Patient experiences of cardiac surgery and nursing ...

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Research and Development

Patient experiences of cardiac surgery and nursing care: a narrative review


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


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 multidimensional 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.


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 conditions, resulting in advances in diagnosis, treatment, medications 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 experience 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 implementation plans which prioritise patient experience and focus on how people perceived the standards of care they 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

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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: [email protected]

Research and Development (Dunckley et al, 2007; Almond et al, 2012), family-focused (Wrigley and Lathlean, 2010; Linden, 2012), and intervention-specific (Perkins, 2008; Radcliffe et al, 2009). Additionally, a qualitative synthesis (Leegard and Fagermoen, 2008) aimed to reflect key themes and experiences in qualitative literature following coronary artery bypass graft (CABG) surgery, which did not reflect nursing-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 evidence to capture a multi-dimensional view of patient experience following cardiac surgery, nursing care or patient experience measurement.


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 following 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 allowing for the inclusion of quantitative and qualitative evidence (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).

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


Patient experience Feedback from patients on ‘what actually happened’ in the course of receiving care or treatment, both objective facts and their subjective view of it (Dr Foster Intelligence, 2010). A measure of the value judgements patients apply to their experience (Matthews and Cornwell, 2012).

Patient satisfaction

Patient Reported Used to demonstrate experience trends and can Experience be used to inform service development and Measures (PREMs) improvement (Jackson et al, 2014). Refers to what nursing care is delivered. For example, cleanliness, physical comfort and physical care (Dr Foster Intelligence, 2010).

Transactional aspects of care

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).

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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 (Population, Intervention, Comparison and Outcome) acronym as a framework (Cooke et al, 2012). A rigorous scoping search was used (Arksey and 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 identified in Table 3; a summary of the paper extraction process appears in Figure 2. Some authors advise not to consider raw data or direct citations as findings (Sandelowski and Barroso, 2002). However, following Weed (2005), raw data were sometimes used as part of the interpretations and reporting to ensure findings were as close to study participants’ accounts as possible. To ensure thematic analysis was systematic and rigorous in its approach, it was conducted using published principles (Pope et al, 2009)

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Phase 2: Systematic literature search

Phase 1: Scoping search

Phase 3: Critical appraisal of identified studies

Phase 4: Thematic synthesis

Figure 1. Methodology

Table 2. Search strategy Search Terms


Database limits

Cardiac surgery

Cumulative Index for Nursing and Allied Health Literature (CINAHL)


Heart surgery Patient experience Measurement Nursing care

Year: 2004–2014

British Nursing Index (BNI) MEDLINE Open grey

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Research and Development ww Following review of the papers, themes were collected, considered and broken down into sub-themes where appropriate. For example, the theme ‘physical’ was broken down further into the sub-themes, ‘pain’ and ‘mechanical ventilation’ ww Themes and sub-themes were then discussed with the project supervisor and finalised.

Quality appraisal

Table 4 summarises the studies meeting the inclusion criteria. A structured quality appraisal tool was adopted (Spencer et al, 2003; Centre for Reviews and Dissemination, 2008). The quality of studies was assessed before synthesis 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, 2003). Therefore, each qualitative study was assessed using the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al, 2007). Quality assessment was assured by identifying a summary score calculated from each COREQ domain: ww Research team ww Reflexivity ww Study design ww Analysis and findings. The assessment highlighted that all studies had weaknesses in the reporting, particularly in research team and reflexivity domains. This is an important consideration as all studies used in-depth interviews to collect data, meaning that the researchers closely engage in the research and with participants, and are unlikely to completely avoid introducing personal bias to the research (Streubert-Speziale and Carpenter, 2003). It is recommended that researchers should identify and state their relationship with participants 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.

