Clinical Nursing Research

Massachusetts General Hospital, Boston
Nursing Interventions for Family Members Waiting DuringCardiac Procedures
Abstract
Anxiety is shared by patients and family members (FMs) and can increase
throughout the FMs waiting during invasive cardiac procedures (ICP). The
purpose of this study was to measure the effects of an informational report (IR)
and a postprocedure visit (PPV), on the anxiety of waiting FMs. There were
151 FMs assigned to 3 groups; Group 1 (50 FMs: standard of care [SOC]),
Group 2 (50 FMs: SOC + IR), and Group 3 (51 FMs: SOC + IR + PPV). Pre/
postvariables measured were: blood pressure (BP), heart rate (HR), skin
temperature (ST), and anxiety. When comparing the BP, HR, ST, and anxiety
there were no differences between groups with either SOC or IR. There
was a significant reduction in anxiety, from baseline to the PPV in Group 3
(F = 10.1; p < .000). A PPV had an impact on FMs and a PPV should be incorporated
as a nursing intervention during ICP.
Keywords
anxiety, family visitation, nursing intervention
Hospitalizations can be a precipitant of anxiety for patients and their family.
For family members (FMs), idle time spent waiting for the completion of the
patient’s scheduled tests and procedures can add to their anxiety. Regardless
264 Clinical Nursing Research 20(3)
of the intent of the hospitalization, the patient and family are separated, removed
from their conventional routine and support, and are now in unfamiliar surroundings.
With the absence of familiar environmental safeguards, FMs are
at risk for heightened anxiety, as well as feelings of vulnerability, loss of control,
fear, and isolation (Leon & Knapp, 2008).
Specifically, patients undergoing invasive cardiac procedures (ICP) are
separated from their family on admission to the procedure area. FMs are asked
to remain in the waiting room during the ICP. There FMs have to tolerate long
waiting periods before they receive any information about their loved one or
have the opportunity to see them on completion of the ICP. Prolonged waiting
periods may add to anxiety already felt by family members. Therefore, the
purpose of this study was to compare the effects of two nursing interventions,
informational report (IR) and a postprocedure visit (PPV) to standard of care
(SOC), on the anxiety level of waiting FMs during a loved one’s ICP.
Background
Family system theory offers a framework for understanding the relationship
between the person and their environment within the context of family. The
central theme of family system theory is the family. Family is viewed as an
interdependent, continually interacting whole that is greater than the sum of
its parts. For those individuals within the context of a family, FMs have been
viewed as a part of a system that is interacting with all its members (Litman,
1974; Van Horn & Kautz, 2007).
The alteration of an individual’s internal environment during an illness experience
can cause mind modulations that affect the equilibrium within the person
and within their family. Mind modulations are the natural process by which
perceptions, thoughts, attitudes, and emotions are converted in the brain to neurohormonal
messages sent to the autonomic nervous system (ANS) (Dossey,
Keegan, & Guzzetta, 2005). The ANS responses to these neurohormonal messages
can alter the cardiovascular, respiratory, immune, and neurological systems.
Anxiety has been described as a subjective, consciously perceived feeling of
apprehension or tension that is associated with ANS arousal expressed in both
psychological and physiological measureable responses.
Researchers consider a hospitalization of a family member, no matter how
short the hospital stay, a crisis that can cause an acute emotional upset within
the family (Eggenberger & Nelms, 2007; Leon & Knapp, 2008). Therefore,
FMs, as a unique part of the patient’s environment, can also suffer mind modulations
from a FM’s illness experience, which can alter the FM’s ANS and
can present as alterations in their body systems.
Trecartin and Carroll 265
Nursing interventions are needed to reduce the contextual stimuli of a
FM’s illness experience. These interventions can potentially be effective in
modulating the responses of FMs (Chien, Chui, Lam, & Ip, 2006; Paavilainan,
Salmin-Toumaala, Kuirakka, & Paussu, 2009). Previous research has documented
that informational nursing interventions have reduced FM’s anxiety
in intensive care units (Chiu, Chien & Lam, 2004; DeJong & Beatty, 2000;
Verhaeghe, Van Zuuren, Duijnstee, & Grypdonck, 2004). These interventions
were in the form of progress reports or attention from a supportive person.
