Iranian Journal of Critical Care Nursing, Winter 2012, Volume 4, Issue 4, Pages: 169 - 176

Design of guidelines evidence-based nursing care in patients with angina pectoris

Maryam Nezamzadeh1, Seyed Mohammad Khademolhosseini1*, Jamileh Mokhtari Nouri1, Abbas Ebadi1

1. Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran

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Abstract
Aims: Evidence-based clinical guidelines effectively guide medical teams and nurses to increase the quality of clinical
work. Designing evidence-based guidelines in critical care units, especially in cardiac care unit is much more needed.
Therefore, this study was conducted to design evidence-based nursing care guidelines for patients with angina pectoris.
Methods: This descriptive-comparative study was conducted in two cardiac care units in Baqiyatallah Hospital in Tehran
in 2011. First, the quality of 30 available care guidelines was investigated via a checklist designed by the researcher in three
levels: good, average and poor.
Then nursing care guidelines were designed based on Stetler model with an evidence-based approach and their quality was
re-investigated. Finally, the collected data was analyzed by the help of descriptive statistics and using SPSS 17 software.
Results: Quality of 26.7 % of the available guidelines was found out to be poor and 73.3 % was proven to be average.
After designing the guidelines, this number increased to 100 %. Finally, an eight evidence-based nursing care guideline was
designed for patients with angina pectoris.
Conclusion: Since the available guidelines are of low quality, designing evidence-based care guidelines can improve
nursing care.

Key words: Care guidelines; Nursing; Evidence-based; Angina pectoris; Cardiac Care Unit

Introduction matter of fact, evidence-based process attempts

In spite of the presence of different programs
to prevent and cure heart disease, 1.9 million
people in America and Europe die due to this
disease every year. The most common
symptom of cardiac ischemia is chest pain.
Chest pain is a common symptom among the
people admitted to the cardiac care unit and
about 2 to 8 percent of these patients
hospitalized in this section show it. About 30%
of patients are re-hospitalized with symptoms
of angina pectoris 2 to 3 years after their first
hospitalization [1-3].
Nursing care is vital for patients with angina
pectoris in critical care unit. Proper
management can prevent the patients from re-
hospitalization. Nurses play an important role
in monitoring, supporting, investigating, and
educating patients [3, 4].
If patients are treated based on scientific
research results, care outcomes can
significantly improve [5]. The application of
scientific evidences to improve performance
and clinical decisions is called evidence-based
care [6-8]. Evidence-based care is a new
concept with less than two decades of age. As a
to improve the quality of information on which
a correct decision in health care can be taken
[9-11].
Evidence-based nursing is a process which has
appeared as a way for health and therapeutic
care based on the latest findings in recent
years. Through this process, nurses can
improve their clinical skills and patients’
performances using the available research
results and take proper clinical decisions. At
any rate, providing effective care based on the
best evidences is an international strategy for
the health institutes today [13].
As it is hard for the health care personnel to
use the huge amount of research results,
clinical guidelines are advised as a facilitator.
Implementing clinical guidelines helps
appropriate clinical decisions to be taken and
also saves time and costs [5]. Evidence-based
guidelines explain administrative procedures of
clinical care and prevent non-standard clinical
work [14].
In 1990, Washington Medical Society stated
that clinical guidelines systematically improve
clinical care and care decisions for patients on