Papers identified from database searching CINHAL (n=18), BNI (n=163), MEDLINE (n=5), Total hits n = 186 Titles scrutinised based on their initial topic relevance n = 186 Abstracts reviewed n = 32 Excluded on basis of abstract n = 14 Papers remaining n = 18 Papers included after full review against inclusion criteria (Table 3) n=5 Additional papers found through: Hand-searching, previous systematic reviews and references from articles n=0 Total papers included in the review n=5

Figure 2. Summary of paper-extraction process


Inclusion criteria


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 participants were the primary sample

Patient experience is the foremost purpose of the review

Patients as primary data

Studies were excluded if patients were not the primary sample. Patient experience was the focus of the review


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

Patient experience of hospital

Studies selected if patient experience was reported reflecting their time as an inpatient for their cardiac surgery


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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Table 3. Inclusion criteria

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Table 4. Summary of included studies Author






Backstrom et al (2006)

Coronary bypass surgery patient’s experiences with treatment and perioperative care—a qualitative interview-based study

To examine how coronary artery bypass surgery patients experienced their care


Nine participants selected, demographically typical of the majority of patients given coronary surgery at study hospital following CABG surgery

The quality of care and patients’ satisfaction can be further enhanced by implementing principles from the peri-operative dialogue model

Gardner et al Patient (2005) experiences following cardiothoracic surgery: An interview study

A thematic analysis of interviews conducted with patients recovering from cardiothoracic surgery, about their memories and experiences of hospital and recovery post discharge


Eight participants following cardiothoracic surgery

Attention to specific areas of patient orientation, education and support was identified to facilitate realistic expectations of recovery

Jackson et al Evaluating (2014) patients’ experiences of heart-valve replacement surgery

Complex This initiative aims to empower patients and Intervention patient organisations to provide feedback on what was important to them in their heartvalve replacement surgery

A working group of 22 members from 17  organisations were recruited to deliver against the aims and objectives through a seven-step process

PREMs can have quantitative and qualitative methodologies to drive service improvement and can be used alongside Patient Reported Outcome Measures (PROMs) to produce a rounded picture of patients’ views on process and outcomes

Thirteen participants following CABG surgery

The study highlights that nurses play a vital role during the immediate postoperative period that goes beyond the more widely recognised technical aspects of their role. The results of this study could be used by nurses to enhance patient experiences and potentially lead to improved physical and psychological outcomes

Ten participants ventilated for greater than 24 hours following CABG surgery

In order to address some of the general, psychological and existential patient experiences, care should be taken to acknowledge the patient and to respect the patient domain and individual time-frames. In nurse-patient communication, it is recommended that caregivers give accurate and unambiguous information

Perkins (2008)

What are the experiences of patients waking from fast-track?

Qualitative Explore patients’ experiences on waking from this particular modality of cardiac surgery. Discover patients’ perceptions of nursing care activities during waking. Highlight any improvements that can be made to nursingcare delivery during this little-known-about time

Schou and Egerod (2008)

A qualitative study into the lived experience of postCABG patients during mechanical ventilator weaning

To provide a contemporary description of the patient experience of weaning, in order to update this aspect of knowledge in the context of newer modalities of mechanical ventilation and sedation

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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 information 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 framework 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, participants, 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.


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



Pain and physical discomfort

Pain related to treatment was not an issue

Mechanical ventilation

Sensations of choking or overheating, pressure and discomfort related to the ET tube

Psychological and emotional


Limitation of invasive monitoring lines impacted on mobility


Negative emotions, distress, anxiety, embarrassment, insecurity, loss of control and hopelessness


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 Patients felt that it was especially important that their relatives stayed in touch during their hospitalisation

Information provision

Patients were generally satisfied with the information that was sent to them prior to their hospitalisation


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 [communication]

Patient experience measurement

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


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Contact with other patients who were in the same situation was very important to exchange experiences

Research and Development contrast, some patients described their pain as ‘absolute agony’ (Perkins, 2008: 376). This is a significant finding, suggestive of variability in effective pain management following 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 postoperatively, 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 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, musculoskeletal, 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 management should reduce pain and physical discomfort, which has been identified by Jackson et al (2014) as a contributory 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.

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Mechanical ventilation

Schou and Egerod (2008) aimed to specifically describe the patient experience of weaning from mechanical ventilation following cardiac surgery. Physical experiences of mechanical ventilation were uncomfortable and strange and 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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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, embarrassment, insecurity, loss of control and reduced self-confidence (Schou and Egerod, 2008). Others experienced emotions of agonising, hopelessness, depression, apprehension 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 depression (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 disturbance 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 discharge. Consideration of psychological screening of inpatients after cardiac surgery to identify these negative emotions 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/prognosis, impact of illness on patient, family and finances, as important measures of patient experience, which is consistent 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, recalling it as ‘busy’ and ‘crowded’, ‘sterile’ and ‘constantly moving’. 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 Downloaded from by on May 29, 2018.

