Research and Development
Patient experiences of
cardiac surgery and nursing
care: a narrative review
Katie Ball, Clinical Research Nurse, Central Manchester University Hospital Foundation Trust, Manchester
(Formerly Staff Nurse, Cardiothoracic Critical Care at time of writing); and Veronica Swallow, Professor in
Child and Family Health, School of Healthcare, University of Leeds, Leeds.
Email: katie.ball@cmft.nhs.uk
C
aring for patients is central to the NHS and
provision of excellent care is what it aspires to
achieve (Department of Health (DH), 2012).
Therefore, it is highly relevant that those experiencing the
service should be consulted to push for continual
improvements (Dr Foster Intelligence, 2010; Tollyfield,
2014). Since the publication of The NHS Plan (DH, 2000)
and Transforming Participation in Health and Care (NHS
England, 2013), there has been an emphasis on patient,
carer and public involvement in care provision, treatment
Abstract
Aim: The aim of the Narrative Review was to explore the patient
experience following cardiac surgery and nursing care. Methodology:
A Narrative Review was used to integrate the findings of different
types of evidence in order to gain an understanding of the patient’s
experience of cardiac surgery and nursing care. Three key databases
were searched; Cumulative Index to Nursing Allied Health Literature
(CINHAL), British Nursing Index (BNI) and Medline. The review involved
critiquing the methodological quality of included studies, thematic
analysis and synthesis of findings. Conclusions: Patients experience
physical discomfort and pain following cardiac surgery. The
psychological experience of cardiac surgery is associated with
negative emotions which are mostly related to weaning from
mechanical ventilation and communication difficulties. Support from
family is of high importance but patients value the support from other
cardiac surgery patients. No studies intended to explore the
experience of nursing care following cardiac surgery. However, patient
experiences of nursing care were reported across the studies.
Recommendations: Future research should specifically explore the
experience of nursing care following cardiac surgery. Current PREMs
Questionnaires are a step forward in patient experience measurement
for cardiac surgery; however they are limited by their feedback
method. Service improvement initiatives should utilise both
quantitative and qualitative data collection methods to obtain a multi-
dimensional view of the patient experience.
Key words
w Cardiac surgery w Heart surgery w Patient experience w Nursing
care w Patient experience measurement
Submitted for peer review: 8 February 2015. Accepted for publication: 5 May 2016.
Conflict of interest: None.
348
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choices and on understanding their experience. Patient
experience is therefore steadily gaining higher priority on
the NHS agenda.
Care and treatment of patients with cardiac conditions
has developed significantly over the past 20 years with the
introduction of the National Service Framework for
Coronary Heart Disease identifying quantifiable clinical
outcomes for patients (DH, 2009). Additionally, several
National Institute for Health and Care Excellence (NICE)
guidelines are grounded in the best available evidence,
guiding issues such as interventional procedures (NICE,
2014a), quality standards (NICE, 2011) and management
guidelines (NICE, 2014b) for patients with cardiac condi-
tions, resulting in advances in diagnosis, treatment, medi-
cations and service improvements (Matthews and
Cornwell, 2012). The emphasis on clinical outcomes (DH,
2013) and patient safety (Commissioning for Quality and
Innovation, 2014) have also been acknowledged in recent
policy (Darzi, 2008), which identifies the patient experi-
ence as an important marker for quality. However, patient
experience has received little research scrutiny (Darzi,
2008; Maben et al, 2012).
Publication of the NHS Patient Experience Framework
(NHS National Quality Board, 2011) and NICE (2013)
guidance for Patient Experience in Adult Services is a step
towards measuring patient experience and improving
quality in health care. This guidance identifies indicators
that contribute to a positive patient experience. However,
while the guidance recognises the inherent difficulty in
measuring patient experience, acknowledging its complex
nature, it fails to offer solutions to these difficulties. This is
in stark contrast to other NICE guidelines which provide
audit tools for monitoring and evaluation. Similarly,
Compassion in Practice, the 3-year vision and strategy for
Nursing, Midwifery and Care staff outlined implementa-
tion plans which prioritise patient experience and focus
on how people perceived the standards of care they
© 2016 MA Healthcare Ltd
received (DH, 2015). However, there is currently no
framework or formative feedback method for patient
experience of nursing-care delivery (Maben et al, 2012).
Previous studies have explored the experience of cardiac
patients. However, these have been disease-specific
British Journal of Cardiac Nursing July 2016 Vol 11 No 7
 Research and Development

