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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
Qassim, Saudi Arabia
2
Department of Medical-­Surgical Nursing,
Faculty of Nursing, Port-­Said University,
Port-Said, Egypt
3
Departmentof Medical-Surgical Nursing,
Faculty of Nursing, Suez Canal University,
Ismailia, Egypt
Correspondence
Shereen Ahmed Ahmed Qalawa, Nursing
College, Qassim University, KSA, Egypt.
Email: s.qalawa@qu.edu.sa and shereen.
q066@yahoo.com
Abstract
Background: Postcardiac surgery, numerous factors have been shown to predict
postoperative harm of QoL, such as age, female sex, history of hypertension, chronic
obstructive pulmonary disease, education level, marital status, and also psycholog-
ical factors such as the presence of mood disorders. So, the essential key to self-­
management is behavioural change, which is necessary to improve the quality of life
of patients and Health outcomes.
Aim: The aim of this study is to evaluate the impact of the education programme on
patients' health outcomes following open heart surgeries.
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
Coronary artery bypass grafting (CABG) persists as the greatest
common cardiac surgery implemented today universally. The past of
this procedure can be drawn back for more than 100 years, and its
progress has been affected by several innovators in the field of car-
diac surgery, who have subsidized both their successes and failures
(Melly et al., 2018).
Furthermore, the burden of cardiovascular disease as a long-­term
illness increasingly requires patients to suppose more responsibility
for their self-­management. Thus, patient education is supposed to be
an essential component of cardiovascular care; conversely, there is
limited evidence about specific therapeutic patient education strat-
egies used and it is the impact on patient self-­management outcomes
(Barnason et al., 2017). In this regard, the World Health Organization
(WHO) has defined health as being “not only the absence of disease
and infirmity but also the presence of physical, mental, and social
well-­being”. To confine this, comprehensive perception and quality
of life (QoL) has become increasingly important in social sciences
and health care (Perrotti et al., 2019).
Postcardiac surgery, numerous factors have been shown to pre-
dict postoperative harm of QoL, such as age, female sex, history of
hypertension, chronic obstructive pulmonary disease, education
level, marital status, and also psychological factors such as the pres-
ence of mood disorders (Perrotti et al.,  2019). For this reason, pa-
tients' concerns related to open-­heart surgery mainly include some
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
hospital costs. Moreover, Coronary artery bypasses grafting (CABG)
as one of the treatment modalities for patients with coronary artery
diseases has a major physical, psychological, and emotional impact
on the patients (Ahmed et al., 2017). As education is the basic ap-
proach to the development of self-­management skills, the strategy
used to implement educational support is expected to affect the
individual level of self-­management and clinical outcomes. So, the
essential key to self-­management is behavioural change, which is
necessary to improve the quality of life of patients and health out-
comes (Talboom-­Kamp et al., 2017).
On the other hand, the effectiveness of preoperative educa-
tion in the postoperative period following cardiac surgery in pa-
tient satisfaction and postoperative outcomes have been the main
concerns (Kalogianni et al.,  2019). Otherwise, individualized edu-
cation is an important issue for preparing patients for the opera-
tion both physically and psychologically attributes to help those
patients to climb emotional, cognitive, and physiological, loss of
working ability, pain, loss of sexual ability, inability to wake up from
anaesthesia, and fear of death reactions resulting from surgery
(Ertürk & Ünlü, 2018).
Unfortunately, emotional and behavioural troubles have been
celebrated as a significant phenomenon postopen-­heart surgery.
Nevertheless, a vast difference exists in the literature about the
presence of psychiatric symptoms, cognitive performance, and qual-
ity of life among those patients (Younes et al., 2019). So, quality of
life (QoL) is a vital concept that assesses physical and mental health
among patients undergoing coronary artery bypass graft (CABG)
surgery using the Short-­Form 36-­item questionnaire (SF-­36) up to
10 years after surgery (Keage et al., 2016; Younes et al., 2019).
Furthermore, nurses have a means role in teaching patients post-
cardiac surgeries to deal with their postsurgical period. There are
facts that effective teaching strategies contribute to enhanced qual-
ity of life, and decreased anxiety and depression. Despite this, there
are no protocols or standards for the greatest educational strategies
for cardiac patients postsurgeries during hospitalization and dis-
charge periods (Veronovici et al., 2014).
