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Received: 5 May 2022    Accepted: 23 November 2022

DOI: 10.1002/nop2.1549

RESEARCH ARTICLE

Impact of educational programme on patient's health outcomes

following open heart surgeries

Samia Eaid Elgazzar1,2  | Shereen Ahmed Ahmed Qalawa1,2  |

Amira Mohammed Ali Hassan3

1
Department of Medical-­Surgical Nursing,
College of Nursing, Qassim University, Al Abstract
Qassim, Saudi Arabia
Background: Postcardiac surgery, numerous factors have been shown to predict
2
Department of Medical-­Surgical Nursing,
Faculty of Nursing, Port-­Said University,
postoperative harm of QoL, such as age, female sex, history of hypertension, chronic
Port-Said, Egypt obstructive pulmonary disease, education level, marital status, and also psycholog-
3
Departmentof Medical-Surgical Nursing, ical factors such as the presence of mood disorders. So, the essential key to self-­
Faculty of Nursing, Suez Canal University,
Ismailia, Egypt management is behavioural change, which is necessary to improve the quality of life
of patients and Health outcomes.
Correspondence
Shereen Ahmed Ahmed Qalawa, Nursing Aim: The aim of this study is to evaluate the impact of the education programme on
College, Qassim University, KSA, Egypt. patients' health outcomes following open heart surgeries.
Email: s.qalawa@qu.edu.sa and shereen.
q066@yahoo.com Patients and Methods: Quasi-­experimental research design carried out in intensive
care for open heart surgery in Suez Canal university hospitals at Ismailia Governate
on all available both sex patients performing open heart surgery for 6-­month period
(60) using the following four tools: the first tool for patient's risk stratification model
Euro Scale sheet; the second tool New York Heart Association scale for assessing
functional abilities; the third tool for health outcomes sheet for assessing patient's
quality of life and health status; and the fourth tool for assessing Hospital Anxiety
and Depression Scale.
Results: There was no significant difference found in the patient's vital signs before
and after the educational programme. On the other hand, there was no statistically
significant difference between overall quality of life and socio-­demographic charac-
teristics before and after the educational programme.
Conclusion: This study concluded that the educational programme has a positive ef-
fect on patients' quality of life in patients' educational programme; improve patient's
health status as indicated by improved patient outcomes.
Relevance to Clinical Practice: The most important finding was the value of the edu-
cational training programme to address the needs of open heart surgery patients,
indicating that after heart surgery, patient education by training can be helpful in self-­
care, and nurses can use a programme containing preparatory information to enhance
results, alleviate patients problems, and improve the quality of life in patients with
CABG.

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2022 The Authors. Nursing Open published by John Wiley & Sons Ltd.

Nursing Open. 2022;00:1–14.  |

wileyonlinelibrary.com/journal/nop2     1
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2      ELGAZZAR et al.

KEYWORDS
educational programme, health outcomes, open heart surgery, quality of life

1  |  I NTRO D U C TI O N anaesthesia, and fear of death reactions resulting from surgery

(Ertürk & Ünlü, 2018).
Coronary artery bypass grafting (CABG) persists as the greatest Unfortunately, emotional and behavioural troubles have been
common cardiac surgery implemented today universally. The past of celebrated as a significant phenomenon postopen-­heart surgery.
this procedure can be drawn back for more than 100 years, and its Nevertheless, a vast difference exists in the literature about the
progress has been affected by several innovators in the field of car- presence of psychiatric symptoms, cognitive performance, and qual-
diac surgery, who have subsidized both their successes and failures ity of life among those patients (Younes et al., 2019). So, quality of
(Melly et al., 2018). life (QoL) is a vital concept that assesses physical and mental health
Furthermore, the burden of cardiovascular disease as a long-­term among patients undergoing coronary artery bypass graft (CABG)
illness increasingly requires patients to suppose more responsibility surgery using the Short-­Form 36-­item questionnaire (SF-­36) up to
for their self-­management. Thus, patient education is supposed to be 10 years after surgery (Keage et al., 2016; Younes et al., 2019).
an essential component of cardiovascular care; conversely, there is Furthermore, nurses have a means role in teaching patients post-
limited evidence about specific therapeutic patient education strat- cardiac surgeries to deal with their postsurgical period. There are
egies used and it is the impact on patient self-­management outcomes facts that effective teaching strategies contribute to enhanced qual-
(Barnason et al., 2017). In this regard, the World Health Organization ity of life, and decreased anxiety and depression. Despite this, there
(WHO) has defined health as being “not only the absence of disease are no protocols or standards for the greatest educational strategies
and infirmity but also the presence of physical, mental, and social for cardiac patients postsurgeries during hospitalization and dis-
well-­being”. To confine this, comprehensive perception and quality charge periods (Veronovici et al., 2014).
of life (QoL) has become increasingly important in social sciences Therefore, critical care nurses should give comprehensive care
and health care (Perrotti et al., 2019). based on organized strategies and evaluate provided care of patients
Postcardiac surgery, numerous factors have been shown to pre- along with the health care team based on their knowledge, planning,
dict postoperative harm of QoL, such as age, female sex, history of programming, and management. The skilled professional nurse in-
hypertension, chronic obstructive pulmonary disease, education dividualizes preoperative instruction to meet the specific needs of
level, marital status, and also psychological factors such as the pres- each patient. Thus, patients' perceptions of health and stressors
ence of mood disorders (Perrotti et al.,  2019). For this reason, pa- have crucial for meaningful nursing and care programmes (Ahmed
tients' concerns related to open-­heart surgery mainly include some et al., 2017).
factor as chances of successful surgery, fear of death, fear of pain,
fear about the treatment regimen, weakness, sleep disturbances, ac-
tivities after surgery, cardiac monitoring, length of hospital stay, and 1.1  |  Justification of the problem
hospital costs. Moreover, Coronary artery bypasses grafting (CABG)
as one of the treatment modalities for patients with coronary artery Based on World Health Organization, 2018 for the period of the
diseases has a major physical, psychological, and emotional impact past 15 years, heart disease has been considered the number one
on the patients (Ahmed et al., 2017). As education is the basic ap- cause of death worldwide. However, more than 610,000 individuals
proach to the development of self-­management skills, the strategy die annually from heart disease in the United States, accounting for
used to implement educational support is expected to affect the one-­fourth of all deaths, and approximately 30.3 million individuals
individual level of self-­management and clinical outcomes. So, the in 2018 from the United States were estimated to have heart disease
essential key to self-­management is behavioural change, which is to mitigate these complications, cardiac surgery is regularly carried
necessary to improve the quality of life of patients and health out- out. Cardiac surgery types include coronary artery bypass grafting
comes (Talboom-­Kamp et al., 2017). (CABG), repair or removal of the heart valve, heart transplant, and
On the other hand, the effectiveness of preoperative educa- installation of machines or artificial hearts for ventricular assistance
tion in the postoperative period following cardiac surgery in pa- (Stigler Granados et al., 2019).
tient satisfaction and postoperative outcomes have been the main So, health-­related quality of life (HRQOL) is a significant indi-
concerns (Kalogianni et al.,  2019). Otherwise, individualized edu- cator of long-­term well-­being, influenced by environmental factors
cation is an important issue for preparing patients for the opera- such as family, culture, community norms, and available resources
tion both physically and psychologically attributes to help those that better and earlier diagnostics and clinical management of con-
patients to climb emotional, cognitive, and physiological, loss of genital heart disease (CHD) have led to decreased mortality and in-
working ability, pain, loss of sexual ability, inability to wake up from creased achieved outcomes (Ladak et al., 2020).
ELGAZZAR et al. |
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1.2  |  Conceptual framework 1.2.2  |  Objective

