Clinical Trial Ofthe Effect Offamily Orientedempowermentmodelon Quality of Lifein Patients
Clinical trial ofthe effect offamily orientedempowermentmodelon quality of lifein patients undergoingcoronary artery bypass graftsurgery.
Dr. Ali Changizi , Assistant Proffesor , Academic Board Member of Qazvin Medical Science University , Qazvin , Iran
Ensieh Mirzaei, Nursing Student (MA) of Critical Cares of Qazvin University Of Medical Sciences , Qazvin , Iran
Dr. Reza Zighami , Assistant Proffesor , Academic Board Member of Qazvin University Of Medical Sciences , Qazvin , Iran
Dr. Mahmood Alipour , Assistant Proffesor , Academic Board Member of Qazvin University Of Medical Sciences , Qazvin , Iran
*Writer: Midwifery & Nursing Faculty , Qazvin University Of Medical Sciences, Bahonar Blv., Qazvin , (0281-3336001-5)
Heart diseasedeath rateshave increased in the world. Family-orientedempowerment modelisimproving thequality of life inpatients with chronic diseases.
Determining the effect offamily orientedempowermentmodelon qualityof life in patientsundergoingcoronary artery bypass graft.
Aquasi-experimental studywas performed onpatients undergoingCABG inbothexperimental and control groupsbefore and after the surgery. Samples put in the groups witha randomarrangement andfamily-orientedempowerment modelwas appliedfor experimental group. Firstly, Mac NewQuality of Life Questionnairewas completedforboth of them. The four-stagemodelof threatperception, problem solving, collaboration and trainingcarried outforexperimental group. One month later, toolsfor bothgroupscompleted and the data were analyzed by Mann-Whitneytestandpairedt-tests and SPSS17software.
Chi-squaretest(p> 0/05)indicated that two groups were similarin terms ofdemographic datasuch asage anddisease duration. The mean score ofthe control groupbefore and after theimplementation of themodel were11/6 ± 5/137and9/6 ± 7/143 (p = 0/001) respectively. They are 13/3 ± 4/133and10/5 ± 2/148 (p = 0/00) respectively inthetestgroup.
These empowering models will lead toenhance the qualityof life by developing the inherentcapacityofindividualsto take responsibility of the life and helpingto make arationaldecisionand evaluatingthem.
Family-orientedempowermentmodel, Coronary Artery Bypass Surgery, Life quality, Semi-experimental, Nursing.
Today,Non-Communicable Diseases havebeenwidely prevailed for thephenomenon ofmodernizing societies, technology developmentand population densityinurban areas, changes in life style andthe desire ofpeopleto unsuitable habits(1).The prevalence ofcoronary arterydisease largelydepends onlifestyle among whichsmoking,diet and exercisecan be implied(2,3). Cardiovascular diseasescaused the death of 5/16million people inthe world in 2002 andit is estimatedthat the number ofdeathsresulting fromthis diseasewill reach25 million in2020 among which19million people will beindevelopingcountries(4,5,6). Cardiovasculardiseasesarethe mostcommon causes of deathin our country too(7).
The prevalencerateofheartdiseasesis estimated 3percent because ofthe younger population in Iran and about twomillion peoplearesuffering fromthis disease(8).
A coronary artery disease isa chronic onewhich not onlyhas a highnumber ofdeaths, but in the long runcausesa restriction ona person's life(9). It is estimated thatcardiovascular diseases were the first incapacitation causes in thelist ofdebilitatingdiseasesinthe world until 2020(10).
CABGisessentialin the treatment ofcoronary arterydiseases andcurrentlyhas been one of themost commonsurgical procedures(11). The AmericanSociety ofThoracicSurgeonsis announced thatin85percent ofpatients whohaveundergoneheart surgery, CABG is performed(12). In Iran, 60 percent of cardiacsurgeryisassociated withcoronaryartery bypass surgery(13).