Therefore, critical care nurses should give comprehensive care
based on organized strategies and evaluate provided care of patients
along with the health care team based on their knowledge, planning,
programming, and management. The skilled professional nurse in-
dividualizes preoperative instruction to meet the specific needs of
each patient. Thus, patients' perceptions of health and stressors
have crucial for meaningful nursing and care programmes (Ahmed
et al., 2017).
1.1  |  Justification of the problem
Based on World Health Organization, 2018 for the period of the
past 15 years, heart disease has been considered the number one
cause of death worldwide. However, more than 610,000 individuals
die annually from heart disease in the United States, accounting for
one-­fourth of all deaths, and approximately 30.3 million individuals
in 2018 from the United States were estimated to have heart disease
to mitigate these complications, cardiac surgery is regularly carried
out. Cardiac surgery types include coronary artery bypass grafting
(CABG), repair or removal of the heart valve, heart transplant, and
installation of machines or artificial hearts for ventricular assistance
(Stigler Granados et al., 2019).
So, health-­related quality of life (HRQOL) is a significant indi-
cator of long-­term well-­being, influenced by environmental factors
such as family, culture, community norms, and available resources
that better and earlier diagnostics and clinical management of con-
genital heart disease (CHD) have led to decreased mortality and in-
creased achieved outcomes (Ladak et al., 2020).
ELGAZZAR et al.
1.2  |  Conceptual framework
According to Youssef (2013), the conceptual framework for the ar-
rangement of health-­quality of life (HRQOL) outcomes model itself
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-
physiological variables; physical and psychological symptoms; func-
tional health status; perception of general health (Ladak et al., 2020);
and overall quality of life (QOL; Figure 1).
1.2.1  |  Significance of study
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-
fect the aspects of QOL in various ways (Mahdizadeh et al., 2016).
Thus, declining mortality and major morbidity rates after cardiac
surgery have led to an increasing focus on patient quality of life
(QOL). Beyond longevity, the impact of cardiac surgery on day-­to-­
day functioning is incredibly salient to patients, their spouses, and
their families. On the other hand, the multidisciplinary team should
plan patient care before, during, and after postopen-­heart surgery
counting the knowledge of self-­c are for postopen-­heart patients to
improve their quality of life (Suwanakitch et al., 2019). Therefore,
this study aims to evaluate the impact of the implementing instruc-
tional scheme on patients' health outcomes following patients'
open-­heart surgeries.
F I G U R E 1  Health-­related quality of life framework (HRQOL) (Peterson and Bredow, 2009)(15)
|
      3
1.2.2  |  Objective
This study aimed to evaluate the impact of the education programme
on patients' health outcomes following open-­heart surgeries.
1.2.3  |  Research hypotheses
1. The postimplementation of instructional scheme functional
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
designed instructional scheme about postopen-­heart surgery
care will show better health outcomes.
2  |  M E TH O D S
A Quasi-­experimental research design was used. This study was
carried out in intensive care for open-­heart surgery in Suez Canal
university hospitals at Ismailia Governate all available sex patients
performing open-­heart surgery for 6 months were precluded in the
study (60 patients). The inclusive patients were adults aged (21–­60)
years old. Data were collected by using three validated adapted tools
after translation to the Arabic language and making some modifica-
tions to be suitable for the population, beliefs, values, and culture.
The tool I: Patient's Risk stratification model Euro Scale sheet in-
cludes 3 parts as socio-­demographic characteristics for patients such
as name, age, sex, job, and education etc. Patient Information about
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4      ELGAZZAR et al.
