Background

The day of the coronary angiography is very important and at the same time stressful for a patient. Through the extensive review of the literature, the importance of informing patients before they undergo invasive cardiac catheterization is highlighted.1,2 A very useful and easy way to inform patients is to use a printed brochure with valid, accessible, and comprehensive information for each patient. This information assists the patient to ease symptoms of anxiety, stress, and fear that may be caused by a lack of specialized knowledge of evasive screening medicine, as well as answering questions and queries that they may have. These feelings are created both by the uncertainties and insecurities associated with the diagnosis of the disease and by the invasive nature of the procedure.

The aim of the present study was to test the potential beneficial effects of an information brochure on undergoing cardiac catheterization for the first time and to highlight the importance of informing patients before coronary angiography and the beneficial effects it has on both reducing their fear and anxiety, in a randomized controlled design with one experimental and one control group. More specifically the following hypothesis was tested: Patients receiving the information brochure experience less anxiety and fear just before and during the medical examination than patients not receiving the information brochure.

Methods

A stratified randomization procedure with respect to the variable sex was used in order to increase internal validity. This meant that within each specified group, a table containing the numbers ‘0’ and ‘1’ in random order, determined to which group the subject was assigned. As a result, patients were randomly assigned to an experimental group receiving the brochure before the cardiac catheterization (N = 44), or to a control group not receiving the brochure (N = 44). The brochure was a 4-page leaflet that had information about cardiac catheterization, the process according to the medical protocol of the hospital, and possible complications.

Oral standard information was provided to all by a hospital nurse while the brochure was given only to the intervention group. All staff members involved were blind with respect to conditions. Participants of both groups were assessed before the procedure on hospital admission. On the day of catheterization, each participant in both groups was assessed to identify their problems, knowledge, fear level, and anxiety level before and after the procedure.

Ethical Considerations

The specific research was carried out at the Army Share Fund Nursing Institution. Approval for the study was obtained from the ethical committee of this hospital. It was conducted on patients of the cardiology clinic who were preparing for coronary angiography. All participants of the study were older than 18 years, fluent in Greek, they had already booked an appointment for cardiac catheterization, and the latter would be their first experience for them. The participants were informed about the aim of the study, the measures that the research team has taken in order to protect their anonymity, and their participation was voluntary.

Measures

The research tools for the study at hand were the fear questionnaire for invasive cardiac catheterization (adapted according to the SFQ), the Information Satisfaction Questionnaire (ISQ), and the stress questionnaire (temporary and permanent) STAI. These tools were accompanied by the collection of a number of patient demographic and cognitive characteristics in association with the data produced by the three aforementioned research tools. For the 2 questionnaires, ISQ and SFQ, internal consistency reliability tests were performed. Cronbach’s alpha (a) was calculated for this purpose. The values of the index that are above 0.70 are considered satisfactory. At the end of this survey, the coefficient value for the ISQ questionnaire was 0.81, which indicates that the translated questionnaire had a very good internal consistency. The same procedure was followed for the SFQ questionnaire. Cronbach’s alpha (a) coefficient for the total SFQ was 0.92 after the completion of the questionnaires which proves high reliability of internal consistency.

Analysis

Mean values, standard deviations (SD), median and interquartile ranges were used to describe the quantitative variables. Absolute (N) and relative (%) frequencies were used to describe the qualitative variables. Pearson’s χ2 test or Fisher’s exact test was used to comparing ratios, where the latter was necessary. To check the type I error, due to the multiple comparisons, the Bonferroni correction was used, according to which the significance level is 0.05 / k (where k = the number of comparisons). Linear regression analysis was used to find independent factors related to the fear scale and the stress scale from which dependence coefficients (b) and their standard errors (standard errors = SE) emerged. The linear regression analysis for the fear scale was performed using logarithmic transformations, due to the irregularity of its distribution. So instead of using the initial values of the scale, their decimal logarithms were calculated and used as a dependent variable. Significance levels were bilateral and the statistical significance was set at 0.05. The statistical program SPSS 22.0 was used for data analysis.

