Roger M. Weetch, BSc (Health Studies), Dip Health Studies, RN.
Staff Nurse, Coronary Care/Cardiology Ward, Bradford Royal InfirmaryMore than 1.4 million people in England suffer from angina (Department of Health, 2000), with an additional 20 000 being diagnosed every year. The British Heart Foundation provides recent figures for the UK: 1 million men and 0.9 million women, with 335 000 new cases a year (Peterson et al, 2003). Angina is central chest pain brought on by stress or exertion and is relieved by rest. It can be caused or exacerbated by anaemia, aortic stenosis and hypertrophic cardiomyopathy.
More than 1.4 million people in England suffer from angina (Department of Health, 2000), with an additional 20 000 being diagnosed every year. The British Heart Foundation provides recent figures for the UK: 1 million men and 0.9 million women, with 335 000 new cases a year (Peterson et al, 2003). Angina is central chest pain brought on by stress or exertion and is relieved by rest. It can be caused or exacerbated by anaemia, aortic stenosis and hypertrophic cardiomyopathy.
Stable angina is normally a symptom of the gradual and progressive narrowing of the coronary arteries by atheroma, reducing the supply of blood to the heart and causing ischaemia at times of increased activity or stress. It is often the starting point for coronary heart disease. Beyond this are the acute coronary syndromes, ranging from unstable angina to myocardial infarction (MI) where a thrombus or ruptured atheromatous plaque causes rapid occlusion of a coronary artery.
Following initial assessment and treatment based on symptoms and history, patients admitted to a coronary care ward in the author's hospital with acute chest pain are screened by testing their blood enzyme levels to determine whether they have had an MI. If there is no rise in cardiac enzyme levels and the patient is diagnosed as experiencing an episode of angina, the amount of education and information given is much more limited. While the care pathway form for non-MI chest pain patients includes a space for 'discussion of risk factors' and there are booklets available, much less emphasis is placed on this than for patients who have experienced an MI.
It is known that patients often do not easily absorb information given during a hospital admission (Ley, 1988). While some may not want information, for most there is so much to cope with that they are simply overloaded and find it difficult to concentrate. Nurses may not always take the time needed or present information in a way that patients can understand. Many patients may need several approaches and to be taught by a number of different means if they are to take it in. Thus, even if nurses feel that they have provided information, patients may leave hospital feeling dissatisfied with the information they have been given about their condition and how to cope with it.
This study was intended to determine the level of satisfaction of patients with the amount and quality of information that they receive. It was intended that the results would enable the nursing staff to review practice in relation to the provision of the appropriate level, type and quality of information and education given to patients with angina.
As Fitzpatrick (1993) states, 'patient satisfaction' is a frequently used term that is rarely defined. It indicates the level of contentment of patients with the aspect of service being considered and therefore includes not only a cognitive component (involving thinking and reasoning) but also an affective one (involving the emotions). Assessing patient satisfaction with information received therefore involves both an objective consideration of the amount and quality of the information absorbed and also the emotional reaction to it. In other words, it is trying to measure a subjective response.
There was no literature found that specifically related to patient satisfaction with information received in hospital following a diagnosis of angina. Studies that have been undertaken mainly concern the preparation for angioplasty or surgery. A study of patients by Smith et al (1997) found a positive correlation between patient satisfaction with education and advice and their overall health outcome. A study of male MI patients under the age of 66 and their spouses (Thompson et al, 1990) showed increased satisfaction with overall care among those receiving additional education. Ley (1988) notes that patients often forget information that is given in hospital. In addition, there may be a failure of understanding, particularly if the information given does not fit into the patient's existing framework of belief (Ley, 1988). Patients may also be reluctant to ask questions. Ley (1988) demonstrates the importance of good communication by listing a number of studies which show a high correlation between this and overall patient satisfaction.
Information should be conveyed by a combination of oral and written means (Ellis et al, 1979) Arthur's (1995) review of written patient information suggests that patient satisfaction is increased by the provision of clear, easily understood material but that most literature aimed at patients is not evaluated for its effectiveness. There are booklets on angina available in the ward, which may or may not be appropriate and nurses should be available to check on a patient's understanding but, with other pressures, this may or may not be possible.
Poor communication has been identified as a major source of dissatisfaction with health care (Lamont, 1993). It seemed appropriate therefore to undertake a study to identify the current position.
As the study aimed to measure a subjective reaction by patients the appropriate method was to undertake a patient survey (Parahoo, 1993). This was done by questionnaire (Figure 1) and the results analysed quantitatively. Qualitative themes for further study were also identified.
The population to be studied were patients suffering from angina who had been hospitalised in the coronary care ward. A convenience sample was taken of those admitted during the time allocated to carry out the study. It was hoped to recruit between 20 and 30 participants initially. All patients discharged from the ward with a diagnosis of angina during the study were asked to participate. They were given a letter of explanation, together with a questionnaire and a stamped addressed return envelope. Assurances were given about the confidentiality of their replies and their anonymity. Previous MI, coronary artery bypass and angioplasty patients were given questionnaires for comparison of their responses.