the types and causes of performing the operation, investigation,
and preoperative care; the risk stratification model Euro Score was
adopted from Bjelland et al. (2002) and is used to calculate patients'
risk level; Tool II: New York Heart Association (NYHA). This tool was
adopted from El-­Baz (2009) is used to give a simple way of classifying
the extent of heart failure. It places patients in one of four categories
based on how much they are limited during physical activity; the lim-
itations/symptoms are about normal breathing and varying degrees
of shortness of breath and/or angina. Tool III: Health Outcomes sheet:
it includes three parts as follows: Part I: SF-­36 (health-­related quality
of life): it was sent to patients preoperatively after they were sched-
uled for open-­heart surgery, and postoperatively 6 months. 36-­SF:
will be adopted from (Chocron et al.,  2000), it is formed from 36
questions to assess the health outcome (Quality of life) across eight
domains, which are both physically and emotionally based. The eight
domains that the SF36 measures are as follows: physical functioning,
role limitations due to physical health, role limitations due to emo-
tional problems, energy/fatigue, emotional well-­being, social func-
tioning, pain, and general health. It consisted of 36 items that assess
eight health dimensions: physical functioning questions (3:12); role
limitations due to physical health problems questions (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 22); social func-
tioning questions (20 and 32); and general health perceptions ques-
tions (1, 2, 33, 34, 35, 36). Health-­Related Quality of Life (Rand 36
item health survey, version1): this was used to assess health-­related
quality of life for study patients before s and after 3 months from
surgery and instructional scheme implementation. It consisted of 36
items that assess eight health dimensions: physical functioning ques-
tions (3:12); role limitations due to physical health problems ques-
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
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
Depression Scale (HADS): It was adopted from(Bjelland et al., 2002)
to measure anxiety and depressive symptoms were assessed at 6
months post-­C ABG using the 1970s' anxiety subscale and the seven-­
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-
cise testing; Part III: Health Complaints Scale (HCS). This scale was
adopted by Hevey et al. (2007) and Pedersen and Denollet (2002).
Which is concerned with measuring disease to cardiac complaints
a disease-­specific measure of cardiac complaints, was administered
twice, namely before surgery and at 6 months' follow-­up. The scale
is a disease-­specific measure developed in cardiac patients, with the
12-­item cognitive complaints subscale representing “health worry”
and “illness disruption” (e.g. “The idea that I have a serious illness”)
and the 12-­item somatic complaints subscale representing “cardio-
pulmonary”, “fatigue” and “sleep” problems (e.g. “Tightness of the
chest”) (Persson & Stagmo,  2008). The HCS is a valid and reliable
measure both in Belgian and Danish cardiac patients. The HCS is
also a sensitive outcome measure for tapping treatment and cardiac
rehabilitation related to an educational programme of postoperative
care implemented through using 5 phases as follows: (1) before edu-
cational pathway development, preparing the tools were used from
the different scientific references and then identifying the patients
who will undergo open-­heart surgeries (during the pre-­operative
phase) followed by collecting baseline data, which help in the design
of an instructional scheme, in addition to literature review. (2) Pre-­
test phase (Prior learning package implementation), The researcher
preoperatively assessed the patients (socio-­demographic data and
medical health) by using a tool (1), health status which should be
identified preoperatively to the patient to perform postoperatively
about open heart surgeries through using tools (2), and the patient's
health outcomes by using a tool (3). (3). Implementation phase, an in-
structional scheme was implemented individualized in a clear and
concise manner, and focused on the points to be learned, using dif-
ferent adult teaching methods. Implementation of an instructional
scheme will be done in two sessions. Each session will be repeated
again. Attendants were chanced to discuss their own experiences
after the researcher clarified to them any queries and explained the
unknown issues. During the pre-­operative period, patients will be
informed about what to expect during the immediate preoperative,
and postoperative periods till discharge, and were invited to express
their feelings of anxiety and their concerns about surgery and recov-
ery. Furthermore, patients were provided with booklets with infor-
mation about surgery and expected outcomes. (4). Evaluation phase
(Post-­test), the researcher evaluated the impact of the implementing
instructional scheme on the patient's health outcomes at the first
visit for patient post open heart surgery for follow-­up in the outpa-
tient clinic by using tools (1, 2, 3).
2.1  |  Ethical considerations
Ethical approval was obtained from the ethical board (REDACTED)
which directed the responsible authorities of the study settings to
take their permission to conduct the study after explaining its pur-
pose to take their permission and gain their cooperation.