Results

Table 1 revealed that the mean age of the studied group subjects was (68.0}8.1 and 65.7}10.2) respectively. The control group consisted of 30 male and 14 female patients, while the intervention group had 31 male and 13 female participants. The majority of the study and control groups were married and pensioners. No statistically significant differences were found between intervention and control groups regarding sociodemographic characteristics.

Table 1. Demographics of the sample
Control group Intervention group
Ν % Ν %
gender Male 30 68.2 31 70.5 0.817‡
Female 14 31.8 13 29.5
Age mean (SD) 68.0 (8.1) 65.7 (10.2) 0.245+
Marital status Unmarried 0 0.0 1 2.3 0.118‡‡
Married 27 61.4 35 79.5
Divorced 6 13.6 3 6.8
Widower- Widow 11 25.0 5 11.4
Profession Civil servant 0 0.0 0 0.0 0.709‡‡
Private employee 3 6.8 6 13.6
Freelancer 3 6.8 5 11.4
Pensioner 31 70.5 26 59.1
Household 3 6.8 4 9.1
Unemployed 3 6.8 2 4.5
Military officer 0 0.0 1 2.3
Farmer 1 2.3 0 0.0
Educational level Primary school 16 36.4 14 31.8 0.666‡‡
Secondary school 9 20.5 12 27.3
High school 9 20.5 7 15.9
College 5 11.4 4 9.1
University 3 6.8 7 15.9
Master degree 1 2.3 0 0.0
PhD 1 2.3 0 0.0
BMI Normal 11 25.0 12 27.3
Overweight 16 36.4 18 40.9
Obese 17 38.6 14 31.8
Smoking No 29 65.9 26 59.1 0.509‡
Yes 15 34.1 18 40.9
Alcohol No 37 84.1 39 88.6 0.534‡
Yes 7 15.9 5 11.4
ΒΜΙ. Mean (SD) 28.7 (4.8) 28.0 (4.5) 0.435+

+Student’s t-test Pearson’s χ2 test ‡‡Fisher’s exact test

Self-assessment of stress

The self-assessment of patients’ stress on a 100-point scale for each group is presented in Table 2 below.

Table 2. Self-assessment of stress
Stress Group P Mann- Whitney test
Control Intervention
mean
(SD)
Median
(Intermediate range)
mean
(SD)
Median
(Intermediate range)
On admission to the coronary angiography laboratory 53.9 (27.5) 60 (30 ─ 70) 34.5 (23.5) 30 (20 ─ 50) 0.001
Before coronary angiography 52.5 (29) 60 (25 ─ 80) 33.9 (23.5) 30 (20 ─ 50) 0.002
During coronary angiography 49.5 (27.5) 55 (30 ─ 70) 34.8 (25.3) 30 (20 ─ 50) 0.011
After coronary angiography 18 (20.6) 10 (0 ─ 25) 9.8 (14.1) 10 (0 ─ 10) 0.020

Τhe anxiety of the patients in the intervention group (those who received the information before the cardiac catheterization procedure) was significantly lower in all measurements compared to the anxiety of the patients in the control group.

Table 3 demonstrates the participants ’ scores on the fear dimensions as to patients who will undergo invasive cardiac catheterization. The results presented in the table show that higher values indicate more fear.

Table 3. The patients’ fear of the 2 groups separately
  Group P Mann- Whitney test
Control Intervention
mean
(SD)
Median
(Intermediate range)
mean (SD) Median
(Intermediate range)
Fear of surgery (short term) 21.5 (11.1) 23.5 (14 ─ 29) 14.3 (10.1) 14 (5 ─ 20) 0.002
Fear of surgery (long term) 17.3 (11.8) 17.5 (8.5 ─ 27) 13.5 (13.5) 11 (2.5 ─ 18.5) 0.062
Fear of surgery (total) 38.7 (19.8) 41 (20.5 ─ 54.5) 27.8 (21.7) 24 (12 ─ 37) 0.009

The patients in the intervention group (those who had received the information about invasive cardiac catheterization) had significantly less short-term fear, but also overall compared to the patients in the control group. In contrast, long-term fear was similar in both groups.