Permission for the study was obtained from the local ethics committee and Medical Research Council guidelines were followed (MRC, 1994).
Thirty patients were identified as having been discharged with a diagnosis of angina during a three-month period and were issued with a questionnaire, of which 16 were returned (53.3%). Seven of these 16 respondents had previously been hospitalised with an MI; eight had angina but no previous MI. One respondent denied all knowledge of having angina and returned a blank questionnaire. The average age of the respondents was 59.7 years, with an age range of 40 to 78. Some 60% of the respondents were male and 40% were female.
The results show a very high level of satisfaction with the overall standard of care (Figure 1). While this was a very general phrase that might have meant different things to different people, the response suggests that any criticism of specific aspects of care should be taken at face value and does not represent general dissatisfaction. The results showed a wide variation of responses with satisfaction slightly above midpoint. Specifically, 73% felt that they needed more information about the effect of angina on their daily activities.
There were significant differences between the results of those patients who had previously had an MI and those who had angina. Those who had previously had an MI were far more satisfied with the information provided, citing the benefits gained from the additional information and advice given during rehabilitation. There were similarities in the responses made by both groups when asked about how approachable nursing staff were, with many agreeing with the statement 'I did not ask any questions because I thought that the staff were too busy'. Most participants agreed that nurses gave them the opportunity to ask questions; however, many, particularly those who had not had an MI, wanted more written and verbal information. Another significant finding was the lack of satisfaction with the information that patients had received from health professionals working in primary care settings.
The concern expressed about the lack of information received from primary care professionals is significant. In a study by MacDermott (2001) it was found that 80% of patients with angina are dealt with in the primary care sector and only receive secondary care if their angina becomes unstable. Patients therefore need to be informed of their condition and how to manage it. The National Service Framework for Coronary Heart Disease (DoH, 2000) calls for a written protocol for those with suspected angina to be drawn up by each primary care practice, which should include lifestyle advice.
The results showed a significant gap in knowledge between those who had previously had an MI and other angina sufferers. More attention therefore needs to be paid to the education of those diagnosed with angina. In particular, patients expressed the need for more information regarding the effect of angina on their daily lives and how to cope with it. It is suggested that this process could be initiated in the ward for patients hospitalised with unstable angina.
It is important that patients are directly informed of the risk factors identified through blood tests. The main controllable risk factors are smoking, obesity, hypertension, cholesterolaemia and diabetes (DoH, 2000). Booklets from the British Heart Foundation are available on each of these topics and should be given to patients.
A single means of conveying information is not always effective (Ley, 1988). It is not sufficient to simply give written information, even with the injunction to ask questions after reading. Verbal information must also be conveyed and nurses must make a deliberate approach to patients to prompt discussion several times during their stay. Some patients clearly feel diffident about taking up nurses' time with talking and need the nurse to take the initiative in promoting conversation. Nurses must show by their attentiveness (Egan, 1990) that they are listening. Another method of presenting information would be the use of video recordings, perhaps showing angina sufferers talking about how they live with their condition. Experience in the ward has shown this to be effective with MI patients.
Some of the respondents had required others to help them complete the questionnaire due to poor eyesight and, in some cases, because English was not their first language. This too has implications for the nature of the information provided for patients which should be addressed such as the need for information in large print and in other languages. Relying on patients' relatives to translate information can bring additional difficulties (Ramtohul, 1993), including a lack of understanding or mistranslation of medical information. Instead of involving the translation services only where essential, it could be helpful to used trained translators familiar with medical terminology for this role.
This study showed that patients who had been hospitalised with angina were dissatisfied with the amount of information that they were given. They wanted to know more about the causes of angina, its treatment, their medication and, in particular, the effect it will have on their daily activities.
Nurses need to be proactive in ensuring that patients are given information about angina and opportunities to ask questions. Patients may be frightened and unsure about the future. Nurses need to be sympathetic listeners and allow patients the opportunity for catharsis (Heron, 1990).
Nurses need to consider the timing and ways of approaching patients. A patient in pain is unlikely to be receptive to lectures about smoking cessation. A patient may not ask questions of a nurse who appears to be busy. If behavioural changes are needed for improved health then the patient may need to go through several different stages such as pre-contemplation, contemplation, action and maintenance to achieve change (Prochaska and DiClemente, 1986). Whether or not they had previously considered changing, the admission to hospital and diagnosis may make them open to the contemplative stage. In order to move from there to the action stage they need to be convinced of the benefits and the possibility of changing.
Hospitalisation may provide the opportunity to initiate the action but this will need to be maintained once the patient returns home. The survey results indicate that patients want more information and may therefore be prepared to act on it.
Statistically a further study is needed to confirm the findings of this survey. However, this study has provided a useful review of existing mechanisms of patient education which we have used to improve care. Box 1 lists the main recommendation of the study and Box 2 details recent developments in the care of patients presenting with pain.
Communication with patients is clearly of great importance. As Ley and Llewelyn (1995) point out, improved communication leads to increased patient knowledge and recall of information, greater patient compliance, a quicker recovery and increased patient satisfaction.
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