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American Journal of Critical Care. 2008;17: 244-245
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Evidence-Based Review (EBR) is the journal club feature in the American Journal of Critical Care. In a journal club, attendees review and critique published research articles: an important first step toward integrating evidence-based practice into patient care. General and specific questions such as those outlined in the "Discussion Points" box aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications of the article for clinical practice. When critically appraising this issue’s EBR article, found on pp 232–243, consider the questions and discussion points outlined in the "Discussion Points" box. Visit www.ajcconline.org to discuss the article online.

Evidence-Based Review and Discussion Points

By Ruth Kleinpell, RN, PhD. Ruth Kleinpell is contributing editor of the Evidence-Based Review section. She is a professor in the Rush University College of Nursing, a teacher-practitioner at the Rush University Medical Center, and a nurse practitioner with Our Lady of the Resurrection Medical Center, Chicago, Illinois.

This prospective, longitudinal study examined the health-related quality of life (HRQOL) of 100 patients undergoing diagnostic coronary angiography. The specific aims of this study were to compare patients with and without high baseline levels of uncertainty and to examine the influence of uncertainty on HRQOL 1 year after the initial angiography. Patients’ HRQOL, symptoms, uncertainty, perceived control, social support, and stressful life events were studied before (4 days to 1 week) angiography and 1 year after angiography. Patients with higher baseline uncertainty had significantly lower levels of perceived control, higher levels of anxiety, and higher levels of depression at 1 year than did patients who had lower uncertainty before the procedure, regardless of outcome and treatment regimen.

Patients who had no evidence of coronary artery disease (CAD) on the angiogram reported more distress before the procedure; however, at 1 year, no differences according to angiographic outcome were apparent in the number of stressful events or in levels of perceived control, anxiety, hostility, depression, or HRQOL. Perceived control was a significant determinant for overall HRQOL.


   Information From the Authors
Top
 Information From the Authors
Implications for Practice
 Investigator Spotlight
 Discussion Points
 
Jo-Ann Eastwood, RN, PhD, CCNS, primary author of this EBR article, reports that the research team considered different approaches to conducting the study.

"We were interested in the immediate effect of the procedure results on women’s feelings of uncertainty," she explains. "However, we realized that 1 year was a reasonable measure of extended follow-up in postangiography patients and we felt that the longer follow-up would add to our knowledge of how uncertainty changed over time."

She also explains that the patients were recruited for the study in physicians’ offices when it was known that the patient would be undergoing coronary angiography.

"I was fortunate to have nurse practitioners and office staff who helped me out by telling the patients about the study, then asking permission for me to call them. After they received permission to contact the patients, I called and arranged a convenient time and place in which to meet them, explain the study, and consent them. These were all elective caths, no emergent ones; hence the 4 days to 1 week from the time they were enrolled."

The study results revealed that depression ratings differed between patients who had CAD shown by angiography and patients who did not. "Depression did correlate with uncertainty and HRQOL," Eastwood notes. "On face value, the subsamples looked different. However, statistically it would be difficult to show an effect because of the small sample size. In the current study, a smaller change in depression scores was associated with a smaller change in disease-specific HRQOL. It is surprising that as depression improved, a corresponding improvement in overall HRQOL was not noted. This finding could be related to instrumentation, since the Quality of Life Index–Cardiac does not include questions specifically targeted at dysphoria and thus might not have been sensitive to improvements in depressive symptoms."


   Implications for Practice
Top
 Information From the Authors
 Implications for Practice
Investigator Spotlight
 Discussion Points
 
Eastwood believes that the study results have significant implications for clinical nursing. "Despite the outcome of a heart catheterization, the patient’s quality of life is influenced by the procedure, and patients remain uncertain even after 1 year has passed," she says. "This is relevant to critical care nursing; it has been shown in the literature that information/education decreases uncertainty. Uncertainty and anxiety are associated with each other. The knowledge that patients’ perceptions of their health have changed is worrisome, and that it is so much of a stressor that it is still measurable 1 year from the time of the cath is important. Also, patients who have had a negative cath are more distressed.