Table 4 presents participants ’ scores on the temporary and permanent stress scales, separately for each group. Higher values indicate more symptoms of anxiety.

Table 4. Patients’ scores on the temporary and permanent stress scales
  Group P Student's t-test
Control Intervention
mean (SD) mean (SD)
Temporary stress 47.3 (13.2) 44.9 (11.2) 0.360
Permanent stress 39.3 (11.8) 40.5 (12.2) 0.627

Regularity was checked in the subgroups according to the Kolmogorov - Smirnov criterion.

Both groups appear to have similar anxiety symptoms. The cognitive characteristics of the patients for the 2 groups separately are given in Table 5 below.

Table 5. The cognitive characteristics of the patients for the 2 groups separately (before cardiac catheterization)
Group P
Pearson's x2test
Control Intervention
Ν (%) Ν (%)
Do you know the procedure of invasive cardiac catheterization? (coronary angiography) Yes 16 (36.4) 35 (79.5) <0.001
No 28 (63.6) 9 (20.5)
Have you received any information from the laboratory staff about the invasive cardiac catheterization procedure? Yes 13 (29.5) 20 (45.5) 0.123
No 31 (70.5) 24 (54.5)
Have you received any printed information material from the laboratory staff about the invasive cardiac catheterization procedure? Yes 3 (6.8) 12 (27.3) 0.011
No 41 (93.2) 32 (72.7)
Have you been informed about the possible complications of the procedure? Yes 14 (31.8) 25 (56.8) 0.018
No 30 (68.2) 19 (43.2)
Have you sought information about the process to be submitted? Yes 16 (36.4) 23 (52.3) 0.133
No 28 (63.6) 21 (47.7)
Do you know from the past the cardiologist who will take care of you? Yes 29 (65.9) 24 (54.5) 0.276
No 15 (34.1) 20 (45.5)

36.4% of the patients in the control group knew about the procedure of invasive cardiac catheterization. The corresponding percentage of patients in the intervention group was significantly higher and equal to 79.5%. Also, 6.8% of the patients in the control group had received some printed information material from the laboratory staff about the procedure of invasive cardiac catheterization while the corresponding percentage of patients in the intervention group was significantly higher and equal to 27.3%. Also, 31.8% of the patients in the control group were informed about the possible complications of the procedure while the corresponding percentage of patients in the intervention group was significantly higher and equal to 56.8%. The other elements of Table 5 above did not differ significantly between the two groups.

Table 6 shows in detail the answers of the patients of each group to the questions concerning their satisfaction with the information they received. It also presents the rating of the participant’s satisfaction with the provided information on the scale of 0 to 16 points. Higher scores correspond to greater satisfaction with the information provided.

Table 6. Patients’ satisfaction with their information
Group P Fisher's exact test
Control Intervention
N % N %
Which of the following categories best applies to you? I would like all the available information and participate in the decision about my illness 37 84.1 32 72.7 0.359
I would just like positive information about my illness 3 6.8 7 15.9
I would only like limited information and I would prefer the doctor to make the decisions 4 9.1 5 11.4
Do you think that the provision of information could be improved? No 2 4.5 5 11.4 0.434
Yes 42 95.5 39 88.6
Explanation regarding Invasive Cardiac Catheterization e.g. procedure. necessity of examination. possible risk Very dissatisfied 0 0.0 1 2.3 0.779
Dissatisfied 2 4.5 1 2.3
Neither 14 31.8 14 31.8
Satisfied 22 50.0 19 43.2
Very satisfied 6 13.6 9 20.5
Information on side effects Very dissatisfied 0 0.0 1 2.3 0.419
Dissatisfied 1 2.3 0 0.0
Neither 19 43.2 13 29.5
Satisfied 21 47.7 25 56.8
Very satisfied 3 6.8 5 11.4
Advises in relation to way of life after Invasive Cardiac Catheterization e.g. diet. exercise. health monitoring plans Very dissatisfied 0 0.0 0 0.0 0.748
Dissatisfied 0 0.0 1 2.3
Neither 16 36.4 14 31.8
Satisfied 19 43.2 22 50.0
Very satisfied 9 20.5 7 15.9
Total information provided Very dissatisfied 0 0.0 0 0.0 0.470
Dissatisfied 3 6.8 0 0.0
Neither 13 29.5 15 34.1
Satisfied 21 47.7 22 50.0
Very satisfied 7 15.9 7 15.9
Information Satisfaction Score. Average (SD) Median (Intermediate Range) 10.9 (2.5) 11 (9 - 12.5) 11.1 (2.3) 11 (9.5 -12) 0.742+