(Dunckley et al, 2007; Almond et al, 2012), family-focused
(Wrigley and Lathlean, 2010; Linden, 2012), and interven-
tion-specific (Perkins, 2008; Radcliffe et al, 2009).
Additionally, a qualitative synthesis (Leegard and
Fagermoen, 2008) aimed to reflect key themes and experi-
ences in qualitative literature following coronary artery
bypass graft (CABG) surgery, which did not reflect nurs-
ing-specific outcomes. No study has attempted to capture
the patient experience of nursing care following cardiac
surgery, nor has a study synthesised different types of evi-
dence to capture a multi-dimensional view of patient
experience following cardiac surgery, nursing care or
patient experience measurement.
ww Direct citations from the abstract and findings of the
primary studies were transcribed into a new document
ww These new documents were analysed and annotated by
the researcher (lead author) with themes that reflected
the patient experience. For example, the theme ‘pain
related to treatment was not an issue’ would be coded as
‘physical’. This became an iterative approach where
themes in the first study reviewed would be adopted in
the following studies, and vice versa. Papers were
reviewed until no new themes were identified
Table 1. Definitions of key terms
Term Definition

Aims Patient experience Feedback from patients on ‘what actually

The purpose of this narrative review was to consider:
ww What is the patient experience of cardiac surgery?
ww What is the experience of receiving nursing care follow-
ing cardiac surgery?
ww What is the current evidence for measuring patient
experience of cardiac surgery and nursing care?
Definitions of key terms used throughout the review are
provided in Table 1.
Research design
A narrative review approach was adopted, thereby allow-
ing for the inclusion of quantitative and qualitative evi-
dence (Dixon-Woods et al, 2004). The review adopted a
systematic search strategy, critical appraisal of included
studies and a transparent review process, to overcome the
inherent limitations and criticism in the absence of a
standardised process for narrative reviews (Pope et al,
2009).
happened’ in the course of receiving care or
treatment, both objective facts and their
subjective view of it (Dr Foster Intelligence, 2010).
Patient A measure of the value judgements patients
satisfaction apply to their experience (Matthews and
Cornwell, 2012).
Patient Reported Used to demonstrate experience trends and can
Experience be used to inform service development and
Measures (PREMs) improvement (Jackson et al, 2014).
Transactional Refers to what nursing care is delivered. For
aspects of care example, cleanliness, physical comfort and
physical care (Dr Foster Intelligence, 2010).
Relational aspects Refers to how nursing care is delivered. For
of care example, experiences of dignity, empathy,
compassion, emotional support, staff attitude
and communication (Dr Foster Intelligence, 2010).

Methods
The review and synthesis was undertaken in four phases
(Figure 1). Formulation of the search terms was supported
by a combination of background reading and the PICO Phase 3:
Phase 2: Phase 4:
(Population, Intervention, Comparison and Outcome) Phase 1: Critical
Systematic Thematic
Scoping appraisal of
acronym as a framework (Cooke et al, 2012). literature
search identified synthesis
A rigorous scoping search was used (Arksey and search
studies
O’Malley, 2005) (Table 2; Figure 2). This involved combing
formulated search terms. For example, ‘cardiac surgery’
was combined with ‘patient experience’ and/or ‘nursing
care’ or ‘measurement’. Limits were placed on database
searches to focus the aims of the review. All titles were
scrutinised and rejected based upon the inclusion criteria Figure 1. Methodology
identified in Table 3; a summary of the paper extraction
process appears in Figure 2. Table 2. Search strategy
Some authors advise not to consider raw data or direct
citations as findings (Sandelowski and Barroso, 2002). Search Terms Databases Database limits
However, following Weed (2005), raw data were some- Cardiac surgery Cumulative Index for Adult
times used as part of the interpretations and reporting to Heart surgery Nursing and Allied Health Year: 2004–2014
© 2016 MA Healthcare Ltd

ensure findings were as close to study participants’ Literature (CINAHL)

Patient experience
accounts as possible. British Nursing Index (BNI)
Measurement
To ensure thematic analysis was systematic and rigorous MEDLINE
in its approach, it was conducted using published princi- Nursing care
Open grey
ples (Pope et al, 2009)

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 Research and Development

ww Following review of the papers, themes were collected,

considered and broken down into sub-themes where
Papers identified from database searching
appropriate. For example, the theme ‘physical’ was bro-
ken down further into the sub-themes, ‘pain’ and CINHAL (n=18), BNI (n=163), MEDLINE (n=5),
‘mechanical ventilation’ Total hits n = 186
ww Themes and sub-themes were then discussed with the
project supervisor and finalised. Titles scrutinised based on
their initial topic relevance
Quality appraisal
n = 186
Table 4 summarises the studies meeting the inclusion crite-
ria. A structured quality appraisal tool was adopted
(Spencer et al, 2003; Centre for Reviews and Dissemination, Abstracts reviewed
2008). The quality of studies was assessed before synthesis n = 32
in order to raise researchers’ awareness about the research
quality prior to presenting the findings. Many primary
qualitative studies are poorly reported (Campbell et al, Excluded on basis of abstract
2003). Therefore, each qualitative study was assessed using n = 14
the Consolidated Criteria for Reporting Qualitative Papers remaining
Research (COREQ) (Tong et al, 2007). Quality assessment
n = 18
was assured by identifying a summary score calculated
from each COREQ domain:
ww Research team Papers included after full review against
ww Reflexivity inclusion criteria (Table 3)
ww Study design
n=5
ww Analysis and findings.
The assessment highlighted that all studies had weaknesses
in the reporting, particularly in research team and reflexiv- Additional papers found through:
ity domains. This is an important consideration as all stud- Hand-searching, previous systematic reviews
ies used in-depth interviews to collect data, meaning that and references from articles
the researchers closely engage in the research and with
n=0
participants, and are unlikely to completely avoid intro-
ducing personal bias to the research (Streubert-Speziale
and Carpenter, 2003). It is recommended that researchers Total papers included in the review
should identify and state their relationship with partici- n=5
pants to allow the reader to scrutinise the impact of this on
the study findings (Tong et al, 2007). This approach would
have increased the credibility of the included studies. Figure 2. Summary of paper-extraction process