For those FMs in the waiting room during a surgical procedure, Leske
(1995, 1996) studied the use of in-person (nurse) and a nurse telephone call
intraoperative report. The report included progress of the surgical procedure,
patient condition, plans for postoperative care, and they would be notified
when patient arrived on the unit compared to standard of care no information
to family members during surgical procedures. Anxiety was measured by the
Spielberger State Anxiety Inventory, heart rate (HR), and mean arterial blood
pressure (BP). There were significant reductions in state anxiety, heart rate,
and mean arterial BP in the FMs who received the in-person only intraoperative
reports (Leske, 1995, 1996).
There is no research addressing the unique needs of the waiting FMs while
a loved one is undergoing a diagnostic/treatment ICP. There are no nursing
intervention studies with waiting FMs during an ICP using IR and/or a PPV
that evaluate the psychological and physiological responses during that time.
With limited data on effectiveness for IR from the surgical arena, this study
tested the effectiveness of an IR and a PPV nursing intervention compared to
SOC; on the anxiety of waiting FMs by measuring state anxiety, BP, heart
rate (HR) and skin temperature (ST).The research hypotheses were:
Hypothesis 1: An IR will reduce BP, HR, and state anxiety in FMs
compared to those family members who receive SOC.
Hypothesis 2: An IR will increase ST in FMs compared to those FMs
who receive SOC.
Hypothesis 3: An IR plus a PPV will reduce BP, HR, and state anxiety
in FMs compared to those FMs who receive SOC.
Hypothesis 4: An IR plus a PPV will increase ST in FMs compared to
those FMs who receive SOC.
Method
This study was quasi experimental using a pre and postdesign to examine the
effectiveness of two nursing interventions, an IR or IR and PPV, for families
266 Clinical Nursing Research 20(3)
that are waiting while a loved one undergoes an ICP. The investigation conformed
to the principles outlined in the Belmont Report and was approved
by the Human Research Committee.
Sample
FM participants were recruited from the waiting FMs at an interventional cardiovascular
therapy center of a large academic medical center. At this medical
center, patients are asked to bring a FM with them so they will have someone
to take them home after an ICP. Patients and their FMs are asked to arrive at
least 1 hr before the scheduled time of the ICP. Investigators approached waiting
FMs after the patient had entered the ICP area. A convenience sample of
FMs from these elective patients were chosen to participate in this study.
Inclusion criteria include any person who is considered a FM by a patient
admitted to the interventional cardiovascular therapy center for an elective
ICP. The FM had to be more than 18 years of age, able to speak and understand
English, and be willing to be available in the waiting room during their
loved one’s ICP.
A convenience sample of 50 FMs was enrolled in each group. Power analysis
based on prior state anxiety measurement indicate that a sample of 45
participants in each group would yield a desired power of .80 to discern significant
differences (medium effect size .50) with an alpha set at p < .05.
Measurement
Demographic Information was collected from the waiting FMs willing to
participate in this study. The FMs were asked about their age, gender, education,
their relationship to the patient., work status, if they took a day off to
accompany patient and if they were waiting alone or with others.
BP, systolic and diastolic, was obtained by using a noninvasive automatic
BP cuff made by Welch-Allyn called the Tycos Classic. Automated indirect
measures of BP correlate well with direct intraarterial measures (Brinton
et al., 1997). From each BP reading, a mean arterial pressure (MAP) was
calculated using the formula of (systolic blood pressure – diastolic blood
pressure)/3 + diastolic blood pressure. MAP is used as it is more constant
than systolic blood pressure and is a good estimate of arterial blood pressure
(Gardner, 1986).
HR was determined by a 1-min count of heart beats per minute utilizing
standard stethoscope.
