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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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556713
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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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
per year, the leading cause of mortality in Europe, and places a
substantial burden on the health care systems and economies
of Europe.1 According to the Federal Statistical Office,2 cardi-
ovascular disease is also the leading cause of death in
Switzerland. In 2010, 14.1% of deaths per 100,000 inhabitants
were due to ischaemic heart disease. In Switzerland 36,353
persons were hospitalized with acute coronary syndrome
(ACS) in 2009. This umbrella diagnosis covers ST elevation
myocardial infarction (STEMI), non-ST elevation myocardial
infarction (NSTEMI) and angina pectoris. Immediate medical
attention is necessary when symptoms are experienced.
1MedicalIntensive Care Unit, University Hospital Basel, Switzerland
2Institute
of Nursing, Zurich University of Applied Sciences,
Winterthur, Switzerland
Corresponding author:
Lukas Weibel, Coronary Care Unit, University Hospital Basel,
Petersgraben 4, CH-4031 Basel, Switzerland.
Email: Lukas.Weibel@usb.ch

Downloaded from cnu.sagepub.com at University of Basel on October 24, 2014

2 European Journal of Cardiovascular Nursing
However, in spite of symptoms such as excruciating
pain, patients with ACS often delay seeking hospital treat-
ment. Delays were also observed in patients who had pre-
viously suffered myocardial infarction, which indicates
that patients should be better prepared to respond to
another cardiac event.3 Studies have shown that patients
with ACS often have a knowledge deficit regarding their
illness and treatment, risk factors and recommended life-
style changes at discharge.4-6 Dracup7 found that 46% of
patients had low levels of knowledge about ACS. Studies
indicated that knowledge influences patients’ understand-
ing and day-to-day behaviour.8-10 The ability to absorb
information and to comply with behavioural changes has
been shown to be influenced by psychosocial factors and
peoples’ characteristics. For example depression has been
shown not only to be associated with increased risk of inci-
dent coronary heart disease11,12 but also to be associated
with poorer prognosis.13,14
Lack of knowledge may affect patients’ awareness of
risk factors, health behaviour and compliance with drug
therapy. Increasing evidence indicates that psychosocial
factors such as depression and anxiety can worsen the
prognosis of coronary heart disease.15
Patient education has been shown to be an important
component of treatment and care, addressing knowledge
deficits and facilitating behavioural changes.16-18
Cardiac rehabilitation programmes were designed for
these patient groups and have been proven to help reduce
overall mortality, risk of re-infarction19 and rates of rehos-
pitalization within 12 months20 and thus represent an
effective intervention for patients with coronary heart dis-
ease. Heran et al.20 demonstrated that cardiac rehabilita-
tion was associated with improved quality of life in seven
of 10 studies. Research on centre-based and home-based
rehabilitation programmes focusing on diet and exercise21
has demonstrated positive effects on desired behavioural
changes. The responsible mechanisms for the positive ben-
efits of cardiovascular rehabilitation are multifactorial and
include a reduction in cardiovascular disease risk factors,
improved diastolic function, positive ventricular remodel-
ling after heart attack, improvement of endothelial func-
tion and inflammatory status and improved electrical
stability of the myocardium.22-26 In spite of these encour-
aging findings, studies in various countries have shown
that only 14–43% of eligible patients participate in cardiac
rehabilitation programmes.27-29
A study by Lau-Walker30 concluded that early interven-
tions designed to address individuals’ sense of control
could increase the attendance and effects of rehabilitation
programmes.
Self-efficacy seems to be an important factor in pursu-
ing behavioural changes. The aim of patient education was
to enhance patients’ perceived self-efficacy, as self-
efficacy beliefs determined health behaviour.31 Higher
self-efficacy was associated with better health status in
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patients with ACS.32 For various chronic conditions, it has
been shown that increased self-efficacy is associated with
improved self-management.33-36
In order to improve self-efficacy and eventually the will
to attend rehabilitation and enhance self-management, indi-
vidualized education and counselling has been proven to be
essential.18,37 Patients’ needs are individual and subjective38
and determined by sex,39 age and severity of disease.40
Timmins41 emphasized that the desire for information
expressed by the patient is of major importance. Turton42
developed the Cardiac Patients Learning Needs Inventory
(CPLNI), a standardized instrument to assess those patients’
information needs.