* Correspondence Author: khadem@bmsu.ac.ir

 170 Design of guidelines evidence-based nursing care in patients with angina pectoris
special conditions [15]. In 1996, Saket et al.
designed clinical guidelines based on the best
available evidences [13].
In 2002, National Institute for Clinical
Excellence (NICE) expressed guideline
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production stages as follows:
• Developing the required criteria for
designing guidelines
• Making regulations and establishing a
work group
• Searching for credible evidence and
analyzing evidences
• Asking experts and consulting about
guidelines
• Developing and disseminating evidence-
based care guidelines [13].
Taylor, in 2003, started to design nursing care
guidelines for critical care units based on the
best and most effective scientific evidences.
Accordingly, a committee of the best clinical
Figure 1 [23]
nurses was established to create guidelines and
they followed the stages of clinical guidelines
production. The stages included: creating
clinical variables, establishing a program
management group, search in scientific and
research sources, considering experts and
advisors’ viewpoints, and finally disseminating
guidelines. These guidelines were followed in
critical care units where patients needed more
care. As a result, it could help nurses to take
better decisions in caring for patients. Taylor
expressed nursing care guidelines for each
patient as well, so that the best decision is
made in each situation [16].
International Health Society announced that it
would support clinical guidelines application
and use of evidences in clinics in order to
develop nursing and midwifery; it also added
that the guidelines needed to be updated based
on the latest research. Some sources in 2004

said that only 38 % of nursing care was based
on research. Therefore, due to the fast changes
in scientific fields, developing and updating
high quality clinical guidelines and gaining
access to valid sources seem necessary [12].
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The results of the study conducted by Dero et
al. in 2004 proved that the guidelines produced
from the best sources could properly guide care
in patients with heart disease [17]. Similarly, in
their study in 2005, Gibler et al. stated that
clinical guidelines performance was useful for
patients with transient angina and myocardium
infarcts. They also mentioned that evidence-
based guidelines can be useful both for the
hospitalized patients and those who are
discharged. They expressed that if heart
specialists and emergency service personnel
follow these guidelines, they can provide better
care for the patients with heart disease and this
would result in better outcomes [18].
In 2007, Ting et al. expressed that applying the
standardized protocol can decrease the disease
diagnosis time and increase the quality of care
[19]. Jon Stanley also pointed out that
developing discharge guidelines in patients
suffering from heart failure would cause a
reduction in the number of patients re-
hospitalized in critical care units [20].
Today, it is essential to take good care of
patients because of the emphasis on resource
management, cost control, effectiveness of
patients care, improving quality and
responsibility [21]. Accordingly, frameworks,
factors, and strategies which can assure
Table 1: Quality of nursing care guidelines
Frequency Present condition
Quality Number
Poor 8 26.7
Average 22
Good 0 0
Total 30
Nezamzadeh M. et. Al. 171
patients care seem necessary. These
frameworks can be presented in form of
clinical guidelines in different units especially
critical care units [14].
Since the most common symptom among
patients who come to critical care units is chest
pain, setting guidelines based on research can
improve the quality of nursing care and reduce
the possibility of these patients get re-
hospitalized. Therefore, nursing clinical care
guidelines for angina pectoris were designed
with an evidence-based approach.
Methods
This descriptive, comparative, and analytical
study was conducted with an evidence-based
approach and based on Stetler model in two
critical care units of Baqiyatallah Hospital in
Tehran in 1389 and 1390. Stetler model
includes:
Preparation: Identifying goals and problems of
care in patients with angina pectoris,
investigating the quality of clinical care
guidelines, designing the guidelines and
reviewing the quality of guidelines
Validation: Reading and reviewing the articles
according to the evidence-based pyramid and
guidelines approval by asking scientific board
members, heart specialists and training
teachers of cardiac care unit as nominal groups
Comparative study: Determining the feasibility
of guidelines in the unit by nurses through
focus group discussion method
Application and Performance: Since some time
After designing
Percent Number Percent
0 0
73.3 0 0
30 100
100 30 100
 172 Design of guidelines evidence-based nursing care in patients with angina pectoris
is required to execute guidelines, and it is
beyond a student’s thesis range, guidelines
were given to the hospital teaching officials
[22].
To assess the quality of available nursing care
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guidelines, a checklist was designed by the
researcher based on nursing process framework
and two instruments were made: AGREE
(Appraisal of Guidelines for Research &
Evaluation), and GLIA (Guideline
Implementability Appraisal). AGREE
instrument contains 23 items and 6 domains,
which has been used to assess the quality of
care guidelines since 2003. GLIA is also an
instrument that investigates the practicality of
guidelines, and studies the measurability of
guidelines in the fields of innovation, validity,
flexibility, and amount of effect on care
process.
The created instrument contained two sections
and 26 (yes - no) questions, 11 questions to
investigate the guideline status and 15
questions to evaluate the guideline quality.
Intra-rater correlation coefficient (ICC) was
found out to be 0.78.
To evaluate the quality of care guidelines, logic
33 was utilized. Final scores were assessed at
three levels: low (0-33%), average (33-66%)
and good (66-100%) and the quality of 30
available nursing care guidelines were
evaluated.
To design guidelines, nursing diagnoses related
to the angina pectoris disease were derived by
a detailed review of articles and based on
nurses’ clinical needs. Articles were prioritized
in evidence-based pyramid (Figure 1). The
articles were selected from Persian valid and
international databases such as Pub Med,
Cochran, Google scholar, Springer, Elsevier,
SID, Magiran in form of whole article text
between the years 2005-2010. Quality of the
eight designed guidelines was measured by a
checklist created by the researcher. The data
was analyzed through descriptive statistics and
SPSS17 software program.
Having prepared the guidelines, a validation
group scientifically investigated them. The
validation group included a nominal group
consisting of scientific board members, heart
specialists and cardiac care unit training
teachers. Also, a focus group directly or
indirectly provided clinical care in cardiac care
unit, confirmed the practicality of the
guidelines, and offered some suggestions for
further explanation about some items. The
focus group consisted of 15 nurses, whose
average age was 36; 13 of them had a BS and 2
of them had an MS; and their average
occupational background was 15 years.
Results
This study proved that none of the available
guidelines were in a good level. However, after
designing guidelines with an evidence-based
approach and considering the previously
identified variables in the checklist, it
increased to 100 % (table 1).
Designed guidelines have two parts: Guideline
status: In this part, the purpose of designing
guidelines is resented first. 8 nursing diagnoses
related to patients with angina pectoris were
derived based on articles:
• Risk for decrease cardiac output
• Chest pain
• Disrrythemia
• Risk for myocardial perfusion altered
• Anxiety
• Risk for activity intolerance
• Impaired in drug regimen
• Knowledge deficient
Then the purpose group, design experts,
criteria for entering and exiting sources, design
method, use and utilized sources were
mentioned. In the end, regarding the fast
development of science, it was declared that
these guidelines would be valid by 1394 and
after that they should be updated by new
sources [24].
 Nezamzadeh M. et. Al. 173

