Abstract
Background: Cardiac rehabilitation programmes are widely accepted as being of benefit to patients with cardiac disease. The time spent waiting for cardiac surgery can be extremely stressful but can be used to address risk factors and provide information to reduce anxiety and prepare the patient for surgery. Aims: To pilot the usefulness of a manual for pre-operative cardiac surgical patients, and assess the feasibility and usefulness to both nurses and patients of a monthly education and support programme for patients waiting for cardiac surgery. Methods: A pilot study of 42 patients followed up for 3 months. Research tools included patient questionnaires and telephone interviews, risk factor measurements and nurse focus groups. Results: Nurses and patients evaluated the manual and overall programme favourably, although the nurses found it was very labour intensive. Changes to risk factors made during the study were small but patients valued the opportunity to raise questions which fell into the categories of medical concerns, hospital procedure and risk factors. Conclusion: The manual is a useful tool for patients waiting for cardiac surgery. The programme is useful and feasible but could be targeted more specifically to patients with raised risk factors.
Introduction
The length of cardiac surgical waiting lists in the UK has increasingly been a cause for concern. This has been highlighted by The National Service Framework for Coronary Artery Disease [1], which has recommended that they be reduced to 3 months. Meanwhile, there is both anecdotal and research evidence [2,3] that patients suffer from anxiety, uncertainty and worsening of symptoms while they wait.
Patients who have had a myocardial infarction or coronary artery bypass surgery are offered cardiac rehabilitation programmes which provide exercises and help the patients address the risk factors that may have contributed to their illness. These programmes have been shown to improve morale and decrease readmissions and visits to GPs [4]. It, therefore, seemed reasonable to offer a form of rehabilitation offering lifestyle advice and risk factor assessments to patients waiting for surgery to give them something to focus on rather than the uncertainty of the operation. At the same time, the nurses would be able to prepare the patients for surgery by taking blood samples for routine analysis, explaining the operation procedure and providing psychological support.
The overall aim of the study in this paper was to pilot a programme to provide support and guidance for patients waiting for surgery by providing a manual and individual nurse-led sessions in the patients' homes or at the hospital.
The specific aims are:
To evaluate, by questionnaire, a newly devised local manual for use by patients waiting for surgery.
To assess the feasibility and usefulness of a preoperative service of support at the patients' homes and at nurse-led clinics in the hospital by analysis of: nurses focus groups; risk factor changes and review of questions; concerns; and problems highlighted by contacts with patients.
Cardiac rehabilitation programmes are widely accepted as being of benefit to patients with cardiac disease [5–7]. Moher et al. have shown that there is good evidence that lifestyle and therapeutic interventions reduce both mortality and morbidity in patients with established cardiac disease [8]. Lewin's angina management programme which used the ‘Heart Manual’ [9] was a home based cardiac rehabilitation programme including stress management techniques and showed a 70% reduction in episodes of angina and 72% reduction in self-reported disability [10]. The British Working Party for Cardiac Rehabilitation [11] suggest that all programmes should provide a variety of written information supplemented by individual discussion and counselling and the national guidelines [12] suggest outcome measures that might be recorded to illustrate the effectiveness of programmes should include risk factor reduction through blood pressure, cholesterol, smoking, weight control and physical activity measures and psychosocial outcomes such as well being and quality of life.
Previous work has shown that placement on a waiting list can be an extremely distressing time for patients as they have little contact with any rehabilitation or cardiac support team and are unsure as to what they can or cannot do [2,13,14] Bengston et al. surveyed all their patients waiting for cardiac procedures and 88% (n = 681) reported chest pain symptoms restricting their activity but half reported that the uncertainty and fear while waiting were more disturbing than chest pain [2]. A local survey by postal questionnaire, of patients waiting for cardiac surgery had revealed similar findings and patients wanted more contact and information on medication, risk factor control and surgery [15]. It seems reasonable to propose that supplying access to some form of rehabilitation service, particularly psychological support, during this wait might help relieve some of the distress.