In light of expected reduction of hospital length of stay
due to fast symptom relief through coronary angioplasty as
standard therapy, condensed but also very early interven-
tion becomes pivotal. Patients might be ready to absorb
information at an early stage of their hospital stay with the
aim to prevent readmissions and to provide support for
behavioural change. The goal of early education is to
improve patients’ knowledge of their disease and treat-
ment, but also to strengthen patients’ beliefs in their own
capabilities to cope more effectively with ACS and plan
for their future after discharge from hospital.
An early individualized patient education intervention
that permitted shared decision making aiming to promote
patient self-efficacy and facilitate patient self-management
has been developed.
The purpose of the study was to pilot test this early
patient education intervention. It has been hypothesized
that self-efficacy and hence participation in rehabilitation
programmes would be increased in patients with ACS.
Additionally, investigation has been made into whether
patients in the intervention group were satisfied with the
intervention.
Methods
A randomized controlled trial was pilot tested at the
Coronary Care Unit (CCU) and medical wards of a Swiss
university hospital between October 2011 and April 2012.
Patients diagnosed with ACS, hospitalized in the CCU and
projected to stay in the university hospital throughout the
entire hospitalization were eligible to participate in this
study. They had to have adequate knowledge of written
and spoken German. Patients with cardiovascular instabil-
ity (systolic blood pressure<90 mmHg and >150 mmHg),
severe arrhythmia, life-sustaining devices (Impella®,
IABP), low oxygen saturation (<90%) increased New
York Heart Association (NYHA) class (> 1) or confused
patients, assessed with the Intensive Care Delirium
Screening Checklist (ICDSC; ≥ 4), were excluded.
On the basis of calculations with G*Power3,43 we
assumed that a sample size of 40 allowed to show an effect
of 0.40 (Cohen’s f = 0.40) in a repeated measures analysis
Weibel et al. 3
Enrolment
Assessed for eligibility (n = 42)
Randomized (n = 40)
Allocation
Allocated to intervention (n = 20)
♦ Received allocated intervention Part 1 (n = 20)
♦ Received allocated intervention Part 2 (n = 19)
♦ One did not receive allocated intervention Part 2
(transfer to other hospital) (n = 1)
Analysis
Analysed (n = 19)
Figure 1.  CONSORT 2010 flow diagram.
of variance and an effect of 0.50 (Cohen’s d = 0.5) in a
dependent t-test, with a power of 0.8 and α = 0.05.44
The investigation conforms with the principles outlined
in the Declaration of Helsinki.45 The study was approved
by the Ethics Committee Canton Basel, Switzerland (Ref.
Nr.EK:332/11).
Recruitment and data collection procedures
After patients gave informed consent, baseline data was
collected in the CCU and patients were assigned to the
intervention or control group by block randomization (see
Figure 1). Five blocks with eight mixed (control/interven-
tion) envelopes were formed.
Baseline data collection covered a demographic ques-
tionnaire and case history data, self efficacy assessed
with the Cardiac Self-Efficacy Scale (13 questions) and
depression and anxiety with the HADS scale (14 ques-
tions). After the randomization, patients were informed
about their assignment to the intervention or the control
group.
Prior to discharge, all the study participants completed
the Cardiac Self-Efficacy and Hospital Anxiety and
Depression Scale–Deutsche (HADS-D) scales for a sec-
ond time. Three weeks after discharge, the telephone fol-
low-up was conducted by a study nurse to determine
Downloaded from cnu.sagepub.com at University of Basel on October 24, 2014
Excluded (n = 2)
♦ Declined to participate (n = 2)
Allocated to control (n = 20)
♦ Received allocated intervention (n = 20)
♦ Did not receive allocated intervention (left
hospital before second measurement) (n = 1)
Analysed (n = 19)
whether patients were participating or had participated in
an inpatient or outpatient rehabilitation programme.
Intervention
Control group. The participants in the control group
received standard care, consisting of information provided
during the attending physician’s daily rounds and through
an information booklet. The individual risk factors were
highlighted to each patient.
Intervention group.  In addition to standard care, the inter-
vention group (IG) received two individually-targeted
educational sessions.