Changes inthepatternof diseases caused to reduceinfectious diseasesand to increase longevityand have beenled toincreased attention toconcepts ofhealth andquality of lifeduring the past decade. The importance of qualityof thelifeand health status isto the extentthathealth careexpertshave expressedfocusing onimprovingthe quality of lifeand health statusin the presentcentury(14). Chronic diseasessuch asdiabetes andcardiovascular diseases arethemost common causes ofsocial, physical and mental problems and result infunctional limitationand reduced qualityof life.Having strengthened the qualityof lifeby reducing theeffects ofthedisease is the primarygoaloftreatmentespeciallyinchronic diseases(15).
Among these, increased needanddesire forsurgery and special attentiontothese caseswillbe necessary to determine theimportance ofquality of life aftersurgery.
Coronary Artery Bypass Surgery is atemporary treatment and not a definitive one(16).According tothe World Health Organization, health related quality of life formed of three physical, mental and social components. Quality of life has been definedasa person's abilityto dowellin the life withsatisfaction(17). The importance of the quality of life is so that its improvement is implied as the most important of intervention treatment objective.This matter becomes important forchronic diseases for whicha definitive treatmentdoesn’t exist(18).
One of the mostprevalentchronic diseasesinrecentyearsiscardiovascular diseases(19). Patients who have undergone coronary arterybypass graft surgeryarethe onesthat maycausesomechangesinthefamily systemandcreateproblemsfor their families.They mayhaveunique needs and health services may not have been predicted for them especiallyto supporttheirfamilies and othercaregivers(20). Family as the most basic unit of society is responsible of providingappropriatehealthcareto the patient(21).
Considering thatheart diseasecanbe continuedfor alifetime, and in addition to the patient, the familyand eventhe communityisalsoaffected in this procedure; it is necessaryfor thepatienttobe empowered to controlthe disease better andimprovethe qualityof life.The conceptofempowerment has been used in the care ofchronic patientssince2004(22) and defined in Diabetes disease asthe processof discovering anddevelopingpersonalcapacity to take the responsibility of the life byhavingtheknowledge andresources toobtain andimplementthe logical choice and enough experience toevaluatethe effectivenessof decisions for the first time(23).Manyexperts believethat empowermentis a dynamic, positive(24,25), social and interactive process(26,27). It is a process that formed bycommunicating withothers(26) and leads to improve the qualityof life, accountability, better interaction withhealth authorities, satisfaction(27), better responseto treatment(28,29), prevention of complications(30), reducehealthcare costs(31)and thepositiveview of disease(32).
Nursing professionhas attemptedtoprovidenursing carebasedonevidence-orientedresearch resultsinrecent years(33).One of thekeystepsto achievethis goalisthe use ofnursingmodels according to thetheories andmodels ofclinicalcare, education and researchactivities(34).
Family-orientedempowerment model has been designed with the emphasis on the effectiveness of individual andother family members’ role in the areas ofmotivation, psychological, knowledge, attitudesandperceived threat. This model has been emerged from qualitative researchof"fundamental theory”. It has created a functional model by formingconcepts, developingconcepts, identifyingthe psychologicaland socialprocessesand deducting empoweringfamily-orientedcentral variable. Thismodelhas been implementedto improve the quality of lifeforpatients with chroniciron deficiency anemia, Thalassemia, hemophilia, diabetes, asthma and epilepsy.
Having helped familiesis the purpose ofempowermentin a way thatitcanbechanged(35).
Family-orientedcareisa health careapproach that can form health care philosophy, plans, strategies,anddesignsimplicity, patients, families and physicians andother health professionals’ daily interactions(36).
Moststudies have been related tocoronary artery bypass surgeryand less attention has been paid to the satisfactionandquality of lifeof thesepatientsand their families(37).
By the objective of family orientedempowermentmodel effecton quality oflife, the research resultsofSoleymaniet al(2010) showed that applyingthismodelon a regular basiscanincreasequality oflife(38).
Masudi(2010) implemented empowerment model inthecontext by assessing theimpact of thismodel onknowledge, attitude and practiceofcaregiversto the patients withmultiple sclerosis.
He concludedthatempoweringcaregivers toMS patients lead to increase their knowledge,understanding andskills and effectivelyassistthemin the careissue andenhancetheirroles.
Due totheimpact of thismodel onknowledge, attitude andperformance, weexpectthat thismodel canincreasethe abilityofpatients’family membersundergoingcoronary artery bypass graft andindirectlyimproves theirquality of careand alsotheir quality of life(39).