McHugh et al. used the time spent waiting for surgery to tackle risk factors and to provide information on surgery and recovery with very positive outcomes [16]. A nurse from the hospital shared a caseload with community nurses to provide risk factor assessment and support lifestyle changes while the patients waited for surgery. It was evaluated as a randomised controlled trial of 98 patients. Compared to a control group, which received no support on the waiting list other than a help line number, the patients in the experimental group had significant beneficial changes for all factors (cholesterol P = 0.003, blood pressure P = 0.011, smoking P = 0.001, BMI P = 0.000) which supported the adoption of such a scheme.
To meet patients' need for psychological support and to address the deficit in cardiac rehabilitation for patients waiting for cardiac surgery, it was decided to set up a nurse-led support and education scheme learning from the programme in Glasgow [16]. Given the benefit gained form the Heart Manual following myocardial infarction [4] and in line with the British Working Party guidelines [11] that information should be reinforced with written guidelines, it seemed worthwhile to compile a manual for surgical patients. The subsequent pilot study aimed to test a support and education system in a London setting with a complementary manual.
Methods: Study Design
Design of the manual
The manual design followed the pattern suggested by Baker and Caraher [17]; listening, interpreting and evaluating. The first phase involves surveying the target audience to find out their needs. The interpreting phase is the writing or designing of the tool to be used whether it be a book or a poster and the evaluating phase is piloting the finished item to see if the objectives have been met. The local survey of patient education and support needs on the waiting list [15] was seen as the listening section and the contents of the manual were based on the areas where patients asked for more information and also on the recommendations of the British Working Party on cardiac rehabilitation [11]. It had clear objectives that were outlined within the manual to prevent the criticism of other health promotion literature, that it is not clear about what it is trying to achieve [18].
Different members of the multi-disciplinary team including a pharmacist, dietician and occupational therapist wrote the individual chapters. It included sections on surgery, blood pressure, diet, weight loss, diabetes, cholesterol management, fitness, medication and stress management An external expert, who had been involved in writing and evaluating health education and promotion literature, reviewed it and several drafts were distributed to the multi-disciplinary team and a group of patients for them to comment.
The manual was intended to be read alongside consultations with a cardiac specialist nurse and the theoretical approach taken towards encouraging lifestyle change was based on behavioural change theory, as it can be argued that unless one addresses how and why people make behaviour changes, they are less likely to make or sustain changes to their health [19]. The model adopted was the Prochaska and DiClemente Stages of Change Model as it seemed practical in both helping patients plan change and to monitor progress along the process [20]. Prochaska and DiClemente stress the importance of taking seriously the efforts individuals make on their own and that their model's aim is to build on these efforts to assist the patient to move forward [20].
Suggested scripts were written for each of the encounters between nurse and patient to ensure that all nurses knew what information to provide and ensure all patients received the same basic information. If patients asked questions about specific topics these areas were explained in more depth. One criticism of behavioural change approaches is that they can lead to victim blaming and patients feeling at fault for having bad health [19]. To discourage this, the scripts encouraged patients to discuss factors that contributed to their heart disease, but to plan positive lifestyle change to maximise their health.
The nurses who were going to be involved in the programme tried out the manual using role-play to address the various risk factors and find their way around the paperwork. This also helped ensure that all nurses were using it in the same way and giving the same advice.
Establishing a pilot scheme
The manual was to be used in conjunction with a support programme and, therefore, a pilot study was established and submitted to the local Ethics Committee to evaluate the usefulness and feasibility of both the manual and such a programme from both the nurses' and patients' point of view. It was intended that this would be preparatory work for a large randomised controlled trial if is was found to be both feasible and was appreciated by patients. The study conformed with principles outlined in the Declaration of Helsinki [21]. All patients going onto the waiting list were telephoned by a cardiac specialist nurse and offered the opportunity to take part in the pilot study. If they agreed, they were asked whether they would like to receive home visits or attend a nurse-led clinic at the hospital. All patients taking part were given a copy of the manual to use. The patients used the manual at home and were reviewed monthly for 3 months. This helped combat the problem of a previous study, which was criticised for not helping patients sustain motivation [22]. As this was only a pilot study to assess the feasibility and usefulness of the programme and manual prior to a longer study, it was decided 3 months was deemed long enough for all involved to become used to both.