First intervention. The first intervention was scheduled
within 48 h after patients had completed the Cardiac
Patient Learning Needs Inventory (CPLNI) whilst in the
CCU, indicating their individual information needs.42
The CPLNI consists of 37 questions and emphasizes
the following topics: anatomy and physiology (five items),
psychological factors (four items), risk factors (three
items), medication information (five items), diet informa-
tion (five items), physical activity (six items), symptom
management (six items) and other pertinent information
(three items).
4 European Journal of Cardiovascular Nursing
The questionnaire has content validity assessed by
medical doctors and specialized nurses. The suitability of
the CPLNI questionnaire for use in Switzerland has been
tested. The results showed that the patients could indicate
their information needs.46
The CPLNI allows marking on a Likert scale (1–5) how
important the question is to the user at this point in time.
After having decided on the importance of each of the 37
questions, the participants in the IG subsequently received
individual needs-based education from the first author on
every topic assessed with four or five points on the scale.
To ensure consistent quality of education, a manual was
prepared, containing the answers to the 37 questions. The
manual included graphics, enabling participants to visual-
ize the disease process.
Second intervention.  The second individual education inter-
vention was performed by the first author face to face on the
day before discharge on the medical ward. Individual risk
factors, current cardiac medication and personal disease
management barriers and facilitators were addressed. In
connection with personal disease management, the topics of
increasing physical activity and the appropriate response to
future chest pain were discussed. Concluding participation
in a rehabilitation programme was recommended.
The two education interventions each lasted about 30
minutes. Due to the monitoring and given structures of the
CCU, privacy could not always be guaranteed in the first
intervention. The second intervention, however, took place
on the ward in a specially reserved room.
Data collection
Cardiac Self-Efficacy Scale.  The Cardiac Self-Efficacy Scale
measures self-efficacy and comprises two subscales:
‘Control symptoms’ and ‘Maintain function’. ‘Control
symptoms’ includes eight questions on a Likert scale of
1–5 (score 8–40) with an emphasis on handling with pain
and shortness of breath, consulting the doctor, taking the
medicine and physical activity during hospitalization. A
higher score means more confidence to manage the symp-
toms properly. The factor ‘Maintain function’ includes
five questions on a Likert scale of 1–5 (score 5–25)
addressing maintaining social activity, maintaining activ-
ity at home and outside of the home, sexual activity and
exercise. A higher score indicates more confidence to per-
form activities adequately. The internal consistency of the
two factors is reported to be high – Cronbach’s α = 0.90 for
‘Control symptoms’ and 0.87 for ‘Maintain function’ –
and validity is described as good.47 In our study the Ger-
man version of the Cardiac Self-Efficacy Scale had a
Cronbach’s α of 0.85 respectively 0.90.
Sullivan’s Cardiac Self-Efficacy Scale was translated
into German and back-translated by the first author48
according to Brislin’s protocol.49
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HADS German version (HADS-D).  HADS is a tool to assess
anxiety and depression. The questionnaire comprises 14
questions.50 The HADS German version has been vali-
dated in almost 6200 patients with cardiac as well as other
internal or psychiatric conditions and often applied clini-
cally. For the subscale anxiety, Cronbach’s α was 0.80, for
the subscale depression, Cronbach’s α was 0.81.51,52
In our study, the HADS-D scale had a Cronbach’s α of
0.85 at T0 and 0.84 at T1.
Attendance to rehabilitation
Data collection of patients participating in a local rehabili-
tation programmes was supported by the rehabilitation
team. The data were extracted from the medical records,
assessing attendance and completion of the programme.
Data from two patients who attended another programme
were provided by themselves.
Data analysis
Intervention and control group data were analysed descrip-
tively (frequency, mean, median, standard deviation and
range). Various tests were used for group comparisons,
depending on the data level (t-test, Mann–Whitney U test
and chi-square test). The significance level was set at
p<0.05. In view of the assumption (based on the literature)
that self-efficacy is increased as a result of the educational
intervention, one-sided tests of significance were used.
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-
ures ANCOVA, in which the HADS anxiety and depres-
sion subscales were used as covariates.
Attendance to the rehabilitation programme and patient
satisfaction were descriptively analysed. For categorizing
the participation we created four groups: ‘full outpatient
rehabilitation’ (>90% attendance), ‘partial outpatient reha-
bilitation’ (<60% attendance), ‘inpatient rehabilitation’
and ‘no rehabilitation’. IG patients were additionally asked
to rate the quality of the intervention.