2.2  |  Procedure
After the collection of references and development of a tool based
on a literature review, the tool was validated after being translated
into Arabic and retranslated by English experts, and face validity was
done by five professors from the Medical-­surgical nursing & critical
care nursing field. A pilot study was carried out after the develop-
ment of the tools on 10% of patients to the test applicability of the
tools then necessary modifications were done according to the find-
ing results of the pilot study and expert opinions. Otherwise, these
patients were then excluded from the sample of research work to as-
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
were described using range (minimum and maximum), mean and
standard deviation. The significance of the obtained results was
judged at the 5% level. The used tests were Chi-­square test for cat-
egorical variables, compare between different groups. Fisher's Exact
or Monte Carlo correction for chi-­square when more than 20% of
the cells have an expected count less than 5, McNemar and Marginal
Homogeneity Test used to analyse the significance between the dif-
ferent stages, Student t-­test. For normally distributed quantitative
variables, to compare between two studied groups, F-­test (ANOVA).
For normally distributed quantitative variables, to compare between
more than two groups and Paired t-­test. For normally distributed
quantitative variables, to compare between two periods.
3  |  R E S U LT S
In Table  1, the sample of the study had a 43.3% in the age group
41–­50 years and consisted of 53.3% women and 46.7 men. Most pa-
tients were married (75.0%). Less than of the sample (43.32%) had
an occupation and half of them had a secondary educational level.
Table  2 represents a comparison between patients' fatigue or
distress associated with physical activity before and after the ed-
ucational programme. The majority of the patient had little effect
on physical activity and it does not cause fatigue or distress with a
significant improvement from pre-­and posteducational programmes
indicated with 53.3% and 38.3%, respectively.
Table 3 shows that there were significant differences between
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
after the educational programme. On the other hand, no significant
difference was found in the patient's vital signs before and after the
educational programme.
Table 4 summarizes the mean scores of psychological status be-
fore educational programmes were 29.75 (SD, 3.61) and 18.25 (SD,
2.24). After the educational programme with statistically significant,
whereas patients' problems as physical, mental, and overall patients
problems scores were improved in the postphase than prephase of
Before After
educational educational
programme programme
No. % No.
Fatigue or distress associated with physical activity?
Physical activity without fatigue 0 0.0 20
or distress
Little effect on physical activity 32 53.3 23
and it does not cause fatigue
or distress
Effect on physical activity and 28 46.7 17
causes fatigue and discomfort
the educational programme and significant (p ≤ 0.05). On the other
hand, no significant difference between pre-­ and posteducational
programme for vital signs measurement.
Table 5 shows an improvement in different quality of life aspects,
and total scores indicated that there was a significant improvement
in the patient's quality of life and the total score from the pre-­ to
post-­test after the application of the educational intervention pro-
gramme. all the components of quality of life were significantly im-
proved in the after educational compared with before educational
programme except social aspect (p ≤ 0.05).
In Table  6, there was a significant difference between age
and psychological status, so the psychological status was higher
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
with Overall problems after the programme, so males had fewer
problems than females after the programme. Also, a significant
difference between position and overall problems before the pro-
gramme, while the not working patients had higher problems than
the workers, but after the programme, they improved like some.
Moreover, there was a significant difference between education
and psychological status, and it was found that illiterate patients
and primary education had the highest score in psychological
status before the programme, but after the programme, they im-
proved overall categories of education.
In Table  7, there was no statistically significant difference be-
tween overall quality of life and socio-­demographic characteristics
before and after the educational programme.
4  |  D I S C U S S I O N
Cardiac surgery is to improve patient outcomes. HRQOL helps one to
estimate all major realms of good rehabilitation, such as patients' per-
ceived well-­being and return to everyday activities. Self-­perceived
health status is now a major predictor of surgical outcomes, despite
having been overlooked in the past. The demographic data of this
study revealed that women outnumbered men 53.3%–­46.7%, with
the largest age group being (31–­4 0 years). The results showed that
TA B L E 2  Comparison between
patients' fatigue or distress associated
with physical activity before and after the
educational programme (n = 60)
% p
MH
33.3 p < 0.001*
38.3
28.3
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
it does not cause fatigue or distress with a significant improvement
from pre-­ and posteducational programmes as indicated by 53.3%
and 38.3%, respectively. However, the findings of a study performed
in Poland in patients who had Coronary Artery Bypass Graft surgery
displayed that before the start of rehabilitation and treatment, dysp-
noea, chest pain, and fatigue were 50%,68%, and 40% in patients,
subsequently rehabilitation these rates decreased to 10%, 12% and
33% (Agostini & Singh, 2009).