Patients were given the opportunity to voice concerns and questions and asked which risk factors they would like to address. They were encouraged to plan lifestyle changes accordingly. The aim was a patient centred approach using Prochaska and DiClemente's Stages of Change model [20]. At 3 months, there was a final review and evaluation and patients were given a questionnaire regarding the manual.
During the 3 months, patients were provided with information about their operation procedure, medication and necessary preparation such as breathing exercises. They were also given the opportunity to discuss any aspect of their health or the planned operation procedure.
Patient selection
Patients were selected from the waiting list if they lived within an hour and half of the hospital. The aim was to recruit six patients a week for 7 weeks to give a convenience sample of 42 patients which seemed a reasonable number to evaluate the manual and fitted in with the numbers of patients being placed on the waiting list each week.
The inclusion criteria were adults of any age waiting for first time coronary artery bypass graft surgery. The exclusion criteria were; inability to read English, additional planned operation, requiring urgent operation within 6 weeks, living more than an hour and a half away, or taking part in other research studies at time of recruitment.
Data collection
The manual: a patient questionnaire on the usefulness of the manual was designed and filled in at the end of the series of visits by all patients completing the programme.
Early risk factor changes
Physiological measurements of risk factors were recorded at baseline and 3 months. The risk factors measured were: blood pressure (hypertension measured as > 140/80); body mass index (raised BMI >28); cholesterol (raised total cholesterol >5 mmol/l); and blood glucose level (raised >6.5 mmol/l) and anxiety and depression as measured by the Hospital Anxiety and Depression Scale [23]. Patients were categorised as depressed or anxious if they scored above 8 as per the questionnaire guidelines, which was in line with the recommendations by Thompson et al. [12]. It was not expected that there would be large changes in 3 months but that early changes might be picked up and it gave an indication of how many patients waiting for surgery had risk factors which had not been adequately managed. The study was not powered to measure changes in risk factors and there was no control group as this was a pilot study looking mainly at the practical issues involved in running such a programme. The effect would be measured in a future randomised study.
Also recorded were: smoking activity; diet; frequency of use of GTN spray; number of episodes of exercise per week; and relevant medical history, but not to measure formally changes for research purposes because it was felt that the measurements would be very subjective. If further referrals were made as a result of the nurses' contact with the patients, these were also recorded. These might be referrals to dieticians or alerting the surgical team to deterioration in health.
At the same time the patients were also scored according to the Prochaska and DiClemente stages of change so that changes in motivation could also be monitored. There was no evidence of the scale being used in this way before and it gave a rather crude analysis but was used to see if it was a feasible measure for a larger study.
Nurses' and patients' views
A qualitative evaluation was done with the nurses involved. The four nurses involved all had at least 10 years experience in cardiac nursing and had undertaken specialist cardiac courses. The nurses took part in two focus groups at the end allowing them to voice their thoughts, feelings and concerns about the benefits and difficulties of the programme.
The author and an independent person who had experience in running such groups facilitated the focus groups and the information from the focus groups was analysed by the author.
Telephone interviews of patients using five open questions were also held 1 month after the patients' last contact to find out their views of the overall programme. The answers were typed up by the nurse for analysis. All patient concerns and questions voiced during their appointments with the nurses were also documented. This helped evaluate whether the programme was actually addressing the issues that were important to the patients.
Data analysis tools
The quantitative data were analysed using descriptive statistics and Wilcoxon rank tests to test for significant changes.
The qualitative data from the patient telephone interviews and comments and questions from the nurse-patient meetings were coded and thematically analysed [24]. The focus group tapes were transcribed, independently checked and then the main points were summarised. These summaries were fed back to the participants and formed the basis of the subsequent group [25].