In the statistical analysis of the rehabilitation data using
a contingency table, cell frequency was found to be too
low to permit detection of significant group differences.
The data were therefore analysed in terms of frequencies.
The IBM Statistical Package for Social Sciences, ver-
sion 19.0 (SPSS 19.0) was used for data analysis.
Results
Sociodemographic data
Forty patients were enrolled in the study. Two persons
were lost to follow-up due to unexpected discharge from
hospital. One person was unexpectedly transferred to a
Weibel et al. 5
hospital close to his place of residence, which made con-
tinued participation impossible. The other person left hos-
pital early and thus missed the second intervention and the
pre-discharge data collection. Ultimately, the analyses
were performed with a total of 38 complete datasets (19
per group; see Table 1).
Nine women and 29 men participated. NSTEMI was
diagnosed in 20 and STEMI in 18 patients, and these diag-
noses were identically represented in both groups. All
characteristics were evenly distributed between both
groups; they differ significantly only in age.
Self-efficacy ratings were analysed for the two sub-
scales ‘Control symptoms’ and ‘Maintain function’ (see
Table 2). At baseline the mean scores did not differ signifi-
cantly between groups although the mean score on
‘Maintain function’ was slightly higher in the intervention
group (14.74 (SD ±1.66) IG vs. 12.53 (SD ±4.01) control
group (CG)).
At follow-up the mean score on the subscale ‘Control
symptoms’ increased in both groups (26.0 (SD ±4.59) in
the CG, and 28.0 (SD ±2.78) in the IG) indicating higher
self-efficacy. On the subscale ‘Maintain function’ the
scores were practically unchanged in the CG (12.95
(SD±3.74) vs. 12.53 (SD±4.01)) whereas they increased in
the IG (14.74 (SD±1.66) vs. 16.42 (SD ±2.43)), indicating
higher self-efficacy.
The scores for anxiety were lower in the CG compared
with the IG (5.79 (SD ±3.91) vs. 6.16 (SD ±4.22) and
depression was slightly higher in the CG compared with
the IG (4.16±2.58 vs. 3.79±2.84). For the depression sub-
scale, the mean value T1 was 4.16 (SD ±2.83) in the CG,
compared with 2.84 (SD ±2.14) in the IG.
According to the Shapiro–Wilk test, the intervention
and control groups were normally distributed regarding
Self-Efficacy Scale ‘Control symptoms’, ‘Maintain func-
tion’ and ‘Total’ and the HADS depression subscale. Only
the HADS anxiety subscale failed to show a normal distri-
bution. Given the equally sized groups, the homogenous
regression slopes within and between groups and over
time, the normal distribution of residuals and the fact that
analysis of covariance is an extremely robust method,54
repeated measures analysis of covariance were used with-
out any reservations.
Repeated measures analysis of variance (see Table 3)
showed a significant difference (p= 0.034) between the CG
and the IG on the subscale for self-efficacy ‘Control symp-
toms’ (T0 24.74±5.43/T1 26.00± 4.59 vs. T0 24.32±2.70/
T1 28.0±2.78) but no difference could be detected on the
subscale for self-efficacy ‘Maintain function’ (p= 0.164).
The significant difference between the CG and IG was
stable for the self-efficacy ‘Control symptoms’ subscale
when we controlled for anxiety (p= 0.036) and depression
(p= 0.041). Even when the anxiety and depression were
simultaneously taken into account a significant difference
was found (p= 0.036). For the ‘Maintain function’ scale no
Downloaded from cnu.sagepub.com at University of Basel on October 24, 2014
differences were found when we controlled for anxiety and
depression.
When we controlled for age, the effect of the interven-
tion was no longer significant, neither in ‘Control symp-
toms’ (p=0.178) nor ‘Maintain function’ (p=0.642) nor
‘Total self-efficacy’ (p=0.262).
Rehabilitation
More participants of the IG participated in a rehabilitation
programme. ‘No rehabilitation’ was reported by 26.3% in
the CG group and 5.3% in the IG. ‘Inpatient rehabilitation’
was undergone by 31.5% in the CG vs. 21.1% in the IG.
‘Partial outpatient rehabilitation’ was reported by 21.1% in
the CG and 26.3% in the IG, while 21.1% in the CG vs.