According to Youssef (2013), the conceptual framework for the ar- This study aimed to evaluate the impact of the education programme
rangement of health-­quality of life (HRQOL) outcomes model itself on patients' health outcomes following open-­heart surgeries.
is quite complex. It acknowledges that health exists on a range from
simple to complex outcomes with five determinants, each having
multiple variables. These five levels of health outcomes include bio- 1.2.3  |  Research hypotheses
physiological variables; physical and psychological symptoms; func-
tional health status; perception of general health (Ladak et al., 2020); 1. The postimplementation of instructional scheme functional
and overall quality of life (QOL; Figure 1). ability scores for open-­heart surgery patients will be higher
compared with instructional scheme implementation scores.
2. Patients undergoing open-­heart surgery who will expose to the
1.2.1  |  Significance of study designed instructional scheme about postopen-­heart surgery
care will show better health outcomes.
One of the main concerns in caring for and improving the patient's
quality of life (QOL) after coronary artery bypass grafting (CABG)
is the treatment team which educational interventions may af- 2  |  M E TH O D S
fect the aspects of QOL in various ways (Mahdizadeh et al., 2016).
Thus, declining mortality and major morbidity rates after cardiac A Quasi-­experimental research design was used. This study was
surgery have led to an increasing focus on patient quality of life carried out in intensive care for open-­heart surgery in Suez Canal
(QOL). Beyond longevity, the impact of cardiac surgery on day-­to-­ university hospitals at Ismailia Governate all available sex patients
day functioning is incredibly salient to patients, their spouses, and performing open-­heart surgery for 6 months were precluded in the
their families. On the other hand, the multidisciplinary team should study (60 patients). The inclusive patients were adults aged (21–­60)
plan patient care before, during, and after postopen-­heart surgery years old. Data were collected by using three validated adapted tools
counting the knowledge of self-­c are for postopen-­heart patients to after translation to the Arabic language and making some modifica-
improve their quality of life (Suwanakitch et al., 2019). Therefore, tions to be suitable for the population, beliefs, values, and culture.
this study aims to evaluate the impact of the implementing instruc- The tool I: Patient's Risk stratification model Euro Scale sheet in-
tional scheme on patients' health outcomes following patients' cludes 3 parts as socio-­demographic characteristics for patients such
open-­heart surgeries. as name, age, sex, job, and education etc. Patient Information about

F I G U R E 1  Health-­related quality of life framework (HRQOL) (Peterson and Bredow, 2009)(15)

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4      ELGAZZAR et al.