Results
Recruitment calls
Sixty-one patients were telephoned and invited to join the study, of which 42 (69%) agreed to take part in the pilot study.
Gender and ages
The sample was made up of 28 (66.7%) males and 14 (33.3%) females. Patients ranged from 42 to 80 years of age (mean 63.36, S.D. 8.51, Fig. 1). All were waiting for first time coronary artery bypass surgery.
Ages of patients
Thirty patients (71.4%) had home visits, eight patients (19%) were seen at the hospital and four patients (9.5%) had a mixture of hospital and home visits.
Referrals from programme to other health professionals
All referrals that were made as a result of the patient contacts were recorded to assess further the usefulness of the programme. Referrals were made to: consultant surgeons [5]; physiotherapists [3]; cardiologists [2]; a GP; social worker; community dietician; an occupational therapist; and a surgical registrar. Topics covered included: blood sugars of a newly diagnosed diabetic; deranged blood results; a patient's deteriorating condition; stress management; and cholesterol-lowering medication.
The patient questionnaire regarding the manual
Thirty-six questionnaires were returned (79%). Descriptive statistics were used on the answers to the quantitative questions to calculate frequencies (Table 1 and Figs. 2–4). The manual was read regularly by most patients indicating considerable interest in their health despite the fact that most of their questions and concerns were related to their admission process or medical concerns rather than risk factors. The fact that the smoking section was used least is probably due to the low numbers of smokers in the sample.
Patient questionnaire answers
Patient questionnaire answers
Most used sections in the manual
Least used sections in the manual
How often manual was used
There was a thematic analysis of the three sections: most useful; least useful; and general comments. Some of the questionnaires were filled in by the nurses on behalf of the patients and this explains why some of the comments are in the third person. The analysis was also performed independently by another researcher and cross-checked to enhance credibility.
Some patients had answered this question in a general sense but most had chosen to refer to specific sections of the manual.
Examples of general comments are:
‘Having a ready reference.’
‘Useful to have a written manual to refer to at home.’
Some patients had commented on the overall programme rather than the manual alone.
‘It was nice to have the support of the Brompton.’
There were also a couple of comments that said all aspects were helpful.
Diet, fitness, stress management and medication were the most referred to specific sections. There were also three comments referring to the explanation of risk factors the manual provided and a couple on each of the following: pre-operative information, causes of coronary artery disease and daily activities. One patient each had listed ‘smoking’ and ‘blood pressure’.
Three aspects to change
The majority of patients [20] either left this section blank or wrote ‘none’, ‘nothing’, or that they couldn't think of anything to change.
Five comments concerned the organisation of sections and consistency of numbering.
It had been a worry when the manual was compiled that it might seem too long. However, only one patient commented on the length saying it was a little too long.
Three comments reflected the need to consider language and reading ability in the provision of information.
There was a specific request for more information after the operation and also for more information on medication.
General comments
In the general comments section patients tended to comment on the overall programme rather than specifically on the manual (17 patients). Comments were made on the usefulness/helpfulness of personal contact/seeing the nurse/having a home visit and on the encouragement and comfort of the nurse contact and getting answers to questions.
Regarding the actual manual, three patients commented that their family had found it helpful to read too and another that their GP had seen it and wanted a copy.
Comments specifically relating to the usefulness of the manual to the patient varied from:
‘I read this manual twice so far but cannot remember much of it…. To use it was very interesting and useful’ to
‘I think it is the bible for heart patients and it is like a reference book.’
Another patient commented that it provided a focus for preparing for the operation.
The usefulness may depend on the patients' previous knowledge as one patient commented that the information was not new as so many friends had been patients too.
Patient comments from telephone interviews
A convenient sample of 20 patients were questioned, most of whom [17] were still waiting for surgery at the time of interview.
No one said they had too many visits. Twelve patients (60%) felt the number of visits was sufficient and five (20%) would have liked them to continue until their operation. One of those who felt he had sufficient visits felt that he would have preferred them spread out throughout his wait. Of those who wanted the visits to continue, two patients said they felt the visits could be reduced to bi-monthly and another that a telephone call would be sufficient. Thirteen patients (65%) commented that the programme was either helpful or useful, nine (45%) that it was reassuring and six (30%) that they appreciated the one-to-one contact.