Table 3. Inclusion criteria

Inclusion criteria Rationale
May 2004 onwards It was necessary to put time limits on the search owing to limitations on
time and resources of the project
Studies were only included if Patient experience is the foremost purpose of the review
participants were the primary sample
Patients as primary data Studies were excluded if patients were not the primary sample. Patient
experience was the focus of the review
Adults Patient group of interest as experience of adults and children may
differ.
Cardiac-surgery patients In particular, coronary artery bypass graft surgery and heart-valve surgery,
as these procedures are often done simultaneously
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Patient experience of hospital Studies selected if patient experience was reported reflecting their time
as an inpatient for their cardiac surgery
Peer-reviewed Only peer-reviewed studies included to ensure a study has been reviewed
and approved by the author’s peers (experts in the same subject area)

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 Research and Development

Table 4. Summary of included studies

Author Title Aims Methodology Participants Conclusions
Backstrom Coronary bypass To examine how Qualitative Nine participants The quality of care and
et al (2006) surgery patient’s coronary artery bypass selected, patients’ satisfaction can be
experiences with surgery patients demographically further enhanced by
treatment and peri- experienced their care typical of the implementing principles from
operative care—a majority of the peri-operative dialogue
qualitative patients given model
interview-based coronary surgery
study at study hospital
following CABG
surgery
Gardner et al Patient A thematic analysis of Qualitative Eight participants Attention to specific areas of
(2005) experiences interviews conducted following patient orientation, education
following with patients cardiothoracic and support was identified to
cardiothoracic recovering from surgery facilitate realistic expectations
surgery: An cardiothoracic surgery, of recovery
interview study about their memories
and experiences of
hospital and recovery
post discharge
Jackson et al Evaluating This initiative aims to Complex A working group PREMs can have quantitative
(2014) patients’ empower patients and Intervention of 22 members and qualitative methodologies
experiences of patient organisations from 17  to drive service improvement
heart-valve to provide feedback on organisations and can be used alongside
replacement what was important to were recruited to Patient Reported Outcome
surgery them in their heart- deliver against the Measures (PROMs) to produce
valve replacement aims and a rounded picture of patients’
surgery objectives through views on process and
a seven-step outcomes
process
Perkins What are the Explore patients’ Qualitative Thirteen The study highlights that
(2008) experiences of experiences on waking participants nurses play a vital role during
patients waking from this particular following CABG the immediate postoperative
from fast-track? modality of cardiac surgery period that goes beyond the
surgery. Discover more widely recognised
patients’ perceptions technical aspects of their role.
of nursing care The results of this study could
activities during be used by nurses to enhance
waking. Highlight any patient experiences and
improvements that can potentially lead to improved
be made to nursing- physical and psychological
care delivery during outcomes
this little-known-about
time
Schou and A qualitative study To provide a Qualitative Ten participants In order to address some of
Egerod into the lived contemporary ventilated for the general, psychological and
(2008) experience of post- description of the greater than existential patient experiences,
CABG patients patient experience of 24 hours following care should be taken to
during mechanical weaning, in order to CABG surgery acknowledge the patient and
ventilator weaning update this aspect of to respect the patient domain
© 2016 MA Healthcare Ltd

knowledge in the and individual time-frames. In

context of newer nurse-patient communication, it
modalities of is recommended that
mechanical ventilation caregivers give accurate and
and sedation unambiguous information