"Perhaps the problem is that they have no answer for what brought them to the physician to begin with. Nurses are in the unique position to identify these patients and to supply information, preventive education, and support."

According to Eastwood, readers of the American Journal of Critical Care can best use information from the study to ensure that patients are well educated. "Patients and families should understand what their outcome is and understand that, even though they did not receive treatment, they still may have disease," she says. "Educating patients about lifestyle changes and providing individualized information on risk-factor modification according to evidence-based guidelines is an ethical and moral duty for nurses. Readers can use this information to develop collaborative practice with dietitians, advance practice nurses, and physicians to enhance communication and education for this target population and to streamline it in an effort to deliver it efficiently given the short time this population of patients is exposed to health care providers."


   Investigator Spotlight
Top
 Information From the Authors
 Implications for Practice
 Investigator Spotlight
Discussion Points
 


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  		Jo-Ann Eastwood

 
This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.

Jo-Ann Eastwood developed an interest in conducting research because of her clinical nursing experiences. "I have been a critical care nurse for more than 30 years," she notes. "My interest in the cardiovascular arena peaked when I worked at Stanford University’s ICU early in my career. I became interested in the inequities of information on women and heart disease in the 1990s during my graduate school education. While I was in the PhD program at UCLA, I worked in a cardiology department in a community hospital. My interest for research was to add to information regarding women and interventional procedures. I was concerned about the paucity of literature addressing cardiac disease in women."

This study was conducted as part of Eastwood’s doctoral research. She explains: "I had been accepted to UCLA for the PhD program and was awarded a Quality of Life Fellowship from a Center Grant. At the same time, I was working part time in interventional cardiology at a community hospital. The rapid admission and discharge of patients undergoing procedures interested me. Having been a clinical specialist, I noted how little time there was for patient exposure to health care providers and for education regarding how this procedure would impact their lives. Also, I was concerned that patients (many of whom were women) might mistake a short hospital stay, often not even overnight, to mean that they were healthy and did not have coronary artery disease."

Eastwood is continuing to conduct additional research and is now part of the Women’s Heart Center Research Team at Cedars-Sinai Medical Center. "I am currently doing a pilot study on premenopausal women and heart disease and will continue to infuse health-related quality of life questionnaires," she says. She also intends to continue conducting research related to heart disease. "Based on the experience I gained doing my dissertation project," she adds, "I would like to develop a research program based on gender differences in patients, particularly women who continue to have symptoms of heart disease but who have had a negative angiogram."


   Discussion Points
Top
 Information From the Authors
 Implications for Practice
 Investigator Spotlight
 Discussion Points
 

  1. Description of the Study
    {square} What was the purpose of the research?
    {square} Why is the problem significant to nursing?

  2. Literature Evaluation
    {square} What previous research related to patients’ health and well-being has been conducted on patients undergoing coronary angiography?
    {square} What has research in illness-related uncertainty demonstrated?

  3. Sample
    {square} What were the inclusion and exclusion criteria?

  4. Methods and Design
    {square} What tools were used to measure HRQOL and the variables of interest in the study?
    {square} When and how were data obtained from the subjects?

  5. Results
    {square} What were the findings of the research?
    {square} How did patients with high vs low illness uncertainty differ with respect to study outcomes?

  6. Clinical Significance
    {square} What are the clinical implications of this study?
    {square} How does the study extend the evidence base on HRQOL for patients undergoing coronary angiography?

eLetters
Now that you’ve read the EBR article and accompanying features, discuss them with colleagues. To begin an online discussion using eLetters, just visit www.ajcconline.org, select the article in its full-text or PDF form from the table of contents, and click "Respond to This Article" from the list on the right side of the screen. All eLetters must be approved by the journal’s coeditors prior to publication.


Related articles in AJCC:

Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography
Jo-Ann Eastwood, Lynn Doering, Janice Roper, and Ron D. Hays
AJCC 2008 17: 232-242. [Abstract] [Full Text]  




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