47.3% in the IG completed an outpatient rehabilitation
programme (see Figure 2).
Patient satisfaction
In general, immediately after the intervention, patients
expressed their gratitude for the individual attention and
the large amount of helpful information they had received
directly from the first author. In the telephone interviews
16 participants of the IG described to the independent
interviewer the intervention as timely and thus not too
early. In these interviews, the comprehensiveness and
quality of the education were also very highly evaluated.
Discussion
The pilot study examined whether early education and
counselling of patients with ACS could lead to an increase
in self-efficacy and could promote better participation in
rehabilitation programmes and whether such an early
intervention finds acceptance by the patients. Since we
assumed that an acute event of ACS could lead to anxiety
and depression, we controlled for these factors. According
to Bandura55 an increase in self-efficacy is the basis for
future behavioural changes. Sol et al.56 successfully dem-
onstrated that improved self-efficacy had an impact on
patients’ health behaviour, namely that it led to more exer-
cise and better food choices. The preliminary data of this
pilot study revealed that the intervention had an effect on
self-efficacy even in such a small sample of 19 partici-
pants in each group. As we pointed out in the IG, a signifi-
cant increase, compared with the CG, was observed for
‘Control symptoms’, one of the two self-efficacy sub-
scales. This positive effect was still significant when the
two factors anxiety and depression were used as covari-
ates. For ‘Maintain function’ – the second self-efficacy
subscale – no significant difference was seen between the
control and intervention groups. These contrasting find-
ings can be explained by the content of the two subscales
and the nature of the intervention. The education covered
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

Downloaded from cnu.sagepub.com at University of Basel on October 24, 2014

8 European Journal of Cardiovascular Nursing
activity. Those activities were of less immediate concern
to patients during their hospital stay and therefore had
been given less weight in the education.
It is a limitation of the study that despite randomization
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.
These findings may suggest that age does influence the
self-efficacy education effect. However, the influence of
age might also only be due to the unequal distribution of
age in the two groups. A power analysis pointed to a sam-
ple size of 200 being required to demonstrate a small effect
(Cohen’s f = 0.1) with a power of 0.8.
Grace et al.57 recommend in the Canadian Cardiovascular
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
these recommendations to the IG. Patients in the IG hence
showed higher attendance to the rehabilitation programmes
and fewer patients declined rehabilitation compared with
the CG. The positive results allay any concerns raised by
the fact that the first intervention occurred within the first
48 hours in the CCU. The patients appeared to be highly
receptive in spite or perhaps because of their acute per-
sonal situation. Mentrup and Schnepp58 showed in their
review that disturbed feelings quickly eased after primary
percutaneous interventions and did not mirror the serious-
ness of the diagnosis of a myocardial infarction. These
patients contested their diagnosis and showed difficulties
in accepting what had happened. This is in contrast with
our IG patients, who might have accepted their diagnosis
due to the fact that the education was individually chosen
and targeted to the personal situation.
The intervention applied in this study represented
patient-centred care, as described by Drach-Zahavy.59 The
intervention was not only orientated toward medical
knowledge and evidence-based guidelines, but included
individual aspects of the patient. Robinson et al.60 showed
in their review that a patient-centred approach is important
to promote adherence. Our study showed that including
key elements for patient-centred care, such as communica-
tion, shared decision making and support for self-
management, increased attendance and adherence in reha-
bilitation programmes.
Conclusion
Self-efficacy increased but a statistically significant effect
disappeared when controlling for age. This might be due to
the small sample size and hence a full powered study also
controlling for gender and educational background is nec-
essary. Despite the non-significant results in self-efficacy
when controlled for age, early education nevertheless ben-
efited patients. Early, individualized education has shown
to lead to higher participation in and compliance with
Downloaded from cnu.sagepub.com at University of Basel on October 24, 2014
rehabilitation programmes. The positive feedback received
from participants in the IG indicated that early education
and counselling has been well accepted and has been per-
ceived as valuable by patients.
Implications for practice
•• ACS patients benefit from individualized educa-
tion in CCU.
•• Patients can express their educational needs
early.
•• Early education enhances attendance to rehabili-
tation programmes.
Acknowledgements
Thanks to S Piazzalonga and Dr O Pfister from the Rehabilitation
Team for their support in access and data collection of patients
participating in rehabilitation programmes.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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