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 Research and Development

The CASP (Critical Appraisal Skills Programme) tool
was used to review studies (Gardner et al, 2005; Backstrom
et al, 2006; Perkins, 2008; Schou and Egerod, 2008). This
tool is well recognised for identifying methodological
issues systematically (Pound et al, 2005). The CASP tool
identified that minimal demographics, context or informa-
tion on patients’ details of stay, albeit in one study (Gardner
et al, 2005), were reported. Similar difficulties were
acknowledged in the qualitative review by Leegard and
Fagermoen (2008) suggesting a weakness in the current
evidence base. Further detail on complications and length
of stay would have allowed comparison between patients
with complications/increased length of stay, and those who
recovered routinely and the impact on patient experience.
Jackson et al (2014) developed a complex intervention.
This study was critiqued using Medical Research Council
(MRC) (Craig et al, 2008) guidance and was therefore
reported separately. They developed the Patient Reported
Experience Measures (PREMs) framework that was
underpinned by current Patient Experience Frameworks
(Picker Institute, 1987; Gerteis et al, 1993; NICE, 2013;
DH, 2013; 2015). However, on review, the PREMs frame-
work is so closely aligned to the NICE Quality standard for
Adult Patient Experience, it cannot claim specificity to
heart-valve surgery. Although this may increase transfer-
ability of the PREMs framework to other specialties, this
requires further testing.
Each paper was read several times by the lead author to
gain an overview of the study aims, methodology, partici-
pants, findings, conclusions and limitations. A second
review of each paper used CASP or MRC guidance. Each
paper was then re-read without the aid of the relevant tool
and further annotations were made.
Findings
For a summary of key themes/sub-themes, see Table 5
below. These key themes indentified will also now be
explored in depth within this section.
Pain and physical discomfort
Findings suggest that patients undergoing heart surgery
experience varying types and severity of pain and physical
discomfort (Gardner et al, 2005; Perkins, 2008; Schou and
Egerod, 2008). This finding is consistent with previous
qualitative (Holland et al, 1997; Doering et al, 2002)and
quantitative (Hunt, 1999; Myles et al, 2001; Bruce et al,
2003), studies from critical care and cardiac surgery.
Contrary to these findings, some patients reported not
being in any pain at all (Perkins, 2008; Schou and Egerod,
2008), and pain was manageable (Gardner et al, 2005). In

Table 5. Summary of themes

Main theme Sub-themes Example
Pain and Pain related to treatment was not an issue
physical Limitation of invasive monitoring lines impacted on mobility
discomfort
Mechanical Sensations of choking or overheating, pressure and discomfort related
ventilation to the ET tube
Psychological Psychological Negative emotions, distress, anxiety, embarrassment, insecurity, loss of
and emotional control and hopelessness
Memory Most patients experienced a lack of orientation to time and place
Confusion and hallucinations One patient recalled vivid hallucinations or hearing voices of people who
had died, the same patient also experienced confusion in the ward area
Support Patients felt that it was especially important that their relatives stayed
in touch during their hospitalisation
Contact with other patients who were in the same situation was very
important to exchange experiences
Information Patients were generally satisfied with the information that was sent to
provision them prior to their hospitalisation

Environment Patients happy with the light tone that was kept on the ward

Nursing care The nurses knew how to get through with gestures, paper and pencil
© 2016 MA Healthcare Ltd

[communication]

Patient The use of PREMs questionnaire should not be limited by the feedback
experience method in which it is used and should be incorporable into existing
measurement systems