Chest pain (NANDA)

Nursing diagnosis
Chest pain associated with
• Decrease in blood flow to heart
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• Increase in cardiac work and decrease in oxygenation

Evaluation criterion / symptoms
Patients’ appearance, complaining about pain, insomnia, BP, RR, Pr, breathing pattern
Nursing interventions
1. Investigating pain intensity and quality through pain visual scale [2, 25]
2. Monitoring patients’ pain [2, 26]
3. Checking vital signs every 5 to 15 minutes during pain attacks until stabilization of the symptoms [26, 27]
4. Communicating with humor [26, 28]
5. Complete rest [29, 30]
6. Use of massage therapy as a non-pharmacologic anti-pain [31]
7. Use of relaxation as a non-medicinal anti-pain [32]
8. Change in position as a non-drug anti-pain [33]
9. Easing the situation [34]
10. Reducing environmental stimuli [35]
11. Restricting patient’s visitors [35]
12. Giving 4 to 6 liters of oxygen through nasal tube (2 to 3 liters in patients with COPD) [29]
13. Nitroglycerin 5 – 10 µ/min, during 15 to 20 minutes in patients with systolic pressure over 90 mmgh, on

doctor's prescription [29, 33]

14. Recommending the doctor to use drugs [29, 33]
15. Consulting with the doctor if no relief in pain [33]
16. Training low fat, low salt diet [36]
17. Training patients about not doing the Valsalva maneuver [37, 38]
18. Training about not smoking [39]
19. Training about cautious taking of caffeine [tea, chocolate, cola drinks] [33, 40]

Designed guidelines: The guidelines were Discussion

designed based on nursing process including 3
parts: diagnosis, evaluation criteria, and
nursing interventions. As it is not possible to
present all the care guidelines in this article,
thus, just one diagnosis is given here as an
example.
In this study, the quality of available guidelines
in cardiac care units was proven to be in an
average level. This is similar to the findings of
the study done by Burgorz et al. In their study,
the quality of available guidelines in oncology
unit was measured via AGREE instrument and
the obtained result was 42.2 % which is an
average level [41].
 174 Design of guidelines evidence-based nursing care in patients with angina pectoris
The guidelines for angina pectoris were
designed according to an evidence-based
process. The evidence-based process can be
helpful for the development of clinical care
guidelines. Accordingly, in 2004, to create
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quality guarantee, Dero et al. used guidelines
produced from the best sources in taking care
of the patients with heart disease in hospitals
[17].
In this study, the guidelines were developed
after determining the nursing diagnoses,
reviewing the articles based on an evidence-
based process, and forming the validation
groups. Taylor, in 2003, created nursing care
guidelines for critical care units. In his paper,
he has mentioned the production of guidelines
based on the best and most effective clinical
evidence. In this process, a committee
consisting of the best clinical nurses was
formed so that they make the guidelines. The
process of making the clinical guidelines
included some stages: creating clinical
variables, forming a program management
group, searching in scientific and research
sources, considering the experts and advisors’
viewpoints, and finally, publication and
dissemination of the guidelines [16].
Several studies confirm that these guidelines
can improve quality of care. In 1388,
Motehadian Tabrizi et al. suggested the effect
of programmed care on reduction of the side
effects of dialysis. In this study, care guidelines
based on valid sources and confirmed by
experts caused the reduction in side effects in
patients treated by dialysis [4].
In 2007, Ting et al. implemented the protocol
on 579 patients suffering from acute infarcts.
This proved that implementing standardized
protocol can reduce disease diagnosis time and
increase the quality of care [19]. In 1384,
Parvarzadeh et al. investigated the effect of
standard clinical care guidelines on the result
of pregnancy. The findings indicated that in
mothers, who had been taken care of according
to the standard care, childbirth factors
increased and they faced fewer problems [42].
In 2005, Gibler et al. recognized clinical
implementation of the guidelines for patients
with transient angina and myocardium infarcts
in the emergency unit useful. They also stated
that evidence-based guidelines are good both
for the hospitalized patients and the ones who
are discharged. Following the guidelines by
heart specialists and emergency service
personnel results in better care for patients with
heart disease and brings about better outcomes
[18].
Conclusion
Low quality of available guidelines determines
the necessity of reviewing and designing care
guidelines. Evidence-based care has been
emphasized on by the authorities of the health
system as a way to improve services.
Considering the outbreak of angina pectoris in
critical care units, heavy costs for its treatment,
and the attempts of clinics to increase the
quality of care, nursing clinical guidelines
based on an evidence-based process can be a
valid source of giving nursing service and
reduce the patients’ hospitalization time and
costs.
With more research done on nursing care in
cardiac care unit and encouraging personnel to
use evidence-based guidelines, increase in the
quality of nursing care can be reached. In
addition, coding the guidelines facilitates their
uses for clinical nurses and also saves the time
dedicated to their registration. Finally, it seems
necessary for all the hospital units to develop
the latest evidence-based guidelines, so that by
implementing them in clinical units, nursing
care quality improves.
Acknowledgments
Thank you to the scientific board members of
Nursing Medical Sciences Faculties in Tehran
and Baqiyatallah University for their support in
scientific fields. We also owe a debt of
gratitude to the authorities and nurses of
cardiac care units of Baqiyatallah University
for their utmost cooperation.

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