The aim of thisstudy is to evaluatethe effect offamily orientedempowerment modelon the qualityoflife in patientsundergoingcoronary artery bypass graft.
In family-orientededucation,there are active participation offamilies inthestudy anddiagnosisof training andthe needs. Sinceempowerment andself-careadvicedirectlylinked together, whennurseshelpheart patientstoidentifytheir problemsandlearnnew skillsthatareimportant for them; theyenablepatientsto solvetheir problems.
Patients can reach to asense ofpersonalempowermentthrough education andfacilitate their access to the necessary resources. It should be notedthat theeffect of this modelhasnot been studiedinthesepatientsso far.
This is a quasi-experimental study. Thestudywas performedon both experimental and controlgroupsbefore andafter the surgery. The study populationincluded allpatients whoundergonecoronary artery bypass graftsurgery. The samplewas consisted of patientswhoundergone coronary artery bypassesfromthe beginningto the end ofthe samplingprocedure inQazvinAvicenna hospital.
Fifty samplesin eachgroupwere tested.Sampling methodwas a conveniencesampling.Alleligible patientswere enrolled.Integrationwas performedusingthe same inclusioncriteria.
Inclusion criteria included patients that have coronary artery bypass graft surgery and no hearing or vision problems and have lack of mental or neurological problemsandeducation or higher degree license and not living in elderly nursing. And exclusioncriteriaincludedlackof patientcooperationandnon-participation inmeetings,hospitalizations, seriouscomplicationsthat associated withthesurgery. According the objective and confidence coefficient of 95 percent (05/0 = α) and capability of 80 percent, and regard to the variance and the mean before and after of inclusion in previous studies, the minimumsamplerequirementby taking theloss into accountineach groupwasn=50.
Samplesdivided intocontrol and experimental groups witha randomarrangement. And implementation of family orientedempowermentmodelIntervention was included into the experimental group.
The studywas conductedinthree phases and informed consentwasobtainedfrom samples before the beginning.The toolsconsisted oftwo partsinthisstudy. First, demographic information questionnairessuch as age,sex, education level, occupation, marital status and family member’s education, gender and agethat werecollectedby theresearcher. Second, NewMacQOL questionnaire that specificallydesigned to measure thequality of lifeof cardiac patients.
This questionnaire evaluated thecardiac patients’ quality of life with threesubscales of emotional, physical, and social functioning. Fourteenquestionsare in theareas ofphysical function and fourteen questions are in the areas of emotional function and also thirteen questions are in the area of social function. Five questions of physical functions evaluate patient symptoms.
Classificationofthe questionsin the questionnaire was sothateach questioncan be found inone, twoorall threeareas. Thus, themeanscoreofphysical function is calculated by the mean scores of14 questionsinthisfield and so as other functions. The finalscoreis estimatedby calculating thescores of allquestions.
Eachquestionnaire questioncontainssevendegrees ofresponse criterion. Each response has positionona continuumrangingfromalwaysto never. The highestpossible scorein eachareais thescoreofsevenand the lowest score is the one which showthehighqualityof lifeand the low qualityof liferespectively.
Validityandreliability of thisinstrumenthas been approvedbyHoferonpatients withmyocardial infarction. It has had acceptable reliability by thecorrelationcoefficient and interdependenceof 0/73(40).
Baqeri have changed the questions accordingto the patients’status andtheircircumstances in Iran.
Scientific validity ofthisquestionnairewas resultedfrom content validity and was used on patientswith myocardial infarctionandreliability coefficient of 0/92. Alsothis tool hasbeen used inpatients withmyocardial infarction,heart failureandpacemaker.
In addition, this tool was localized byAsadi-Lari study in patientswith myocardial infarction in 2003.
Internal correlation in emotional and physical areas was reported by Cranach’s alpha coefficientof 92/0 andthe coefficient of 0/94 for social areaand0/95 for all the areas(41).
In the first step that is pre-intervention one, research instrumentswere completedby the samples inboth of the groups.The second step (intervention)was implemented just for experimental group.