ST is the measure of distributed heat of the skin that is generated by metabolic
activity. Peripheral vasodilation reflects relaxation, but the release of
Trecartin and Carroll 267
the neurotransmitters, (e.g., epinephrine, cortisol, norepinephrine) reflect a
mind modulation that causes peripheral vasoconstriction. ST was measured
with the infrared temperature scanner, Dermatemp, ST 1001 (Exergen Corporation,
Watertown, MA). The infrared probe is placed close to the index finger.
Temperature accuracy is listed to within + 0.20 with repeatability measured
within 0.10 Fahrenheit.
State-Trait Anxiety Inventory (STAI) is a 40-item self-report scale that is
used to measure anxiety. The STAI is composed of two separate self-report
scales that measure state and trait anxiety. For the purpose of this study, only
the state anxiety scale was used to assess the current perceived level of anxiety.
This scale asked respondents to evaluate how they feel “right now” to a
series of 20 items. Construct validity was established with a large group of
college students and has been used in similar studies (Leske, 1995, 1996,
2002; Spielberger, Gorsuch, Luchene, Vagg, & Jacobs, 1983).
In this study, the internal consistency was α .93 to .95. For the purposes of
this study, the threshold for anxiety in this study was determined to be more
than or equal to a score of 35 on the state STAI. This threshold was selected
with references to norms for 50 to 69-year-old age group as this was age of
samples and has been used as a threshold in other studies (An et al., 2004;
Spielberger et al., 1983).
Interventions
There were two nursing interventions that were tested. The first was an IR.
This report was given to waiting FMs by the study nurse in the waiting area
and included notification that the ICP was about halfway completed and the
location of the recovery area (Cunningham, Hanson-Heath, & Agre, 2003;
Leske, 1996). No clinical data or results were included in this report.
The second nursing intervention consisted of a PPV to the loved one after
the completion of the ICP. The study staff accompanied the waiting family
member to the patient’s bedside. And there was a 5-min visit between FMs
and their loved one. After 5 min, study staff accompanied the family back to
the waiting area. This visit occurred close to admission into the recovery area
and before discharge or transfer to an inpatient hospital room was decided.
The time limit was defined due to the lack of privacy and the small space in
the recovery area.
Procedure
A three-stage sampling procedure was used to test the effect of the two nursing
interventions, IR and a PPV. All FMs were approached using a standard
268 Clinical Nursing Research 20(3)
script approved by the Human Research Committee by study investigators.
Verbal consent was used.
For Group 1, the first 50 FM participants received SOC. The SOC was
extremely variable during the study period. Some individual staff kept FMs
up to date whereas others did not, but no FMs received a standardized IR
provided halfway through the ICP. For Group 2, the next 50 FM participants
received the SOC plus an IR. For Group 3, the final 50 FM participants
received the SOC plus an IR, and a PPV.
Once data were collected from Group 1, the next group of FMs, Group 2,
was enrolled and these FMs received SOC, and the IR. Group 3 was enrolled
once Group 2 enrollment was complete, and these FMs received SOC plus an
IR and the 5-min PPV.
All FM participants were approached on arrival and after they consented,
were asked to complete the state only STAI, have their BP, HR, and ST taken
by study staff in the waiting room once. In Group 1, the FMs were asked to
complete the State only STAI, have their BP, HR, and ST taken by study staff
at an estimated halfway point in the participants’ procedure whereas Groups
2 and 3 completed the STAI and had their BP, HR, and ST taken by study
staff right after the IR that was provided halfway through the patients’ procedure.
Group 3 FMs were asked to complete the STAI, had their BP, HR, and
ST taken by study staff again after the 5-min PPV. MAPs were calculated for
all BP measurements.
Analysis
The data were entered into the SPSS statistical package (Version 17.0) and
the analysis proceeded with descriptive statistics on the demographic data of
the FMs. Differences between participant’s baseline and data collected at the
halfway point for Groups 1 and 2 was assessed utilizing t-tests and between
Groups 1, 2, and 3, by analysis of variance (ANOVA). Repeated measures
ANCOVA was utilized to compare mean scores within participants for
Group 3 controlling for baseline STAI, waiting time and previous waiting
experience. The significance level was set at p < .05.