Research and Development


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 professionals 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 problems 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 procedures 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 postoperatively, 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 354

the operating surgeon, and individualised to their particular case (Backstrom et al, 2006). These findings suggest that patients require information at key time-points along their cardiac surgery journey.


The clinical environment was part of the patient experience following cardiac surgery. Some found the ICU to be calm and quiet (Perkins, 2008); similarly, patients appreciated 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 particularly threatening and unsettling. It is important that these findings are considered within the dynamic and changing context of the ICU environment. Environmental considerations 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 haemodynamic 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 ‘relational’ aspects of nursing care delivery. Definitions of these terms can be found in Table 1. Experiences of communication were reported across all studies, and are therefore 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 reported that nurses used non-augmentative methods of communication such as gestures, pen and paper, and computers, 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 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).

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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 agitation after cardiac surgery owing to the cerebral effects of cardiopulmonary bypass (Woods et al, 2009). Much confusion 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; however, despite this, patients still experienced disorientation with time (Perkins, 2008). One patient recalled vivid hallucinations 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 disorientation and confusion with time have important implications for nursing practice. Nurses should be mindful that patients following cardiac surgery experience disorientation with time and, therefore where possible, should reassure and orientate patients to time and place. This may lead to a positive patient experience and reduced confusion in the clinical area.

Research and Development 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 experience (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 communication 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

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 experience of nursing care following cardiac surgery. Jackson et al (2014) developed a PREMs framework and questionnaire for patient experience following heart-valve surgery. A small-scale pilot study of the questionnaire was inconclusive in measuring patient experience, but instead found quantitative outcomes for patient satisfaction. It is therefore difficult to assess the PREMs’ suitability for measuring patient experience. However, when findings of reviewed qualitative studies (Gardner et al, 2005;

Figure 8. PREMs framework alignment

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Patient experience framework for heart-valve surgery

NICE Quality Standards

Examples from narrative

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

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

Information, communication and education on clinical status, progress, prognosis and processes of care in order to facilitate autonomy, self-care and health promotion

2, 3, 5, 12, 14

Patients wanted information pre and postoperatively to be given by the operating surgeon, and individualised to their particular case

Physical comfort including pain management, help with activities of daily living and clean comfortable surroundings


The experience of pain, either acute or general in nature, as well as the severity of the pain was reported across the studies

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


Patients felt that the nurse looking after them held significant power in being able to allay the patients’ fears

Welcoming the involvement of family and friends, who patients and service users rely on, in decisionmaking and demonstrating awareness and accommodation of their needs as caregivers


The most important source of support described by patients across the studies was that of family members

review findings

Source: Adapted from NICE, 2013; Jackson et al, 2014

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Research and Development


This narrative review of the qualitative and quantitative evidence provides a unique contribution to our understanding 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 considering 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 satisfied 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 cardiac 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 measuring patient experience of nursing care following cardiac surgery, although the PREMs framework and questionnaire 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-experience measures for cardiac surgery and former patients could be included as advisors in these projects to ensure that they are user-led developments.


There is no standardised procedure for conducting narrative 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

Owing to the flexible nature of narrative reviews allowing for the inclusion of different research methods (qualitative 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, particularly 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.


Almond SC, Salisbury H, Ziebland S (2012) Women’s experience of coronary heart disease: why is it different? British Journal of Cardiac Nursing 7(4): 165–70. doi: 10.12968/bjca.2012.7.4.165 Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 8(1): 19–32 Ashworth P (1980) Care to communicate: An investigation into problems of communication between patients and nurses in intensive therapy units. Royal College of Nursing, London Bäckström S, Wynn R, Sørlie T (2006) Coronary bypass surgery patients’ experiences with treatment and perioperative care - a qualitative interview-based study. J Nurs Manag 14(2): 140–7 Blumenthal JA, Lett HS, Babyak MA et al (2003) Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 362(9384): 604–9 Breivik H, Stubhaug A (2008) Management of acute postoperative pain: still a long way to go! Pain 137(2): 233–4. doi: doi: 10.1016/j. pain.2008.04.014 Bruce J, Drury N, Poobalan AS, Jeffrey RR, Smith WC, Chambers W (2003) The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study. Pain 104(1–2): 265–73 Campbell R, Pound P, Pope C et al (2003) Evaluating metaethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med 56(4): 671–84 Centre for Reviews and Dissemination (2008) Systematic Reviews. CRD’s guidance for undertaking reviews in health care. University of York, York. (accessed 21 June 2016) Cogan J (2010) Pain management after cardiac surgery. Semin Cardiothorac Vasc Anesth 14(3): 201–4. doi: 10.1177/1089253210378401 Commissioning for Quality and Innovation (2014) Delivering the NHS safety thermometer CQUIN 2013/14. (accessed 21 June 2016) Cooke A, Smith D, Booth A (2012) Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res 22(10): 1435–43. doi: 10.1177/1049732312452938