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contrast, some patients described their pain as ‘absolute
agony’ (Perkins, 2008: 376). This is a significant finding,
suggestive of variability in effective pain management fol-
lowing cardiac surgery.
Pain could be categorised into three main types:
ww Acute (related to surgery)
ww Chronic (pre-existing)
ww General (pain from invasive monitoring lines or lack of
mobility).
For example, patients reported physical discomfort from
invasive monitoring lines, catheters, chest drains, nausea,
thirst, numbness, immobility and the endotracheal tube
(ET), with one patient developing a pressure sore, thus
creating further pain and discomfort (Gardner et al, 2005;
Perkins, 2008; Schou and Egerod, 2008).
The review presents important findings for nurses who
should recognise that pain manifests in various ways. An
awareness of risk factors for postoperative pain are also
important considerations for nurses managing pain post-
operatively, and may contribute towards a positive patient
experience. These risk factors may include (Breivik and
Stubhaug, 2008; Sommer et al, 2008; Tan et al, 2008;
Hinrichs-Rocker et al, 2009):
ww <60 years of age
ww Surgery lasting >2 hours
ww Depression
ww Psychological vulnerability
ww High-stress levels
ww Surgeon.
The contribution of this awareness is supported by the
PREMs Framework (Jackson et al, 2014) that emphasises
pain management as an important domain for patient
experience. An understanding of the profound impact
that poor pain management has on all body systems (e.g.
pulmonary, cardiovascular, gastro-intestinal, muscu-
loskeletal, endocrine, psychological, muscle weakness and
depression) may enhance patient outcomes (Cogan, 2010).
Nurses should gather information relating to risk factors
to identify patients that are at a greater risk of acute and
chronic pain postoperatively to enable implementation of
effective pain-management strategies. Effective pain man-
agement should reduce pain and physical discomfort,
which has been identified by Jackson et al (2014) as a con-
tributory factor to patient experience. The ability of
patients to recall detailed accounts of the experience of
pain indicates its significance in their experience and the
quality of care received.
Mechanical ventilation
Schou and Egerod (2008) aimed to specifically describe the
patient experience of weaning from mechanical ventilation
following cardiac surgery. Physical experiences of mechan-
ical ventilation were uncomfortable and strange and
© 2016 MA Healthcare Ltd
included sensations of choking, overheating, and pressure
and discomfort such as swollen vocal chords, swallowing
difficulties and a sore throat (Gardner et al, 2005; Perkins,
2008; Schou and Egerod, 2008). One patient described
using a coping strategy to help tolerate the ET which they
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Research and Development
had learned from preoperative information (Perkins,
2008). These findings indicate that mechanical ventilation
is not a pleasant experience for patients. However, relevant
and effective information given prior to cardiac surgery
could equip patients with strategies to effectively cope with
weaning from mechanical ventilation.
Psychological and emotional
Psychological
The psychological experience of cardiac surgery in the
immediate postoperative period was mostly associated
with negative emotions of distress, anxiety, embarrass-
ment, insecurity, loss of control and reduced self-confi-
dence (Schou and Egerod, 2008). Others experienced
emotions of agonising, hopelessness, depression, appre-
hension and regret (Gardner et al, 2005). These negative
emotions were commonly associated with weaning from
mechanical ventilation (Schou and Egerod, 2008). This is
consistent with others’ findings that highlighted depres-
sion (Blumenthal et al, 2003), and post-traumatic stress
disorder (Schelling et al, 2003) also being associated with
mortality following cardiac surgery (Blumenthal et al,
2003). In addition, patients reported emotional distur-
bance and depression years after cardiac surgery
(Rymaszewska et al, 2003; Tolmie et al, 2006).
The findings suggest a correlation between patients
experiencing negative emotions postoperatively and an
increased likelihood of psychological issues following dis-
charge. Consideration of psychological screening of inpa-
tients after cardiac surgery to identify these negative emo-
tions would allow for early assessment and intervention to
reduce the long-term risk of psychological disturbance
and thus potentially decrease the risk of mortality. Jackson
et al (2014) identified emotional support and alleviation of
fear and anxiety about issues, such as clinical status/prog-
nosis, impact of illness on patient, family and finances, as
important measures of patient experience, which is con-
sistent with other studies in the review.
Memory
There were conflicting findings for patients’ ability to recall
events following cardiac surgery. Perkins (2008) found that
all participants had detailed and lengthy memories of the
initial postoperative period following fast-track surgery.
Similarly, Gardner et al (2005) reported that patients had
vivid memories of the intensive care environment, recall-
ing it as ‘busy’ and ‘crowded’, ‘sterile’ and ‘constantly mov-
ing’. In contrast, one patient who required three admissions
to the intensive care unit (ICU) only remembered the third
admission; this memory was associated with agonising
emotions. This important finding suggests that patients
may be more likely to recall negative experiences following
cardiac surgery. Ability to recall these experiences may be
associated with a fast-track protocol; a process aimed at
earliest possible discharge, often receive less sedative and
analgesic medications than with the conventional protocol,
and consequently could provide more detailed accounts
when recalling their experiences (Perkins, 2008).
353
 Research and Development
Confusion and hallucinations
Confusion and agitation were reported across studies, and