The intervention that is family-oriented empowerment model was performed based on the mentioned steps and 1-2days after thesurgeryandstabilizing the patient status. Each stepwasperformedin1-2sessions each with30-45 minutes.
In the first step that is the threat understanding, patients’ problems were introduced with at least one family member as a group discussion by increasingknowledge and awarenessabout thedisease anditscomplications andtreatment. Then for the second run, participants’ problems (patients andfamily members) were extractedduringprevious sessions.
At this step(problem solving),in additionto deepknowledgeof the diseaseprocessand its complications,patientshad activeparticipationin their care plan with self-confidence and educationalpamphletsand bookletsin the field ofactivity, surgical sitecare, subsequentvisitswith doctor, nutrition, prevention of infection, asleep and warningsymptoms were presented for theparticipants.Andtheir questionswere answered.
In addition, practical approach was used to learn new skills. Thusthe practicalskillsrequiredfor eachpatientisfirstdescribedand thenthose skillsare displayedfor them.
Themobilityprogramafter surgeryand problems resulting fromfailure to performthem howwere explainedtheoreticallyfor the patients.
Then the practical application steps like stretching exercises were done completely in front of patients to learn it to them.Skillswerelaterdividedinto smaller parts and done step by stepandthepatientwas askedtodoonetask. Thenthe patientwasallowedtobepracticedandskilled in that behavior.
The patientwas asked torepeattheexercise tobeableto do italone. Finally the patient was being efficient in that skill.
In order to family participationinpatientcare, these training and pamphlets were provided for family members by participants in thethird step(educational participation).
Inthisstep,the family was considered asasource of supporttoimprovetheprocess ofempowermentthroughself-improvement and self-esteem.
Fourthstep ofthe model(evaluation) consists of two parts:
First was the evaluationprocessforeach sessionthat done by askinga few questionsabout thematters presented inprevious sessions to ensurethemental and practical contributiontothecare planand required follow-up. Then,finalevaluationquestionnaireswhich completedby thepatient'squality of life questionnaire one monthafter the intervention inthe intervention groupandone month aftercompletion of the LifeQuality Questionnaire in the control group.
These evaluations were done in order todetermine the effectiveness ofcompletinglife quality questionnaire.
To start, the license was got of Vice Chancellor forResearch and Avicenna colleagues. Projectobjectiveswereexplainedtoallparticipants and informed and written consentandvoluntaryparticipationinthe projectwas received.It was explained for theparticipantsthatthey areallowed to leave theplanat any timeandtheirnamewill remainconfidential. Educational materialssuch aspamphletsandeducational softwarerelated totheintervention group were provided forthecontrol group. Control group got the surgery matters of all patients.
After completing the questionnaires, Mann-Whitneytestto compare thequality of life scoresbetween the two groups, T-testtocomparethe three sub-scales ofphysical, mentaland socialgroups and Paired t-testto comparepre-and post-tests for each group in 17 SPSSsoftware environment were used to analyze the data.
The standard deviation and the mean of theage of the participants were (5/917 ± 59/6).
Among theexperimental group,72.7 percent(32 persons) were the menand27/3 percent(12 persons) were the women. And in thecontrol group66/7percent(n = 32) were men and 33/3 percent(n = 16) were women. Intotal,69/6percent(64 persons)of the men and30/4percent(= 28 persons) of the women were studiedin this research. Ninety persons (97/8percent) of thestudy caseswere under diplomalevelofeducation. Intotal, ninety persons (97/8) had theDiplomaand two persons (2/2 percent)had notdiploma.
Depending onthe significantdiseases, Thirty five persons(66/3percent)of the subjectshadonly one type ofsignificant disease. (With background)
In theexperimentalgroup,sixpatients (6/13%),with a diagnosis ofmyocardial infarctionandthirty eight patients(4/86percent) with a diagnosis ofunstable anginawere admitted in the hospital.
In the control group, unstable angina was superior and forty six patients (95%) witha diagnosis ofunstable angina and two patients (2/4%) witha diagnosis ofstrokewere includedin the study.