the types and causes of performing the operation, investigation, measure both in Belgian and Danish cardiac patients. The HCS is
and preoperative care; the risk stratification model Euro Score was also a sensitive outcome measure for tapping treatment and cardiac
adopted from Bjelland et al. (2002) and is used to calculate patients' rehabilitation related to an educational programme of postoperative
risk level; Tool II: New York Heart Association (NYHA). This tool was care implemented through using 5 phases as follows: (1) before edu-
adopted from El-­Baz (2009) is used to give a simple way of classifying cational pathway development, preparing the tools were used from
the extent of heart failure. It places patients in one of four categories the different scientific references and then identifying the patients
based on how much they are limited during physical activity; the lim- who will undergo open-­heart surgeries (during the pre-­operative
itations/symptoms are about normal breathing and varying degrees phase) followed by collecting baseline data, which help in the design
of shortness of breath and/or angina. Tool III: Health Outcomes sheet: of an instructional scheme, in addition to literature review. (2) Pre-­
it includes three parts as follows: Part I: SF-­36 (health-­related quality test phase (Prior learning package implementation), The researcher
of life): it was sent to patients preoperatively after they were sched- preoperatively assessed the patients (socio-­demographic data and
uled for open-­heart surgery, and postoperatively 6 months. 36-­SF: medical health) by using a tool (1), health status which should be
will be adopted from (Chocron et al.,  2000), it is formed from 36 identified preoperatively to the patient to perform postoperatively
questions to assess the health outcome (Quality of life) across eight about open heart surgeries through using tools (2), and the patient's
domains, which are both physically and emotionally based. The eight health outcomes by using a tool (3). (3). Implementation phase, an in-
domains that the SF36 measures are as follows: physical functioning, structional scheme was implemented individualized in a clear and
role limitations due to physical health, role limitations due to emo- concise manner, and focused on the points to be learned, using dif-
tional problems, energy/fatigue, emotional well-­being, social func- ferent adult teaching methods. Implementation of an instructional
tioning, pain, and general health. It consisted of 36 items that assess scheme will be done in two sessions. Each session will be repeated
eight health dimensions: physical functioning questions (3:12); role again. Attendants were chanced to discuss their own experiences
limitations due to physical health problems questions (13:16); role after the researcher clarified to them any queries and explained the
limitations due to emotional problems questions (17:19); energy/ unknown issues. During the pre-­operative period, patients will be
fatigue questions (23–­27–­29-­31); emotional well-­being questions informed about what to expect during the immediate preoperative,
(24–­25–­26-­28-­30); bodily pain questions (21 and 22); social func- and postoperative periods till discharge, and were invited to express
tioning questions (20 and 32); and general health perceptions ques- their feelings of anxiety and their concerns about surgery and recov-
tions (1, 2, 33, 34, 35, 36). Health-­Related Quality of Life (Rand 36 ery. Furthermore, patients were provided with booklets with infor-
item health survey, version1): this was used to assess health-­related mation about surgery and expected outcomes. (4). Evaluation phase
quality of life for study patients before s and after 3 months from (Post-­test), the researcher evaluated the impact of the implementing
surgery and instructional scheme implementation. It consisted of 36 instructional scheme on the patient's health outcomes at the first
items that assess eight health dimensions: physical functioning ques- visit for patient post open heart surgery for follow-­up in the outpa-
tions (3:12); role limitations due to physical health problems ques- tient clinic by using tools (1, 2, 3).
tions (13:16); role limitations due to emotional problems questions
(17:19); energy/fatigue questions (23–­27–­29-­31); emotional well-­
being questions (24–­25–­26-­28-­30); bodily pain questions (21 and 2.1  |  Ethical considerations
22); social functioning questions (20 and 32); and general health per-
ceptions questions (1, 2, 33, 34, 35, 36); Part II: is Hospital Anxiety and Ethical approval was obtained from the ethical board (REDACTED)
Depression Scale (HADS): It was adopted from(Bjelland et al., 2002) which directed the responsible authorities of the study settings to
to measure anxiety and depressive symptoms were assessed at 6 take their permission to conduct the study after explaining its pur-
months post-­C ABG using the 1970s' anxiety subscale and the seven-­ pose to take their permission and gain their cooperation.
item depression subscale from the Hospital Anxiety and Depression
Scale (HADS). The HADS is a valid and reliable instrument (Chocron
et al.,  2000) to predict mortality in patients referred for exer- 2.2  |  Procedure
cise testing; Part III: Health Complaints Scale (HCS). This scale was
adopted by Hevey et al. (2007) and Pedersen and Denollet (2002). After the collection of references and development of a tool based
Which is concerned with measuring disease to cardiac complaints on a literature review, the tool was validated after being translated
a disease-­specific measure of cardiac complaints, was administered into Arabic and retranslated by English experts, and face validity was
twice, namely before surgery and at 6 months' follow-­up. The scale done by five professors from the Medical-­surgical nursing & critical
is a disease-­specific measure developed in cardiac patients, with the care nursing field. A pilot study was carried out after the develop-
12-­item cognitive complaints subscale representing “health worry” ment of the tools on 10% of patients to the test applicability of the
and “illness disruption” (e.g. “The idea that I have a serious illness”) tools then necessary modifications were done according to the find-
and the 12-­item somatic complaints subscale representing “cardio- ing results of the pilot study and expert opinions. Otherwise, these
pulmonary”, “fatigue” and “sleep” problems (e.g. “Tightness of the patients were then excluded from the sample of research work to as-
chest”) (Persson & Stagmo,  2008). The HCS is a valid and reliable sure the stability of answers. The tool reliability was tested through
ELGAZZAR et al.       5 |

Cronbach's alpha coefficient as follows: Split half method was used 2.4  |  Statistical analysis of the data
for both knowledge and attitude tools. The reliability coefficient ‘r’
was calculated using Karl Pearson's coefficient. The reliability coef- Data were fed to the computer and analysed using IBM SPSS soft-
ficient was 0.88 and 0.93 for functional abilities & risk identifica- ware package version 20.0. (Armonk, NY: IBM Corp) qualitative data
tions. Reliability for health outcomes; anxiety & depression scales
questionnaire was established with interrater–­intrarater method. TA B L E 1  Distribution of the studied patients according to
The correlation co-­efficient ‘r’ was calculated using interclass corre- demographic data (n = 60)
lation. The reliability co–­efficient was 0.920. Hence the structured Demographic data No. %
questionnaire was considered to be reliable for the present study.
Age (years)
Data were collected through distributing the questionnaire to pa-
Less than 30 3 5.0
tients; data were collected from August 2019 until February 2019
31–­4 0 31 51.7
according to availability of patient's follow-­up schedule, the purpose
41–­50 26 43.3
of the study was explained prior to get the questionnaire sheet, and
needed time to answer ranged from 30–­45 minutes. The educa- Gender

tional programme was conducted in fourth sessions each session Males 28 46.7
takes 45 minutes; the first session describe the open heart surgeries Females 32 53.3
definition, indications, types, Daily living activities, proper foods the Length
second session about caring for the surgery area and diet, bathing, From 151–­175 cm 40 66.7
suitable dressing, exercises, the last session for corrective action From 176–­200 cm 20 33.3
when facing warning signs as a preventive measure. Data were re- Weight
vised, coded, entered, analysed, and tabulated using SPSS version
From 51–­75 kg 44 73.3
20. Both descriptive statistics (frequency, percentage), and inferen-
From 76–­100 kg 16 26.7
tial statistics (chi-­square test), Pearson Correlation Coefficient test
Social Status
were used according to the type of variables. Statistical significance
Single 5 8.3
was considered at p-­value ≤0.05.
Married 45 75.0
Divorced 10 16.7