is therefore a significant finding (Gardner et al, 2005;
Perkins, 2008; Schou and Egerod, 2008). It is expected that
patients may experience a period of confusion and agita-
tion after cardiac surgery owing to the cerebral effects of
cardiopulmonary bypass (Woods et al, 2009). Much con-
fusion was linked by patients to a disturbed sense of time
and orientation. The UK Intensive Care Society (1997)
recommend that ICUs have clocks visible to patients; how-
ever, despite this, patients still experienced disorientation
with time (Perkins, 2008). One patient recalled vivid hal-
lucinations or hearing voices of people who had died; the
same patient also experienced confusion in the ward area
(Gardner et all, 2005). The substantial reports of disorien-
tation and confusion with time have important implica-
tions for nursing practice. Nurses should be mindful that
patients following cardiac surgery experience disorienta-
tion with time and, therefore where possible, should reas-
sure and orientate patients to time and place. This may
lead to a positive patient experience and reduced confu-
sion in the clinical area.
Support
Patients considered the presence of their own family to be
the most important source of support post surgery (Schou
and Egerod, 2008). However, some reported lacking the
energy to effectively interact with relatives (Perkins, 2008).
Despite this, patients wanted relatives present when profes-
sionals were giving information, for their own support, but
also to relieve relatives’ anxiety (Backstrom et al, 2006).
Patients valued the collegiality and companionship of
other patients more than talking to professionals (Gardner
et al, 2005). Contact with other patients allowed them to
exchange experiences and talk about feelings and prob-
lems with someone in a similar situation (Gardner et al,
2005). This was also reflected in the findings with patients
reporting feelings of isolation if nursed in a side room
(Gardner et al, 2005; Backstrom et al, 2006).The sense of
collegiality was demonstrated through patients helping
other patients who were in pain or who ate poorly. This is
an important consideration for professionals who manage
bed allocations. Where possible, patients of similar proce-
dures and postoperative time points could be nursed
together to encourage support and collegiality, possibly
improving their experience.
Information provision
Information provision is required at key points along the
journey, including preoperatively, immediately postopera-
tively, and following discharge (Backstrom et al, 2006).
Pre-admission information about approximate surgery
dates and general information helped patients prepare for
surgery, and they were generally satisfied with this.
Furthermore, the format of information, in this case a
video, was very informative and helped patients prepare
for the challenges of surgery and the hospital stay. Patients
wanted information to be given pre and postoperatively by
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the operating surgeon, and individualised to their particu-
lar case (Backstrom et al, 2006). These findings suggest
that patients require information at key time-points along
their cardiac surgery journey.
Environment
The clinical environment was part of the patient experi-
ence following cardiac surgery. Some found the ICU to be
calm and quiet (Perkins, 2008); similarly, patients appreci-
ated the light tone kept on the ward (Backstrom et al,
2006). It is not clear what ‘light tone’ meant to patients as
this was unexplored by the interviewer. In contrast, as
mentioned, some patients found the clinical area to be
‘busy’, ‘crowded’ and ‘sterile’ (Gardner et al, 2005). In the
same study, one patient found the environment particu-
larly threatening and unsettling. It is important that these
findings are considered within the dynamic and changing
context of the ICU environment. Environmental consid-
erations are also reflected in the PREMs framework by
Jackson et al (2014).
The sound of equipment within the ICU environment
may be significant to patient experience, but the type of
noise reported varied. Patients reported the sound of
humidified oxygen, suctioning, and alarms from haemo-
dynamic monitors as significant noises (Perkins, 2008).
Nursing care
An aim of this review was to explore the experience of
nursing care following cardiac surgery. However, no study
specifically aimed to explore the experience of nursing
care following cardiac surgery. Therefore, findings which
explicitly related to nursing care were identified and
included. It could be argued that patient experiences of
interventions such as extubation, for example, where the
persons delivering the intervention were referred to as
‘they’ in the accounts could have been delivered by nurses,
as this is common practice in ICU settings. However, for
the purpose of this review, this assumption was not made.
Patients were generally satisfied with their experience of
nursing care and recalled both ‘transactional’ and ‘rela-
tional’ aspects of nursing care delivery. Definitions of
these terms can be found in Table 1. Experiences of com-
munication were reported across all studies, and are there-
fore significant to patient experience. The most vivid
experience of communication between nurses and patients
was associated with being mechanically ventilated
(Perkins, 2008; Schou and Egerod, 2008). Patients report-
ed that nurses used non-augmentative methods of com-
munication such as gestures, pen and paper, and comput-
ers, and this was valued (Schou and Egerod, 2008). In
contrast, one patient felt that communication could have
been made easier for him, and expressed a preference for
the use of closed questions which required only a nod or
© 2016 MA Healthcare Ltd
shake of the head (Perkins, 2008). One patient felt that
nurses were not even trying to communicate and this is
consistent with a classic study which found that critical
care nurses focused more on the technical aspects of care
(Ashworth, 1980).
British Journal of Cardiac Nursing July 2016 Vol 11 No 7