Generally, Kolmogorov-Smirnov statisticquality of lifeof48/1anda significance level of0/025represents that thescaleisnot normal. Soto compare the twogroups,theMann-Whitneynonparametric testwas used.Independent t-tests within themental, emotionaland social areas,before andafter the intervention,have been showed significant statistical differences inthe scores of life quality compared withthe control group. Sincepvalue= 0/05, so there was no significantdifference between thetest and control groups onthe physical aspect.
Since pvalue=0/008, there was a significant difference between the two groups on the social aspect. And finally, pvalue is 0/03 on emotional aspect so there was a significant difference between the two groups.
Table 1: Comparison of quality of lifesubscales betweenexperimental and control groups.p-value / Significance level / Standard deviation / Post-test mean / Pre-test mean / number / group / scales
0/056 / 0/169 / 5/22 / 41/50 / 37/72 / 44 / experimental / Physical aspect
0/059 / 4/16 / 40/06 / 38/18 / 48 / control
0/008 / 0/206 / 5/24 / 32/93 / 29/93 / 44 / experimental / Social aspect
0/009 / 4/31 / 31/54 / 31/25 / 48 / control
0/030 / 0/981 / 8/49 / 73/81 / 65/79 / 44 / experimental / Emotional-mental aspect
0/030 / 8/50 / 72/16 / 68/06 / 48 / control
Table 2 : Comparison of pre- test and post- test mean score in experimental groupp-value / Standard deviation and mean / number / step / Experimental group
0/000 / 133/45±13/37 / 44 / Pre-test / Total scale
148/25±10/59 / 44 / Post-test
0/000 / 37/72±4/66 / 44 / Pre-test / Physical aspect
41/50±2/92 / 44 / Post-test
0/000 / 29/93±3/55 / 44 / Pre-test / Social aspect
32/93±3/50 / 44 / Post-test
0/000 / 65/79 ±7/72 / 44 / Pre-test / Emotional-mental aspect
73/81 ±5/84 / 44 / Post-test
Along with quality of life, health is defined as an individual’s conception in relation to improvement and mentaland physicalperformancecapacity.Thisconceptaffectsevery aspect oflife(42). This research has showed that family-orientedempowerment modelimprove the qualityof life in patientsundergoingcoronary artery bypass graftsurgery. Different aspects of quality of life specially social and emotional-mental aspects have been improved in these patients by applying this model. So, these patients can improve their self care and interdependence. Quality of lifescoresonemonth after the interventionshowed that a significantincrease in all three aspectsof physical,mental and social have been established in theexperimental group.
Althoughquality of life scores were increased in the control groupcompared to before thesurgery,this increasewas higherin the experimental group and QOLscorescompared tobefore the surgeryincreasedin all three aspects. This rateis notsignificantin thecontrol group.Physical criteria evaluationrelated to thequality of lifeinpatients withcoronarydiseaseis very importantand show that this criteria score has increased in experimental group after one month of intervention. This also shows the effect offamily orientedempowerment model that is employedinthisgroup of patients.
Implementation offamily-orientedcarecreatespositive feelingsinhealth care workers. By theseactions, family understandingandparticipationin caring thesepatientsare promotingat home and their anxiety is reduced(43). Thisresearchsuggestsrehabilitationprograms of family-orientedempowerment model.The research resultsof Smithet al(2002) showed that after implementing these programs, a significant differencewereseenbetween thetwo groups inthe area ofphysical and social functioning, general health and physical limitations(44) .Research of Fayyaziandcolleagues(1390) showed that quality of lifehasnot improved in the patient mental aspect withoutrunningany careprogram andmodeloneand threemonths afterCABGsurgery.
Regarding to the results ofthe presentstudyand asignificant difference that observed inpsychological and mental aspects scoresoffamily orientedempowerment model, this model can beused as a substitute forcounselingprograms in thepatients undergoingcoronary artery bypass graftsurgery. Sinceinthismodel all thefactors affecting the problems associated with surgery have been considered (Physical activity, diet,medicines, how doing activities,postoperativecare, stress management, wound care,blood pressure monitoringandwarning signs and so on) and familyinvolvementinfollow-up actions andtrainingthemperceived as a principle, the life quality after the interventioncompared with before the interventionhas been enhanced.