2.3  |  Scoring system Residence

Wife 44 73.3
The scoring systems for Tool I include patients' risk levels and Children 10 16.7
patients were classified into three risk groups: (1) low (additive Relatives 6 10.0
score of 0–­2), (2) medium (scores 3–­5), and (3) high risk (scores Occupation
3–­5) perform in the preoperative period while classifications of Work 37 61.7
functional status for patients divided into four groups in class II Not working 23 38.3
or III because functional capacity is such a powerful determinant
Type of work
of the outcome it remains arguably the most important prognos-
Officer 26 43.3
tic marker in routine clinical use in heart failure today (Bjelland
Worker 3 5.0
et al., 2002; El-­B az, 2009) and Tool II including quality of life scale
Self-­employment 8 13.3
to assess open heart surgery patient's level of Quality of life. It
Retired 8 13.3
ranged from zero to 2 scores which zero score for I cannot' judge,
1 score for no, and 2 scores for yes then classified as good qual- Housewife 15 25.0

ity of life for above 75%, fair 50–­75%, poor ≤50% with Scoring Income
system for all questions from 0 to 100. A score of 100 represents Sufficient 50 83.3
the highest level of functioning possible. The scores of the items Insufficient 10 16.7
were summed up and the total scores were divided by the number Educational Level
of the items, giving a mean score. These scores were expressed in Illiterate 9 15.0
means and standard deviations (Chocron et al.,  2000) while the Primary 1 1.7
Anxiety and Depression Scale (HADS). responses to both sub-
Secondary 30 50.0
scales are indicated on a four-­p oint Likert scale from 0 to 3 (score
Bachelor 20 33.3
range 0–­21) cut-­off scores. It is used for both subscales to identify
Smoking
patients with anxiety and depressive symptoms. This cut-­off has
Yes 31 51.7
been shown to balance sensitivity and specificity optimally (Dąbek
No 29 48.3
et al., 2017).
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6      ELGAZZAR et al.

were described using numbers and percentages. Quantitative data the educational programme and significant (p ≤ 0.05). On the other
were described using range (minimum and maximum), mean and hand, no significant difference between pre-­ and posteducational
standard deviation. The significance of the obtained results was programme for vital signs measurement.
judged at the 5% level. The used tests were Chi-­square test for cat- Table 5 shows an improvement in different quality of life aspects,
egorical variables, compare between different groups. Fisher's Exact and total scores indicated that there was a significant improvement
or Monte Carlo correction for chi-­square when more than 20% of in the patient's quality of life and the total score from the pre-­ to
the cells have an expected count less than 5, McNemar and Marginal post-­test after the application of the educational intervention pro-
Homogeneity Test used to analyse the significance between the dif- gramme. all the components of quality of life were significantly im-
ferent stages, Student t-­test. For normally distributed quantitative proved in the after educational compared with before educational
variables, to compare between two studied groups, F-­test (ANOVA). programme except social aspect (p ≤ 0.05).
For normally distributed quantitative variables, to compare between In Table  6, there was a significant difference between age
more than two groups and Paired t-­test. For normally distributed and psychological status, so the psychological status was higher
quantitative variables, to compare between two periods. at the age of 31–­4 0 years old than at other ages before the pro-
gramme, while after the programme there was no relationship
and all of them got better. As for gender, there was a relationship
3  |  R E S U LT S with Overall problems after the programme, so males had fewer
problems than females after the programme. Also, a significant
In Table  1, the sample of the study had a 43.3% in the age group difference between position and overall problems before the pro-
41–­50 years and consisted of 53.3% women and 46.7 men. Most pa- gramme, while the not working patients had higher problems than
tients were married (75.0%). Less than of the sample (43.32%) had the workers, but after the programme, they improved like some.
an occupation and half of them had a secondary educational level. Moreover, there was a significant difference between education
Table  2 represents a comparison between patients' fatigue or and psychological status, and it was found that illiterate patients
distress associated with physical activity before and after the ed- and primary education had the highest score in psychological
ucational programme. The majority of the patient had little effect status before the programme, but after the programme, they im-
on physical activity and it does not cause fatigue or distress with a proved overall categories of education.
significant improvement from pre-­and posteducational programmes In Table  7, there was no statistically significant difference be-
indicated with 53.3% and 38.3%, respectively. tween overall quality of life and socio-­demographic characteristics
Table 3 shows that there were significant differences between before and after the educational programme.
the before and after a programme in terms of arterial blood gases
(PaO2 and PaCO2) with 42.72 ± 0.78 to 37.18 ± 0.75 and 88.02 ± 0.89
to 99.15 ± 0.68, respectively (p = 0.05) with improvement changes 4  |  D I S C U S S I O N
after the educational programme. On the other hand, no significant
difference was found in the patient's vital signs before and after the Cardiac surgery is to improve patient outcomes. HRQOL helps one to
educational programme. estimate all major realms of good rehabilitation, such as patients' per-
Table 4 summarizes the mean scores of psychological status be- ceived well-­being and return to everyday activities. Self-­perceived
fore educational programmes were 29.75 (SD, 3.61) and 18.25 (SD, health status is now a major predictor of surgical outcomes, despite
2.24). After the educational programme with statistically significant, having been overlooked in the past. The demographic data of this
whereas patients' problems as physical, mental, and overall patients study revealed that women outnumbered men 53.3%–­46.7%, with
problems scores were improved in the postphase than prephase of the largest age group being (31–­4 0 years). The results showed that

TA B L E 2  Comparison between
Before After
patients' fatigue or distress associated
educational educational
with physical activity before and after the
programme programme
educational programme (n = 60)
No. % No. % p

Fatigue or distress associated with physical activity?