The majority of patients in both groups would like to have all the necessary information available to them. They would also like to participate in the decision about their illness, with the percentages being 84.1% for the control group and 72.7% for the intervention group. In addition, 95.5% of patients in the control group and 88.6% of patients in the intervention group believed that the provision of information could be improved. The mean patient satisfaction score of the control group was 10.9 points (SD = 2.5 points) while for the intervention group patients was similar and equal to 11.1 points (SD = 2.3 points). Therefore, patients’ satisfaction with the information provided was similar in the two groups.

Discussion

Our findings demonstrate that patients in the intervention group had significantly less short-term and overall fear compared to the patients in the control group. Therefore, they are in agreement with previous findings of relevant studies which reported also that the intervention group had lower fear compared to the control group, indicating that education reduces psychological problems such as fear and anxiety3 and that patients who had received the necessary training before cardiac catheterization showed significantly fewer psychological problems.4,5 The reduction of psychological problems such as fear was a result of the use of educational programs was also the key result of a research conducted by the Jamshidi and colleagues.6 Furthermore, the results of this study are also consistent with the research of Dehghani and colleagues who have shown that training programs in patients undergoing invasive cardiac catheterization play an important role in reducing fear and anxiety.5

In our research, the anxiety of the patients in the intervention group was significantly lower compared to the one that patients of the control group experience. Our finding is in agreement with the results presented by Dogan and colleagues which indicated that the use of patient-centered educational interventions can reduce their stress.7 Regarding the level of information provided to patients who undergo such evasive screening procedures, research conducted by Buzatto and Zanei and Aboalizm and colleagues., showed, in accordance with this study’s results, that inadequate information and lack of education of patients about cardiac catheterization increase their stress levels.8,9 Finally, in another study by Garvin and colleagues, where 2 groups of patients were used, one intervention group and one control group, the intervention group (the informed group) recorded lower stress rates compared to the control group throughout the coronary angiography.10

Conclusions

Informing patients before coronary angiography plays an important role in reducing their anxiety and fear symptoms. Patients’ gender is important in the manifestation of their anxiety and fear. The role of nurses in the education of patients is considered necessary and of great importance.

Suggestions

Additional suggestions for further research are:

  • Specially trained nurses must collect and list all the necessary information that patients need

  • Conducting research that will examine the relationship between the patient’s adaptation to the hospital environment and previous education they received on health issues.

  • The creation of an approved brochure regarding coronary angiography.

  • The use of posters or instructional videos.

  • Appropriate information for patients’ relatives.

Study Restrictions

  • Limited time frames as defined by the respective work time frames.

  • The results may not generalize to all those undergoing invasive cardiac catheterization as the number of patients was small.

  • It is necessary to conduct generalized surveys with more participants admitted to public and private hospitals.

  • It is necessary to consider additional factors that may aggravate the feelings of fear and anxiety of patients who are waiting for an upcoming coronary angiography (waiting time, existence, or not of a supportive environment).


Author Contribution

MM had the supervision of the whole study

VP and IA made the research protocol

VP and IP wrote the manuscript

AN and IA made the analysis of the data collection

MM and PS reviewed the manuscript

Conflict of Interest Statement

There is no conflict of Interest

Funding

No funding was granted for the research