The patients were divided evenly as regards whether they had made any changes to their lifestyle (10 said yes, nine said no). Of those who said ‘yes’ six said they had made changes to their diet, five had increased their level of exercise and one that he or she had done both. Of those who had not made changes, half said it was because they had no changes to make as their risk factors were under control.
Nurses' focus groups
The second focus group built on the summary of the first and both summaries were fed back to the participants in accordance with guidelines on running focus groups [24]. The first group allowed participants to voice their positive and negative thoughts and the second became a trouble-shooting session as they worked through the difficulties encountered.
The programme
There is no room for a full report, but in general the nurses felt the programme fitted in with the National Service Framework for Coronary Heart Disease [1] and will need adapting as GPs become more involved with risk factor management and run local clinics. The preoperative screening aspect proved very important and provided hard auditable data to measure problems which if undetected would have led to delay of surgery. The contacts were also a means of highlighting worsening symptoms. Discussing the operation was of more interest to the patients than discussing risk factors but the programme did raise the profile of risk factors for both them and their families. The whole programme, however, proved very time consuming which needs bearing in mind for developing it further.
The manual
With the manual, there was some difficulty finding the different sections and it was felt future editions should have coloured tabs separating sections, a more user friendly risk factor assessment sheet and more graphics for patients who cannot read well. It prompted discussion and patients read through it between visits. The nurses thought patients wouldn't have known what questions to ask if they hadn't had the manual but it gave focus for patient discussion and knowing what their risk factors were empowered the patients and encouraged responsibility for health.
Negative factors
There was not as great an impact on risk factors as had been hoped and it was difficult to use the programme with the elderly who did not necessarily want to make changes to their lifestyle.
There was a lack of clarity of how to intervene when problems were encountered but it was decided to write broad protocols to help with problems raised by surgical screening and in the future to hold weekly meetings to review new problems encountered.
The greatest frustration was being unable to affect the ultimate problem of having a waiting list and the need for operation dates but this was beyond the remit of the study.
Risk factors
The risk factor measurements are recorded in Table 2. There was a data collection problem at the final assessment: where recordings were within normal limits at baseline they were not always re-measured. This is the case for nine of the 12 patients whose blood pressure measurements are missing. However, there were significant numbers of patients who had raised risk factors such as blood pressure (systolic > 140 mmHg: 57.1% n = 24), and body mass index (BMI > 28: 47.6% n = 20) at the baseline assessments which shows the need to ensure these patients are monitored regularly and also a large number of patients who were classed as anxious at baseline (42.9%) but very few patients scored highly enough to be classified as depressed.
Risk factors at baseline and final assessments
Risk factors at baseline and final assessments
There were nine smokers in the sample and the measurement relied on self-reporting by patients of numbers of cigarettes smoked per day. No definite statements can be made from the data but the trend did appear to be moving towards a smaller intake of tobacco (Fig. 5).
Daily cigarette intake at baseline and final measurement
Wilcoxon signed rank tests were performed to look for differences between the baseline and final readings but were only significant for blood pressure and blood glucose and while both showed a reduction at the final measurement point the blood glucose figures must be viewed with caution because of the small numbers involved and because the sample was not powered.
It was difficult to ensure that all nurses recorded the stages of change consistently and from the nurse focus groups it became clear that in the future there should be more consultation between nurses to ensure they are using the tool in the same way. They were a useful guide for the nurses in monitoring progress but were not mentioned by the patients
Analysis of questions and concerns
This was a thematic analysis of all the patients' comments, concerns and questions written in the concerns and questions section of the form by the nurses at each patient contact. A substantial number of patients (19 recorded) commented on the need to have a date for their operation.
Other concerns fell into three broad categories: medical questions; questions related to their admission, stay and discharge arrangements; and matters relating to the risk factors.