MH
Physical activity without fatigue 0 0.0 20 33.3 p < 0.001*
or distress
Little effect on physical activity 32 53.3 23 38.3
and it does not cause fatigue
or distress
Effect on physical activity and 28 46.7 17 28.3
causes fatigue and discomfort
ELGAZZAR et al. |
      7

TA B L E 3  Comparison between patient's physiological parameters before and after the educational programme (n = 60)

Before educational programme After educational programme

No. % No. % p

ABG gases
P_CO2
t
Normal 60 100.0 60 100.0 p < 0.001*
Min. –­Max. 42.0–­4 4.0 36.0–­38.0
Mean ± SD. 42.72 ± 0.78 37.18 ± 0.75
HCO3
t
Normal 60 100.0 60 100.0 p = 0.899
Min. –­Max. 24.0–­26.0 24.0–­26.0
Mean ± SD 24.97 ± 0.80 24.98 ± 0.77
P_O2
t
Normal 60 100.0 60 100.0 p < 0.001*
Min. –­Max. 87.0–­89.0 98.0–­100.0
Mean ± SD 88.02 ± 0.89 99.15 ± 0.68
PH
t
Low 1 1.7 0 0.0 p = 0.386
Normal 1 1.7 7 11.7
High 58 96.7 53 88.3
Min. –­Max. 0.0–­7.70 7.40–­7.70
Mean ± SD 7.43 ± 0.98 7.53 ± 0.07
Vital signs
Blood pressure
Systolic
t
Low 60 100.0 59 98.3 p = 0.114
High 0 0.0 1 1.7
Min. –­Max. 130.0–­133.0 130.0–­133.0
Mean ± SD 131.18 ± 1.11 131.23 ± 1.13
Diastolic
t
High 60 100.0 60 100.0 p = 0.808
Min. –­Max. 80.0–­83.0 80.0–­90.0
Mean ± SD 81.57 ± 1.16 82.02 ± 2.15
Pulse
t
Normal 60 100.0 59 98.3 p = 0.381
High 0 0.0 1 1.7
Min. –­Max. 83.0–­86.0 83.0–­95.0
Mean ± SD. 85.03 ± 0.90 85.23 ± 1.57
Respiratory
t
Low 0 0.0 1 1.7 p = 0.549
High 60 100.0 59 100.0
Min. –­Max. 23.0–­26.0 20.0–­26.0
Mean ± SD 25.02 ± 0.81 24.90 ± 1.04
Temperature
t
Normal 14 23.3 15 25.0 p = 1.000
High 46 76.7 45 75.0
Min. –­Max. 37.0–­38.0 37.0–­38.0
Mean ± SD 37.39 ± 0.23 37.38 ± 0.23

Abbreviations: MH, Marginal Homogeneity Test; t, Paired t-­test.

*Statistically significant at p ≤ 0.05.
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8      ELGAZZAR et al.

TA B L E 4  Comparison between pre and

Before educational After educational
post educational programmes according
programme programme
to psychological scale, and patients'
Mean ± SD Mean ± SD t p problems (n = 60)

Psychological status scale

Total score 29.75 ± 3.61 18.25 ± 2.24 20.583* <0.001*
Patients Problems
Physical problems
Total score 30.00 ± 5.01 11.15 ± 1.18 28.130* <0.001*
Average score 2.50 ± 0.42 0.93 ± 0.10
% score 62.50 ± 10.43 23.23 ± 2.45
Mental problems
Total score 32.68 ± 1.91 13.22 ± 2.87 41.769* <0.001*
Average score 2.72 ± 0.16 1.10 ± 0.24
% score 68.09 ± 3.98 27.53 ± 5.98
Overall problems
Total score 62.68 ± 5.32 24.37 ± 3.04 47.464* <0.001*
Average score 2.61 ± 0.22 1.02 ± 0.13
% score 65.30 ± 5.54 25.38 ± 3.17

Abbreviation: t, Paired t-­test.

*Statistically significant at p ≤ 0.05.