Further information, about the context in which the
data were collected may have provided an interesting
insight into patients’ communication expectations.
However, new evidence places great emphasis on the
importance of relational aspects of care and patient expe-
rience (Robert et al, 2011). Therefore, nurses working with
patients following cardiac surgery should be mindful of
not only the technical aspects of care, but relational
aspects of care—particularly communication and its
impact on patient experience.
Patients experienced nursing presence in varying
degrees. Some patients recalled an awareness of nurses
‘being there’ (Perkins, 2008), while others described more
vividly hearing the voices of nurses (Gardner et al, 2005;
Perkins, 2008). This is consistent with findings from
Zikorus (2007), which is a nurse’s personal account of
critical illness exploring her experience of holistic care and
appreciation of nurses ‘being there’ in ICUs. Patients
would have liked nurses to spend more time talking,
touching or just making eye contact with them (Schou and
Egerod, 2008). This contrasting finding suggests that
nurses should individualise patients’ contact and commu-
nication needs.
One study found differing perceptions in the patients’
and nurses’ concepts of ‘time’. Patients reported nurses
using words such as ‘soon’ and ‘now’, particularly relating
to extubation, when in fact hours or days would pass by
(Schou and Egerod, 2008). This was irritating for some
patients, with one saying they would rather not be given
Figure 8. PREMs framework alignment
Patient experience framework for heart-valve surgery
Respect for patient-centred values, preferences and
expressed needs, including: cultural issues, dignity,
privacy, independence of patients and service users;
an awareness of quality-of-life issues and shared
decision-making
Information, communication and education on clinical
status, progress, prognosis and processes of care in
order to facilitate autonomy, self-care and health
promotion
Physical comfort including pain management,
help with activities of daily living and clean
comfortable surroundings
Emotional support and alleviation of fear and
anxiety about issues such as clinical status, prognosis
and impact of illness on patients, their families and
finances
Welcoming the involvement of family and friends,
© 2016 MA Healthcare Ltd
who patients and service users rely on, in decision-
making and demonstrating awareness and
accommodation of their needs as caregivers
Source: Adapted from NICE, 2013; Jackson et al, 2014
British Journal of Cardiac Nursing July 2016 Vol 11 No 7
itish Journal of Cardiac Nursing. Downloaded from magonlinelibrary.com by 131.172.036.029 on August 1, 2016. For personal use only. No other uses without permission. . All rights reserve
Research and Development
an indication of time. Despite this disparity, patients did
understand that there were other patients requiring care,
and would excuse the nurse’s behaviour. However, they
appreciated being offered a reason for a delay and when
they could expect that an intervention would likely occur.
An accurate or quantified communication of time may be
more beneficial for patients at this time (Magnus and
Turkington, 2006). Further findings related to nursing
time were found with patients highlighting a difference
between nursing time on the ICU and a general ward area
(Gardner et al, 2005). The latter was associated with a lack
of nursing time from patients’ perspectives (McKinney
and Deeny, 2002).
Patient experience measurement
The terms ‘patient satisfaction’ and ‘patient experience’ are
used interchangeably in the literature; yet, they have subtly
different meanings (Shale, 2012). For clarity, they are
defined in Table 1 along with other key terms.
No studies specifically aimed to measure patient experi-
ence of nursing care following cardiac surgery. Jackson et
al (2014) developed a PREMs framework and question-
naire for patient experience following heart-valve surgery.
A small-scale pilot study of the questionnaire was incon-
clusive in measuring patient experience, but instead found
quantitative outcomes for patient satisfaction. It is there-
fore difficult to assess the PREMs’ suitability for measur-
ing patient experience. However, when findings of
reviewed qualitative studies (Gardner et al, 2005;
NICE Quality Examples from narrative
Standards review findings
1, 4, 5, 6, 8, 9 Nurses were able to use augmentative
methods of communication such as
gestures, pen and paper and, in some
cases, computers to facilitate
communication
2, 3, 5, 12, 14 Patients wanted information pre and
postoperatively to be given by the
operating surgeon, and individualised
to their particular case
10 The experience of pain, either acute or
general in nature, as well as the
severity of the pain was reported
across the studies
10 Patients felt that the nurse looking
after them held significant power in
being able to allay the patients’ fears
13 The most important source of support
described by patients across the
studies was that of family members
355
 Research and Development
Backstrom et al, 2006; Perkins, 2008; Schou and Egerod,
2008) are considered against the PREMs framework, some
consistencies are found (Figure 8).
This is important, demonstrating that findings from the
qualitative studies which included both heart-valve and
CABG surgery can be correlated with the PREMs frame-
work. Therefore, the framework could be suitable for
measuring patient experience following other types of
cardiac surgery; however, this would need further piloting
in different patient populations. Furthermore, these cor-
relations demonstrate that different types of feedback
methods, in this case user involvement versus existing
qualitative studies, highlight important similarities of
patient experience across different surgical procedures
and that using different feedback types may be a robust
method for developing patient experience measures for
cardiac surgery.
Conclusion
This narrative review of the qualitative and quantitative
evidence provides a unique contribution to our under-
standing of the patient experience of cardiac surgery and
of receiving nursing care following cardiac surgery. The
review also updates the current evidence for measuring
patient experience of cardiac surgery and nursing care.
Our findings indicate the importance of nurses consider-
ing the physical, psychological and emotional aspects of
patients’ experiences of cardiac surgery. However, as none
of the studies considered patients’ experiences of nursing
care following cardiac surgery, findings which explicitly
related to nursing care were identified and included.
Patients’ accounts suggest that they were generally satis-
fied with their experience of nursing care and they recalled
both ‘transactional’ and ‘relational’ aspects of nursing care
delivery. Nevertheless, the lack of studies that specifically
investigated the patient experience of nursing care in car-
diac surgery highlights the urgent need for future studies
that begin addressing this important aspect of cardiac
nursing.
Another gap in the literature is the lack of studies meas-
uring patient experience of nursing care following cardiac
surgery, although the PREMs framework and question-
naire for patient experience following heart-valve surgery
may be suitable for use following other types of cardiac
surgery. In future studies, different feedback types may
provide a robust method for developing patient-experi-
ence measures for cardiac surgery and former patients
could be included as advisors in these projects to ensure
that they are user-led developments.
Limitations
There is no standardised procedure for conducting narra-
tive reviews, and they have been criticised for this.
Therefore, to demonstrate that this narrative review
adopted a logical and transparent approach to searching,
data extraction, quality appraisal, thematic analysis and
synthesis output, the COREQ guidelines were adopted
(Tong et al, 2007).
356
itish Journal of Cardiac Nursing. Downloaded from magonlinelibrary.com by 131.172.036.029 on August 1, 2016. For personal use only. No other uses without permission. . All rights reserve
Owing to the flexible nature of narrative reviews allow-
ing for the inclusion of different research methods (quali-
tative and quantitative), it was difficult to appraise the
studies using a single approach. Therefore, studies sharing
the same methodology were critically appraised using the
same appraisal tool, to allow for some consistency. It was
however difficult to weigh the quality of the studies, par-
ticularly with a small number of studies.
The authors acknowledge the review is limited by the
number of included papers. While this is identified as a
limitation, it is also a strength of the current review which
paves the way for future rigorous research in this area as it
presents important findings, and conclusions are drawn
highlighting the urgent need for future research into the
topic.
No studies in the review purposely aimed to capture the
experience of nursing care following cardiac surgery.
Therefore, all conclusions that are specific to nursing care
were interpreted by the lead author/researcher. As a
researcher having nursing experience of working with
patients following cardiac surgery, personal bias may have
affected the conclusions drawn. In an attempt to avoid
this, only conclusions drawn which were explicit about
nursing were included in the review.  BJCN
Acknowledgements: The study was funded by NHS England
and Health Education East Midlands. The study would not
have been possible without the support of the Care Maker
Research Internship programme.
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Research and Development
Key Points
Cardiac surgery patients are able to recall a variety of physical,
w
psychological, emotional, environmental and nursing care
experiences
While none of the studies explicitly aimed to explore the patient
w
experience of nursing care following cardiac surgery, the current
review contributes to our understanding of the patient experience of
cardiac surgery and receiving nursing care following cardiac surgery
Patients’ accounts suggest that they were generally satisfied with
w
their experience of nursing care and they recalled both ‘transactional’
and ‘relational’ aspects of nursing-care delivery
There is an urgent need for future studies to explicitly capture the
w
patient experience of nursing care in cardiac surgery
In future studies, different feedback types may provide a robust
w
method for developing patient-experience measures for cardiac
surgery and former patients could be included as advisors in these
projects to ensure that they are user-led developments
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Summary Instructions for authors