However, there were also six patients who were quoted as having no questions or concerns.
Medical questions
There were various questions regarding medications. The medication covered included aspirin, atenolol, statins and GTN (Glycerol Trinitrate). There was evidence of the patients having read the manual and questioning their own prescriptions.
‘Didn't know about using GTN prophyllacticaly until she read manual’
Many patients had specific medical questions about the operation ranging from: the number of grafts required; results of specific tests; how the operation would be done; and why it should be done if it did not cure the problem.
‘Would like to know more about the operation.’
A quarter of the patients were concerned about worsening symptoms and other concerns related to symptoms such as pins and needles, double vision and shortness of breath in the heat. One patient wanted to know what could go wrong while he was on the waiting list.
Hospital admission, stay and discharge
Pre-operative questions concerned practical issues such as: whether the patients could book holidays; what clothes to bring; where to shave; and what accommodation and parking facilities were available. Most questions were general questions.
Four patients were concerned about actually making it through the operation because of past experiences.
‘Anxious about admission as mother died in hospital with hospital acquired infection.’
The other concerns regarding stay in hospital concerned getting adequate analgesia and how long the stay would be.
Patients had several concerns about aftercare. These included concerns about how they would get home, how well they would be and who would look after them. Linked with these were concerns about carers who were ill/elderly themselves.
‘How will husband cope? He has had a stroke.’
Risk factors
The manual and the risk factor assessment appeared to stimulate some questions and concerns regarding risk factors but only half the patients mentioned risk factors at their consultations.
There were various questions about diet and weight loss. One patient's whole family was using the manual, which suggests that, the health promotion aspect of the programme reaches more than just the patient. The comments about weight loss were about the frustration of not achieving despite their efforts.
‘Weight being up concerns her, she is aware she should try and prevent it going up.’
Eight patients had concerns about the amount of exercise they could manage. Two of these were concerned that they could no longer play golf or bowls, as they had been doing before their heart problems. Another two were thwarted in their attempts to walk more by the shortness of breath and chest pain, which was not relieved by GTN spray. Two patients had tried to go to the local cardiac rehabilitation classes but had been refused because they were on the waiting list for surgery. One patient was attending a rehabilitation class but this was because he had been going since his heart attack and the team had decided he could continue until surgery.
Only one patient commented on smoking and that was to say that it was difficult to give up and he had had a lot of different opinions from different health professionals.
Twelve patients commented on anxiety or depression. Their stressors were not necessarily related to their illness.
‘Gets stressed quite easily with being out of work.’ ‘Main problem seems to be lack of focus /objectives in life following retirement.’
Not many patients wanted to take up stress management sessions, although one patient was referred to the occupational therapy department for stress management.
‘He doesn't want to get involved in any stress management type things. Did say he appreciated talking to me about his worries.’
Interestingly, one patient said his anxiety was increasing as he got nearer to his operation and another that he found his preparation for surgery booklet provoked anxiety.
Discussion
To return to the aims of the study, the review of the manual was performed by the patient questionnaire, the nurses focus group and an analysis of the comments and questions voiced during the patients consultations. These showed it was used regularly but needs a few formatting changes to make it more user friendly. Patients commented on the usefulness of the various chapters but the nurses felt that it was difficult for patients to find their way around. The variety of questions and concerns voiced by the patients showed that the manual still leaves certain questions unanswered and patients, even if they had controlled risk factors, benefited from a one-to-one contact with a nurse while on the waiting list.
The second aim was to assess the feasibility of the programme from telephone interviews with a group of patients and from the nurses' focus groups. Looking at the programme overall it seems there are sufficient numbers interested in further contact to make some sort of intervention necessary.
The nurses' comments tended to relate to the practical delivery of the programme and they had found it very labour intensive whereas patients were very appreciative but not all felt they needed to make lifestyle changes if their risk factors were already under control. The nurses highlighted the need for clear protocols as to how problems, such as raised blood pressure, should be managed. Such issues were not mentioned by earlier studies [16,26], but are practical issues on which the success of such a programme relies.
