-leaving 1 5.3% 1 5.3%  
qualification
 Completed 2 10.5% 0 0%  
compulsory
education
 Apprenticeship 9 47.4% 10 52.6%  
  Secondary school 1 5.3% 2 10.5%  
 Higher vocational 2 10.5% 2 10.5%  
training
 University 1 5.3% 4 21.1%  
 Doctorate 3 15.8% 0 0%  
Diagnosis 1.0b
 NSTEMI 10 52.6% 10 52.6%  
 STEMI 9 47.4% 9 47.4%  
Coronary heart 0.210b
disease
  One-vessel disease 3 15.8% 6 31.6%  
  Two-vessel disease 6 31.6% 9 47.4%  
 Three-vessel 9 47.4% 4 21.1%  
disease
BMI 0.447c
 Normal weight 7 36.8% 10 52.6%  
18.6–24.9
 Overweight 7 36.8% 4 21.1%  
25.0–29.9
 Class I obesity 2 10.5% 3 15.8%  
30.0–34.9
 Class II obesity 2 10.5% 2 10.5%  
35.0–39.9
 Class III obesity > 1 5.3% 0 0%  
40.0
Smoking status 0.136b
 Non-smoker 8 42.1% 7 36.8%  
 Smoker 2 10.5% 7 36.8%  
  Former smoker 9 47.4% 5 26.3%  
CK enzymes 1.0b
 <1000 15 79.0% 15 79.0%  
 >1000 4 21.0% 4 21.0%  
at-test.
bChi-square test.
cMann–Whitney U test.
*p<0.05.
Source: University Hospital Basel, Switzerland.
R: range; STEMI: ST elevation myocardial infarction; NSTEMI: non-ST elevation myocardial infarction; BMI: body mass index; CK: creatinine kinase

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Weibel et al. 7

Table 2.  Differences in self-efficacy (Self-Efficacy Scale), anxiety and depression (HADS) between T0 and T1.

Control group n=19 Intervention group n=19

  Baseline T0 T1 Baseline T0 T1
Self-Efficacy Control symptoms 24.74±5.43 26.00±4.59 24.32±2.70 28.00±2.78
Scale Maintain function 12.53±4.01 12.95±3.74 14.74±1.66 16.42±2.43
  Total 37.26±8.81 38.94±7.85 39.06±3.06 44.42±4.42
HADS Anxiety 5.79±3.91 4.32±3.54 6.16±4.22 4.21±3.99
  Depression 4.16±2.58 4.16±2.83 3.79±2.84 2.84±2.14

Source: University Hospital Basel, Switzerland.

Table 3.  Analysis of variance and covariance.

Variable Fdf p Cohen’s f Power


Analysis of Variance (ANOVA)
Self-Efficacy Scale, Symptom control (group/time) F1,38=4.845 0.034* 0.367  
Self-Efficacy Scale, Maintain function (group/time) F1,38=2.016 0.164 0.236 0.282
Self-Efficacy Scale, Total (group/time) F1,38=4.621 0.038* 0.358  
Analysis of Covariance (ANCOVA) with covariate anxiety and depression_Total_T1
Self-Efficacy Scale, Symptom control – Anxiety + F1,38=4.755 0.036* 0.369  
Depression (group/time)
Self-Efficacy Scale, Maintain function – Anxiety + F1,38=1.965 0.170 0.236 0.276
Depression (group/time)
Self-Efficacy Scale, Total – Anxiety – Depression F1,38=4.430 0.040* 0.360  
(group/time)
Analysis of Covariance (ANCOVA) with covariate age
Self-Efficacy Scale, Symptom control – age F1,38=1.893 0.178 0.231 0.268
(group/time)
Self-Efficacy Scale, Maintain function – age F1,38=0.220 0.642 0.078 0.074
(group/time)
Self-Efficacy Scale, Total – age (group/time) F1,38=1.297 0.262 0.193 0.198

*p<0.05.
Source: University Hospital Basel, Switzerland.

Figure 2.  Rehabilitation participation.


Source: University Hospital Basel, Switzerland.

mainly compliance with treatment, awareness of individ- differences appeared in the subscale ‘Control symptoms’,
ual exercise limits and associated exertion-induced symp- which addresses these topics. The subscale ‘Maintain
toms, and adaptation of activities to the new situation. function’ addresses maintaining social activity, activity at
Therefore, we were not surprised that the detected home and outside of the home, sexual and physical

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8 European Journal of Cardiovascular Nursing

activity. Those activities were of less immediate concern rehabilitation programmes. The positive feedback received
to patients during their hospital stay and therefore had from participants in the IG indicated that early education
been given less weight in the education. and counselling has been well accepted and has been per-
It is a limitation of the study that despite randomization ceived as valuable by patients.
an uneven age distribution in the two groups could not be
avoided. Analysis of covariance showed that the effect of
education was lost when age was added to the equation. Implications for practice
These findings may suggest that age does influence the
self-efficacy education effect. However, the influence of •• ACS patients benefit from individualized educa-
age might also only be due to the unequal distribution of tion in CCU.
age in the two groups. A power analysis pointed to a sam- •• Patients can express their educational needs
ple size of 200 being required to demonstrate a small effect early.
(Cohen’s f = 0.1) with a power of 0.8. •• Early education enhances attendance to rehabili-
Grace et al.57 recommend in the Canadian Cardiovascular tation programmes.
Society position paper the use of innovative and system-
atic referral strategies to Cardiac Rehabilitation pro-
grammes, including a discussion at the bedside. We applied Acknowledgements
these recommendations to the IG. Patients in the IG hence Thanks to S Piazzalonga and Dr O Pfister from the Rehabilitation
showed higher attendance to the rehabilitation programmes Team for their support in access and data collection of patients
and fewer patients declined rehabilitation compared with participating in rehabilitation programmes.
the CG. The positive results allay any concerns raised by
the fact that the first intervention occurred within the first Conflict of interest
48 hours in the CCU. The patients appeared to be highly The authors declare that there is no conflict of interest.
receptive in spite or perhaps because of their acute per-
sonal situation. Mentrup and Schnepp58 showed in their Funding
review that disturbed feelings quickly eased after primary This research received no specific grant from any funding agency
percutaneous interventions and did not mirror the serious- in the public, commercial, or not-for-profit sectors.
ness of the diagnosis of a myocardial infarction. These
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