Introduction
British Journal of Cardiac Nursing (BJCN) is a clinical and
professional review journal for nurses who wish to be fully informed
of developments in the specialty of cardiac nursing. It aims to
provide the highest standards of clinical reviews and to offer a
forum for the exchange
of knowledge and experience from which patients will benefit.
We welcome submissions from both first time and experienced
authors. The supportive review process often provides
inexperienced authors with constructive advice on how to improve
their articles. Articles published in the journal will normally fall
into the following categories: clinical, care study, drug focus,
practical procedures, research and development and career focus.
There will also be book reviews, comment pieces and letters.
Submission
All articles should be submitted online at: http://www.epress.
ac.uk/bjcardn/webforms/author.php. Documents should be
double-spaced (including references) and formatted for A4 paper
and all pages should be numbered. For purposes of confidentiality,
author identification should appear only on the title page. You will
receive an email stating that your article has arrived and has
been sent for review. All clinical and research articles should
include an abstract of between 100 and 150 words, key words,
and 5–6 key points, i.e. phrases that summarise the major
themes of your article. Conflict of interest: Please declare any
conflicts of interest, i.e. any possible interests, financial or
otherwise, which may embarrass the author or the journal if
highlighted at a later date.

General advice Peer review

Here are some general points to keep in mind when writing an article
for the journal. BJCN aims to present all articles, including original
research, in an easy-to-read informative style. Simplicity is key, so
please avoid jargon. Consider the key take home message from your
article. It may be helpful to distil the essence of your article into four
or five key points before you start and use these to guide your
writing. Be very clear about what your article adds to the literature. If
this is obvious, your article is more likely to be accepted. A key aim
of BJCN is to be of practical use to its readers, so take care to
outline the implications for practice. Read other articles from BJCN
for ideas on style and layout. Organise your article in a logical
All articles submitted for publication in BJCN are peer reviewed
before publication. The review process will take approximately 8–12
weeks. When the reviews are complete the Editor will contact you
regarding the suitability of your article for publication. Decisions
regarding peer-reviewed articles fall into the following categories:
accept; accept subject to amendment; requires amendment before
a second review; and reject. Authors of rejected article may be
invited to extensively revise their article and resubmit for peer
review again. Queries regarding progress of article reviews should
be directed to the Editor via email at bjcardn@markallengroup.com.
If your paper is accepted for publication you will receive proofs for
© 2016 MA Healthcare Ltd

manner. Subheadings, pictures and boxes all help break up the text correction at a later date before the article is published. For full
for readers and help maintain interest in the article. If you have not guidance on referencing, submission of illustrations and other
written for publication before, it can be helpful to take advice from details, please download the instructions for authors in full from
colleagues. Always proof read and check spellings carefully. http://www.cardiac-nursing.co.uk/downloads/auth_guid.pdf

358 British Journal of Cardiac Nursing July 2016 Vol 11 No 7

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