As regards, the patient's physiological parameters before and
after the educational programme the results showed that the pro-
gramme affected significant improvement in the arterial blood gas
measurement (PaO2 and PaCO2). While Agostini and Singh  (2009)
stated that Incentive spirometers (IS) can enhance gas exchange
other researchers stated this is unusual after thorax surgery. Finally,
they decided tits can help oxygenation and gas exchange subse-
quently thorax surgery.
There was a statistically significant difference in psycholog-
ical status before and after the educational programme. While
patients undergoing open-­heart surgery experience high levels of
anxiety because they have no idea what to expect from the pro-
cedure. Unfounded assumptions, concerns, and problems in the
postoperative period result from a lack of necessary knowledge
and training during the preoperative period (Cebeci & Çelik, 2011).
Our findings are consistent with previous quasi-­experimental re-
search that found that after CABG surgery, discharge education or
a cardiac rehabilitation programme decreased anxiety and depres-
sion (Yildiz et al.,  2014; Zhang et al.,  2012). According to Zhang
et al.  (2012) stated that formal preoperative education delivered
by qualified nurses decreases anxiety and other complications in
CABG patients.
As regards, patient problems as physical, mental, and overall
patient problem scores were improved significantly in the post-
phase than prephase of the educational programme and sig-
nificant (p ≤ 0.05). our result is inconsistent with some studies
(Højskov et al.,  2019) found that the intervention had no impact
on self-­reported physical and mental health, anxiety, pain, sleep,
or health-­related quality of life, but all of the results had a simi-
lar relation. This finding concurs with Bsharat and Karadag  (n.d.)
who reported that the intervention group had fewer problems
than anticipated, while the control group had more problems than
expected for the following palpitation, loss of appetite, constipa-
tion, dizziness, fatigue, attention deficit disorder, trouble falling
asleep, insomnia, back pain, shoulder pain, and leg oedema are
all symptoms of attention deficit disorder. While Al-­A hdal and
Abdullah (2020) conducted a quasi-­experimental design at Sudan
Heart Center for a total of 128, showing quality of life education
programme for recovery patients increases patient outcomes, as
shown by the lack of postoperative complications, and patient
satisfaction. Ratajska et al.  (2020) demonstrated that safe and
sufficient nutrition greatly aids in the reduction of surgical stress,
the maintenance of physiological functional capability, and the fa-
cilitation of postoperative functional recovery, avoiding problems
and improving outcomes.
The results of the study show a positive effect of health edu-
cation on quality of life and improving patient outcomes. Attention
to results shows a significant difference in all aspects of quality
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-
ing concurs with Arthur et al. (2000) who found that the interven-
tion group had a higher quality of life than the control group during
the waiting period. Up to 6  months after surgery, the improved
quality of life lasted. According to Shah et al. (2016), early mobiliza-
tion and exercise appear to be critical in preventing postoperative
complications, improving functional performance, and reducing the
duration of hospital stay in patients who have undergone cardiac
surgery. Similarly, other studies (Babaee et al., 2007) mentioned that
the pain, energy, emotional reaction, physical mobility, sleep, and
overall average quality of life improved significantly between the
control and study groups, as measured by the Nottingham Health
Profile. Physical function, role limitations resulting from emotional
status, role limitations resulting from physical status, mental well-­
being vitality, and overall average quality of life all showed signifi-
cant improvements between the two groups, as calculated by the
SF-­36. The findings show that providing health education to CABG
patients improves their quality of life.
There was a significant difference between age and psycho-
logical status, so the psychological status was higher at the age of
31–­4 0 years old than at other ages before the programme, while
after the programme there was no relationship and all of them got
better. Other studies, found that according to the logistic model,
demographic variables that can influence a patient's recovery,
such as age, gender, insurance, personal control over the dis-
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
Bypass Graft patients (Sadeghi et al.,  2017). While the findings
of this study are not supported by data from another study that
found no substantial relationship between age and stress (Falcoz
et al., 2006).