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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 framework. 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 correlations 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.

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Key Points w Cardiac surgery patients are able to recall a variety of physical, psychological, emotional, environmental and nursing care experiences w While none of the studies explicitly aimed to explore the patient 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 w Patients’ accounts suggest that they were generally satisfied with their experience of nursing care and they recalled both ‘transactional’ and ‘relational’ aspects of nursing-care delivery w There is an urgent need for future studies to explicitly capture the patient experience of nursing care in cardiac surgery w In future studies, different feedback types may provide a robust 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 3 months after cardiac surgery. Anesthesiology 95(4): 862–7 NHS England (2013) Transforming participation in Health and Care. ‘The NHS belongs to us all’. P. A. L. Directorate. London, NHS England. (accessed 22 June 2016) NHS National Quality Board (2011) NHS Patient Experience Framework. DH, London. (accessed 22 June 2016) National Institute for Health and Care Excellence (2011) Chronic heart failure quality standard. [QS9]. NICE, London. uk/guidance/qs9 (accessed 22 June 2016) National Institute for Health and Care Excellence (2013) Patient Experience in adult NHS services: improving the experience of care for people using adult NHS services. [CG138]. NICE, London. https:// (accessed 22 June 2016) National Institute for Health and Care Excellence (2014a) Extracorporeal membrane oxygenation (ECMO) for acute heart failure in adults. NICE interventional procedure guidance. [IPG482]. NICE, London. (accessed 22 June 2016) National Institute for Health and Care Excellence (2014b) Atrial fibrillation: management. [CG180]. NICE, London. https://www.nice. (accessed 22 June 2016) Perkins C (2008) What are the experiences of patients waking from fast-track. British Journal of Cardiac Nursing 3(8): 373–82. doi: 10.12968/bjca.2008.3.8.30724 Picker Institute (1987) Principles of patient-centred care. http:// (accessed 22 June 2016) Pope C, Mays N, Popay J (2009) Synthesizing Qualitative and Quantitative Health Evidence: A Guide to Methods. Open University Press, Maidenhead Pound P, Britten N, Morgan M et al (2005) Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med 61(1): 133–55 Radcliffe EL, Harding G, Rothman MT, Feder GS (2009) ‘It got right to the spot’ The patient experience of primary angioplasty: a qualitative study. Eur J Cardiovasc Nurs 8(3): 216–22. doi: 10.1016/j. ejcnurse.2009.02.001 Robert G, Cornwell J, Brearley S et al (2011) What matters to patients’? Developing the evidence base for measuring and improving patient experience. The King’s Fund, London. (accessed 22 June 2016) Rymaszewska J, Kiejna A, Hadryś T (2003) Depression and anxiety in coronary artery bypass grafting patients. Eur Psychiatry 18(4): 155– 60 Sandelowski M, Barroso J (2002) Reading Qualitative Studies. Int J Qual Meth 1(1): Article 5 Schelling G, Richter M, Roozendaal B et al (2003) Exposure to high stress in the intensive care unit may have negative effects on health-

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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.

All articles should be submitted online at: http://www.epress. 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.

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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 manner. Subheadings, pictures and boxes all help break up the text for readers and help maintain interest in the article. If you have not written for publication before, it can be helpful to take advice from colleagues. Always proof read and check spellings carefully.

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 [email protected]. If your paper is accepted for publication you will receive proofs for correction at a later date before the article is published. For full guidance on referencing, submission of illustrations and other details, please download the instructions for authors in full from


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