Regarding the usefulness of the programme, what the nurses appreciated was the chance to pick up problems prior to patients being admitted and newly diagnosed diabetes and blood abnormalities would have led to delayed operations if they had not been picked up prior to admission. The programme was not able to show large reductions in risk factors but it had not been powered to do so. What was highlighted was the number of patients who needed further intervention to control their risk factors. Approximately half the patients had raised blood pressure or body mass index and there were similar numbers with anxiety. This echoes the work of Bengston et al. [2,27] on anxiety and the reductions shown after 3 months, while not powered, suggest that these visits are useful. It is hoped that following the study with a randomised controlled trial with those patients with raised risk factors would show similar results to Lewin [10] in his work with the Heart Manual.
Another issue which was raised among the nurses was that of the appropriateness of providing risk factor advice to the elderly and while no one would want to deprive them of support which they might find beneficial, the point illustrated the need to provide a service which does not necessarily focus only on risk factors and lifestyle advice but provides support on the level most appropriate for the patients. The appointments, which were intended as pre-dominantly risk factor management sessions with an opportunity for patients to ask questions about their operations, became a screening and counselling service as problems were highlighted and referred. The comments from patients on the manual evaluation questionnaire and during the telephone interviews showed they valued the programme and appreciated this additional input while they waited for their operations.
The fact that more patients opted for home visits has implications for any future programme as the home visits are more time consuming in terms of the travel involved and transport costs.
Study limitations
Collection of data on risk factors was inconsistent. Blood pressure was recorded on all patients at the baseline assessment but only 71.4% (30) had a final blood pressure recording. This seemed to be largely because the initial blood pressure was within normal limits and so was not rechecked. This was also the case for patients with BMI and cholesterol within normal range; not all were re-measured at the final assessment.
The nurses themselves were involved in a learning process as the study progressed which was partly why the quantitative data collection process was not as thorough as it might have been. They were also getting used to paperwork and holding appointments that were in a different format to that which they were used to.
Unlike other evaluations of rehabilitation programmes [8] the pilot study did not specifically measure morbidity or costs but this was only a pilot study and there was no comparative control group. It aimed to explore the feasibility of the programme and the problems highlighted assist this evaluation.
The comments and concerns of the patients did not raise any issues which were not expected which proved the programme targeted the right issues, however, it could not affect the issue foremost in many patients' minds, that of when they would receive a date for their operation. Since the study ‘Extending Patients’ Choice' [1] has been introduced by the government, it has helped to address this problem by giving patients more choice about where they have their operation.
Recommendations
From the analysis of the data collected it seems the manual was well used and, therefore, should be available with one-to-one support for all patients with raised risk factors. However, changes to the format as outlined in the results should be made, including tabs to delineate the individual sections and improved printing quality.
The nurses following the focus groups agreed to expand the programme to assess and manage risk factors for all patients waiting for cardiac surgery but only follow-up those patients with raised risk factors. However, before expansion, the practical issues of recording measurements and getting blood samples processed in the laboratories must be addressed. It was also agreed to hold regular meetings as a team to allow exchange of ideas regarding the different problems encountered and a file would be compiled to record the assistance and problems encountered with other healthcare professionals. This would enable a clear framework for problem solving to be developed and protocols for problems such as cholesterol lowering.
To follow on from the revised programme a randomised controlled trial is planned for those patients with raised and uncontrolled risk factors to see whether these may be reduced if patients are followed up with a nurse-led intervention.
Conclusion
The Fit For Surgery programme built on previous work which had highlighted a need to provide more support for patients waiting for coronary artery bypass graft surgery. The pilot programme and newly devised manual were intended to provide psychological support and risk factor management and both nurses and patients felt this had been achieved. It also proved to be useful for screening patients for potential problems. By using quantitative and qualitative data collection tools, the study has provided a broad perspective from both the patients' and nurses' perspective, which will enable a practical, workable programme of support to be developed in the future. It built on previous work and will now itself form the basis for a new programme and a larger study of risk factor reduction.