the majority of the patient had little effect on physical activity and by qualified nurses decreases anxiety and other complications in
it does not cause fatigue or distress with a significant improvement CABG patients.
from pre-­ and posteducational programmes as indicated by 53.3% As regards, patient problems as physical, mental, and overall
and 38.3%, respectively. However, the findings of a study performed patient problem scores were improved significantly in the post-
in Poland in patients who had Coronary Artery Bypass Graft surgery phase than prephase of the educational programme and sig-
displayed that before the start of rehabilitation and treatment, dysp- nificant (p ≤ 0.05). our result is inconsistent with some studies
noea, chest pain, and fatigue were 50%,68%, and 40% in patients, (Højskov et al.,  2019) found that the intervention had no impact
subsequently rehabilitation these rates decreased to 10%, 12% and on self-­reported physical and mental health, anxiety, pain, sleep,
33% (Agostini & Singh, 2009). or health-­related quality of life, but all of the results had a simi-
As regards, the patient's physiological parameters before and lar relation. This finding concurs with Bsharat and Karadag  (n.d.)
after the educational programme the results showed that the pro- who reported that the intervention group had fewer problems
gramme affected significant improvement in the arterial blood gas than anticipated, while the control group had more problems than
measurement (PaO2 and PaCO2). While Agostini and Singh  (2009) expected for the following palpitation, loss of appetite, constipa-
stated that Incentive spirometers (IS) can enhance gas exchange tion, dizziness, fatigue, attention deficit disorder, trouble falling
other researchers stated this is unusual after thorax surgery. Finally, asleep, insomnia, back pain, shoulder pain, and leg oedema are
they decided tits can help oxygenation and gas exchange subse- all symptoms of attention deficit disorder. While Al-­A hdal and
quently thorax surgery. Abdullah (2020) conducted a quasi-­experimental design at Sudan
There was a statistically significant difference in psycholog- Heart Center for a total of 128, showing quality of life education
ical status before and after the educational programme. While programme for recovery patients increases patient outcomes, as
patients undergoing open-­heart surgery experience high levels of shown by the lack of postoperative complications, and patient
anxiety because they have no idea what to expect from the pro- satisfaction. Ratajska et al.  (2020) demonstrated that safe and
cedure. Unfounded assumptions, concerns, and problems in the sufficient nutrition greatly aids in the reduction of surgical stress,
postoperative period result from a lack of necessary knowledge the maintenance of physiological functional capability, and the fa-
and training during the preoperative period (Cebeci & Çelik, 2011). cilitation of postoperative functional recovery, avoiding problems
Our findings are consistent with previous quasi-­experimental re- and improving outcomes.
search that found that after CABG surgery, discharge education or The results of the study show a positive effect of health edu-
a cardiac rehabilitation programme decreased anxiety and depres- cation on quality of life and improving patient outcomes. Attention
sion (Yildiz et al.,  2014; Zhang et al.,  2012). According to Zhang to results shows a significant difference in all aspects of quality
et al.  (2012) stated that formal preoperative education delivered of life between before and after the application of educational
ELGAZZAR et al. |
      9

TA B L E 5  Comparison between pre and post educational programmes according to quality of life (n = 60)

Before educational programme After educational programme

Quality of life No. % No. % Test of sig. p

Activity
Poor <50% 40 66.7 60 100.0 McN = 4.300* <0.001*
Fair 50–­75% 18 30.0 0 0.0
Good ≥75% 2 3.3 0 0.0
Total score 8.65 ± 3.25 7.80 ± 0.99 t = 1.960 0.055
Physical
Poor <50% 56 93.3 0 0.0 MH = 7.263* <0.001*
Fair 50%–­75% 2 3.3 5 8.3
Good ≥75% 2 3.3 55 91.7
Total score 1.08 ± 0.42 2.92 ± 0.28 t = 28.812* <0.001*
Physiological
Poor <50% 58 96.7 1 1.7 MH = 3.969* <0.001*
Fair 50%–­75% 2 3.3 57 95.0
Good ≥75% 0 0.0 2 3.3
Total score 0.10 ± 0.40 2.02 ± 0.22 t = 32.148* <0.001*
Social
Poor <50% 15 25.0 0 0.0 MH = 4.796 0.061
Fair 50%–­75% 45 75.0 24 40.0
Good ≥75% 0 0.0 36 60.0
Total score 3.75 ± 0.44 3.80 ± 0.75 t = 0.465 0.643
Pain
Poor <50% 0 0.0 0 0.0 McN 0.000 1.000
Fair 50%–­75% 60 100.0 60 100.0
Good ≥75% 0 0.0 0 0.0
Total score 50.88 ± 3.31 49.78 ± 2.95 t = 2.001* 0.050*
Overall quality of life
Poor <50% 12 20.0 0 0.0 McN = 3.464* <0.001*
Fair 50%–­75% 48 80.0 60 100.0
Good ≥75% 0 0.0 0 0.0
Total score 64.47 ± 4.65 66.32 ± 3.46 t = 2.544* 0.014*

Abbreviations: McN, McNemar test; MH, Marginal Homogeneity Test; t, Paired t-­test.
*Statistically significant at p ≤ 0.05.

programmes for patients undergoing open-­heart surgery. This find- status, role limitations resulting from physical status, mental well-­
ing concurs with Arthur et al. (2000) who found that the interven- being vitality, and overall average quality of life all showed signifi-
tion group had a higher quality of life than the control group during cant improvements between the two groups, as calculated by the
the waiting period. Up to 6  months after surgery, the improved SF-­36. The findings show that providing health education to CABG
quality of life lasted. According to Shah et al. (2016), early mobiliza- patients improves their quality of life.
tion and exercise appear to be critical in preventing postoperative There was a significant difference between age and psycho-
complications, improving functional performance, and reducing the logical status, so the psychological status was higher at the age of
duration of hospital stay in patients who have undergone cardiac 31–­4 0 years old than at other ages before the programme, while
surgery. Similarly, other studies (Babaee et al., 2007) mentioned that after the programme there was no relationship and all of them got
the pain, energy, emotional reaction, physical mobility, sleep, and better. Other studies, found that according to the logistic model,
overall average quality of life improved significantly between the demographic variables that can influence a patient's recovery,
control and study groups, as measured by the Nottingham Health such as age, gender, insurance, personal control over the dis-
Profile. Physical function, role limitations resulting from emotional ease, and illness perception, have a significant relationship with
 |
10      ELGAZZAR et al.