As for gender, there was a relationship with overall problems
after the programme, so males had fewer problems than females
after the programme. These findings are inconsistent with those (Han
et al., 2014; Pačarić et al., 2020 & Pedersen & Denollet, 2002) that
demonstrated the impact of single socio-­demographic variables such
as age, gender, and marital status on HRQL. There are also some stud-
ies that, recommended the reasons that could contribute to these dif-
ferences between men and females including biological influences,
such as the effect of psychosocial factors, and female sex hormones,
for occurrence, women's numerous roles due to new variations in
society.
This study result showed no statistical significance between overall
quality of life and socio-­demographic characteristics before and after
the educational programme. This result is congruent with Rumsfeld
et al. (2004) who reported that gender, age, lifestyle, and risk factors
were not predictors of poorer quality of life assessment after rehabil-
itation. While another study not in the line with (Dąbek et al., 2017)
found that concomitant disorders, age, presence of risk factors, life-
style, and level of knowledge, impact the course of the illness and its
management and the quality of life of the affected patients.
4.1  |  Study limitations
This study has numerous limitations. Mainly, the study was per-
formed in merely one cardiovascular surgery unit, and the study par-
ticipant redirects to only one area of Egypt. Hence, our results cannot
be generalized to entirely cardiac surgery patients. Second, long-­term
prospective studies are desirable after open-­heart surgeries.
R ECO M M E N DATI O N S
From the foregoing discussion, it can be seen that the implemen-
tation of multimedia educational programmes for postcardiac sur-
geries patients showed a remarkable improvement in the patient's
level of self-­management and acquiring the ultimate positive and
noticeable improvement in the patient's quality of life as health
outcomes, also, there are obvious needs for instructional scheme
or guidelines offered on simple media to those patients to minimize
complications postcardiac surgeries and increased patient's coping
and adherence with their treatment modalities. Efforts should be
carried out to design and implement interventions that suit cardiac
intensive care units with field evidence and increased facilities, pa-
tient education strategies, and documentation of noncompliance
with cardiac patients with their disease, treatment, and follow-­up
appointments.
AU T H O R C O N T R I B U T I O N S
Authors' S.A.Q contributed to conceived and designed the study,
written methodology, discussion, Conclusions and recommenda-
tions parts and the acquisition, analysis, or interpretation of data
for the work; S.E.E contributed conceived and designed the study,
analysis, or interpretation of data for the work, written introduction,
conceptual framework, Abstract and reviewed the manuscript and
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
and data entry and checked the article for plagiarism. All authors
have critically reviewed and approved the final draft and are respon-
sible for the content and similarity index of the manuscript.
AC K N OW L E D G E M E N T S
I wish to express my deepest appreciation and sincere gratitude to
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.

to thank all head nurses and patients who so generously offered
their experiences and so willingly answered all questions. Hospital
Director for helping through facilitate and permission in gathering
this study. The authors thank the patients in cardiac surgery who
decided to participate in the research and the intensive cardiac unit
nursing staff for their support.
F U N D I N G I N FO R M AT I O N
There are no funding sources to support this study in any form of
grants, equipment, drugs, etc.
C O N FL I C T O F I N T E R E S T
There are no conflicts of interest.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets generated and analysed during this study are available
from the corresponding author on reasonable request.
E T H I C S A P P R OVA L A N D C O N S E N T TO PA R T I C I PAT E
Ethical approval was obtained from the ethical board (REDACTE)
which directed the responsible authorities of the study settings to
take their permission to conduct the study after explaining its pur-
pose to take their permission and gain their cooperation.
ORCID
Samia Eaid Elgazzar  https://orcid.org/0000-0002-9820-7813
Shereen Ahmed Ahmed Qalawa  https://orcid.
org/0000-0003-4257-3272
Amira Mohammed Ali Hassan  https://orcid.
org/0000-0002-4974-4639
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How to cite this article: Elgazzar, S. E., Qalawa, S. A. A., & Ali
Hassan, A. M. (2022). Impact of educational programme on
patient's health outcomes following open heart surgeries.
Nursing Open, 00, 1–14. https://doi.org/10.1002/nop2.1549