TA B L E 6  Relation between psychological status scales, with socio-­demographic characteristics (n = 60)

Psychological status scale Overall problems

Before After Before After

Socio-­demographic
characteristics Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Age (years)
Less than 30 years 71.43 ± 12.37 45.24 ± 4.12 63.19 ± 3.66 24.65 ± 3.94
31–­4 0 years 73.73 ± 7.31 43.55 ± 5.19 65.09 ± 5.67 25.10 ± 3.19
41–­50 years 67.31 ± 8.61 43.13 ± 5.73 65.79 ± 5.66 25.80 ± 3.15
F(p) 4.428* (0.016*) 0.215 (0.807) 0.331 (0.720) 0.421 (0.659)
Gender
Males 71.51 ± 10.24 42.86 ± 5.42 64.58 ± 5.82 24.52 ± 3.01
Females 70.24 ± 6.95 43.97 ± 5.27 65.92 ± 5.30 26.14 ± 3.16
t(p) 0.557 (0.580) 0.807 (0.423) 0.929 (0.357) 2.031* (0.047*)
Length
From 151–­175 cm 71.73 ± 8.73 43.33 ± 5.61 65.60 ± 5.64 25.08 ± 3.38
From 176–­200 cm 69.05 ± 8.21 43.69 ± 4.84 64.69 ± 5.44 25.99 ± 2.67
t(p) 1.142 (0.258) 0.255 (0.800) 0.597 (0.553) 1.051 (0.297)
Weight
From 51–­75 kg 72.13 ± 8.84 43.13 ± 5.27 65.51 ± 5.77 24.98 ± 3.14
From 76–­100 kg 67.26 ± 6.87 44.35 ± 5.56 64.71 ± 4.99 26.50 ± 3.07
t(p) 1.991 (0.051) 0.780 (0.438) 0.487 (0.628) 1.669 (0.101)
Social Status
Single 72.38 ± 8.68 38.57 ± 1.99 63.33 ± 2.26 23.13 ± 0.47
Married 70.90 ± 8.73 44.02 ± 5.41 65.28 ± 5.68 25.69 ± 3.21
Divorced 69.76 ± 8.62 43.33 ± 5.12 66.35 ± 6.17 25.10 ± 3.45
F(p) 0.156 (0.856) 2.477 (0.093) 0.487 (0.617) 1.554 (0.220)
Residence
Wife 70.78 ± 8.76 43.72 ± 5.26 65.29 ± 5.56 25.76 ± 3.23
Children 71.43 ± 9.39 43.57 ± 5.39 66.67 ± 5.81 24.17 ± 3.21
Relatives 70.24 ± 7.02 41.27 ± 6.15 63.02 ± 5.09 24.65 ± 2.34
F(p) 0.038 (0.963) 0.555 (0.577) 0.806 (0.452) 1.212 (0.305)
Position
Work 69.24 ± 8.74 42.86 ± 5.05 63.77 ± 5.04 25.06 ± 3.21
Not working 73.40 ± 7.85 44.41 ± 5.73 67.75 ± 5.53 25.91 ± 3.10
t(p) 1.860 (0.068) 1.100 (0.276) 2.870* (0.006*) 1.010 (0.317)
Type of work
Officer 69.14 ± 9.15 42.67 ± 5.08 64.18 ± 5.50 24.92 ± 3.19
Worker 73.02 ± 11.98 42.86 ± 6.30 61.46 ± 3.13 27.08 ± 2.76
Self-­employment 68.15 ± 6.73 43.45 ± 5.21 63.28 ± 4.08 24.74 ± 3.55
Retired 76.79 ± 7.06 44.05 ± 5.83 66.15 ± 7.43 25.26 ± 3.04
Housewife 71.59 ± 7.87 44.60 ± 5.86 68.61 ± 4.27 26.25 ± 3.18
F(p) 1.541 (0.203) 0.332 (0.855) 2.506 (0.052) 0.707 (0.591)
Income
Sufficient 71.71 ± 8.44 43.14 ± 5.35 65.27 ± 5.55 25.21 ± 3.25
Insufficient 66.43 ± 8.36 45.0 ± 5.20 65.42 ± 5.83 26.25 ± 2.68
t(p) 1.811 (0.075) 1.007 (0.318) 0.075 (0.940) 0.948 (0.347)
Educational Level
ELGAZZAR et al. |
      11

TA B L E 6  (Continued)

Psychological status scale Overall problems

Before After Before After

Socio-­demographic
characteristics Mean ± SD Mean ± SD Mean ± SD Mean ± SD

Illiterate 77.51 ± 5.47 43.12 ± 6.01 64.93 ± 6.65 24.77 ± 3.28

Primary 85.71 47.62 66.67 21.88
Diploma 70.56 ± 8.26 43.02 ± 5.15 65.59 ± 5.68 25.42 ± 2.93
Bachelor 67.50 ± 8.22 44.05 ± 5.54 64.95 ± 5.22 25.78 ± 3.54
F(p) 4.518* (0.007*) 0.354 (0.786) 0.084 (0.969) 0.616 (0.608)
Smoking
Yes 71.20 ± 7.98 43.32 ± 5.71 67.47 ± 5.63 25.71 ± 3.13
No 70.44 ± 9.32 43.60 ± 4.97 62.97 ± 4.47 25.04 ± 3.23
t(p) 0.338 (0.737) 0.200 (0.842) 3.446* (0.001*) 0.816 (0.418)

Abbreviations: F, F for ANOVA test; t, Student t-­test.

*Statistically significant at p ≤ 0.05.

various recovery products. Furthermore, it appears that these el- 5  |  CO N C LU S I O N A N D

ements may be used as predictors of recovery in Coronary Artery R ECO M M E N DATI O N S
Bypass Graft patients (Sadeghi et al.,  2017). While the findings
of this study are not supported by data from another study that From the foregoing discussion, it can be seen that the implemen-
found no substantial relationship between age and stress (Falcoz tation of multimedia educational programmes for postcardiac sur-
et al., 2006). geries patients showed a remarkable improvement in the patient's
As for gender, there was a relationship with overall problems level of self-­management and acquiring the ultimate positive and
after the programme, so males had fewer problems than females noticeable improvement in the patient's quality of life as health
after the programme. These findings are inconsistent with those (Han outcomes, also, there are obvious needs for instructional scheme
et al., 2014; Pačarić et al., 2020 & Pedersen & Denollet, 2002) that or guidelines offered on simple media to those patients to minimize
demonstrated the impact of single socio-­demographic variables such complications postcardiac surgeries and increased patient's coping
as age, gender, and marital status on HRQL. There are also some stud- and adherence with their treatment modalities. Efforts should be
ies that, recommended the reasons that could contribute to these dif- carried out to design and implement interventions that suit cardiac
ferences between men and females including biological influences, intensive care units with field evidence and increased facilities, pa-
such as the effect of psychosocial factors, and female sex hormones, tient education strategies, and documentation of noncompliance
for occurrence, women's numerous roles due to new variations in with cardiac patients with their disease, treatment, and follow-­up
society. appointments.
This study result showed no statistical significance between overall
quality of life and socio-­demographic characteristics before and after AU T H O R C O N T R I B U T I O N S
the educational programme. This result is congruent with Rumsfeld Authors' S.A.Q contributed to conceived and designed the study,
et al. (2004) who reported that gender, age, lifestyle, and risk factors written methodology, discussion, Conclusions and recommenda-
were not predictors of poorer quality of life assessment after rehabil- tions parts and the acquisition, analysis, or interpretation of data
itation. While another study not in the line with (Dąbek et al., 2017) for the work; S.E.E contributed conceived and designed the study,
found that concomitant disorders, age, presence of risk factors, life- analysis, or interpretation of data for the work, written introduction,
style, and level of knowledge, impact the course of the illness and its conceptual framework, Abstract and reviewed the manuscript and
management and the quality of life of the affected patients. led to conduct analysis follow-­up and interpretation and organized
reference; A.M. A contributed to the conception/design of the work,
acquisition/ interpretation of data for the work, the data collection
4.1  |  Study limitations and data entry and checked the article for plagiarism. All authors
have critically reviewed and approved the final draft and are respon-
This study has numerous limitations. Mainly, the study was per- sible for the content and similarity index of the manuscript.
formed in merely one cardiovascular surgery unit, and the study par-
ticipant redirects to only one area of Egypt. Hence, our results cannot AC K N OW L E D G E M E N T S
be generalized to entirely cardiac surgery patients. Second, long-­term I wish to express my deepest appreciation and sincere gratitude to
prospective studies are desirable after open-­heart surgeries. everyone who has contributed to this work. In particular I would like
 |
12      ELGAZZAR et al.

TA B L E 7  Relation between overall quality of life and socio-­demographic characteristics before and after the educational programme
(n = 60)

Overall quality of life

Before After

Poor (n = 12) Fair (n = 48) Fair (n = 60)

Socio-­demographic characteristics No. % No. % No. %

Age (years)
Less than 30 years 1 8.3 2 4.2 3 5.0
31–­4 0 years 7 58.3 24 50.0 31 51.7
41–­50 years 4 33.3 22 45.8 26 43.3
2 MC
χ ( p) 1.240 (0.653) –­
Gender
Males 6 50.0 22 45.8 28 46.7
Females 6 50.0 26 54.2 32 53.3
2
χ (p) 0.067 (0.796) –­
Length
From 151–­175 cm 9 75.0 31 64.6 40 66.7
From 176–­200 cm 3 25.0 17 35.4 20 33.3
2 FE
χ ( p) 0.469 (0.734) –­
Weight
From 51–­75 kg 6 50.0 38 79.2 44 73.3
From 76–­100 kg 6 50.0 10 20.8 16 26.7
2 FE
χ ( p) 4.176 (0.066) –­
Social Status
Single 2 16.7 3 6.3 5 8.3
Married 8 66.7 37 77.1 45 75.0
Divorced 2 16.7 8 16.7 10 16.7
2 MC
χ ( p) 1.703 (0.397) –­
Residence
Wife 8 66.7 36 75.0 44 73.3
Children 0 0.0 10 20.8 10 16.7
Relatives 4 33.3 2 4.2 6 10.0
χ2(MC p) 8.737* (0.008*) –­
Position
Work 6 50.0 31 64.6 37 61.7
Not working 6 50.0 17 35.4 23 38.3
χ2(FEp) 0.864 (0.508) –­
Type of work
Officer 5 41.7 21 43.8 26 43.3
Worker 0 0.0 3 6.3 3 5.0
Self-­employment 1 8.3 7 14.6 8 13.3
Retired 2 16.7 6 12.5 8 13.3
Housewife 4 33.3 11 22.9 15 25.0
2 MC
χ ( p) 1.334 (0.947) –­
Income
Sufficient 11 91.7 39 81.3 50 83.3
Insufficient 1 8.3 9 18.8 10 16.7
ELGAZZAR et al. |
      13

TA B L E 7  (Continued)

Overall quality of life

Before After

Poor (n = 12) Fair (n = 48) Fair (n = 60)

Socio-­demographic characteristics No. % No. % No. %

2 FE
χ ( p) 0.750 (0.670) –­
Educational Level
Illiterate 0 0.0 9 18.8 9 15.0
Primary 0 0.0 1 2.1 1 1.7
Diploma 6 50.0 24 50.0 30 50.0
Bachelor 6 50.0 14 29.2 20 33.3
χ2(MC p) 3.700 (0.306) –­
Smoking
Yes 8 66.7 23 47.9 31 51.7
No 4 33.3 25 52.1 29 48.3
χ2(FEp) 1.352 (0.245) –­

Abbreviations: FE, Fisher Exact; MC, Monte Carlo; χ2, Chi square test.
*Statistically significant at p ≤ 0.05.

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