Findings
There were 151 participants in this study, 33 males (22%)/118 females
(78%), with a mean age of 55.4 + 14 years with a range of 20 to 86 years.
Table 1 displays the demographic variables of this sample based on group
assignment. There were no significant differences on demographic variables
Trecartin and Carroll 269
Table 1. Clinical and Demographic Variables by Group
Group 1 Group 2 Group 3 p
Age 57.5 ± 16.5 55.1 ± 13.4 56.6 ± 12.3 .68
Gender (males/females) 12/38 12/38 9/42 .67
Education .21
High school 12 14 8
Less than 4 years of
college
9 11 19
4 years of college 28 25 23
Relationship to patient .077
Wife 19 22 22
Child 11 13 12
Husband 12 3 5
Parent 7 3 6
Friend 1 6 2
Sibling 0 3 4
Working status .12
Full-time 21 27 21
Part-time 6 3 12
Not working 22 20 18
Took day off to be
present
19 24 27 .35
Accompanied by others .14
No 30 21 23
Yes 19 28 28
between groups. There were 74 FMs (49%) who were alone in the waiting
room during the IPC. Thirty-eight (25%) of the FMs had previous experience
in the waiting area of the invasive cardiovascular therapy center and 51
(34%) had experience with other waiting areas in this academic medical
center. The waiting time for these FMs varied between 2 to 13 hr with a mean
of 5.5 hr in the waiting area.
Baseline data for the study variables are presented in Table 2. The physiological
variables of systolic BP, HR, respiration, and ST, were not significantly
different between Groups 1, 2, and 3. There was a significant difference
in diastolic BP between groups that influenced MAP.
Comparing the study variables from baseline to after the IR that Groups 2
and 3 received, there were no significant difference in any study variables
270 Clinical Nursing Research 20(3)
Table 2. Study Variables at Baseline
Group 1 Group 2 Group 3 f p
Blood pressure (BP)
Systolic 131 ± 23 138 ± 24 133 ± 22 1.79 .169
Diastolic 81 ± 14 88 ± 13 84 ± 14 3.5 .032
Mean (MAP) 98 ± 16 105 ± 15 99 ± 17 3.4 .035
Heart rate (HR) 70 ± 11 74 ± 11 72 ± 14 1.26 .286
Skin temperature (ST) 85 ± 5 86 ± 5 86 ± 6 0.510 .601
State anxiety 41.3 ± 12 43.1 ± 12 40.9 ± 12 .424 .655
Table 3. Study Variables of Group 1 and Groups 2 and 3 Comparing from Baseline
to After Informational Report
Group 1
(N = 50)
Groups 2 and 3
(N = 101) t p
Blood pressure (BP)
Systolic 132 ± 25 138 ± 24 −0.608 .543
Diastolic 81 ± 14 83 ± 13 −1.015 .313
Mean (MAP) 98 ± 16 100 ± 17 −0.868 .385
Heart rate (HR) 72 ± 13 74 ± 15 −1.20 .228
Skin temperature (ST) 84 ± 5 84 ± 90 −1.06 .287
State anxiety 42.2 ± 14 42.0 ± 14 0.041 .967
between Group 1, no IR, and Groups 2 and 3 who received an IR. These data
are displayed in Table 3.
Comparing the study variables from baseline, to IR, to after a visit to the
recovery area in Group 3, there were significant differences in ST and state
anxiety scores. There were no significant main effects of BP, HR, ST, STAI
at baseline, total wait time, or previous waiting room experience on Group 3
variables measured after the PPV. ST and state anxiety were lower after the
PPV (p < .003). Data are displayed in Table 4.
In summary, Groups 1, 2, and 3 were comparable on the demographic
variables that were collected in this study. For the study variables, there were
no differences between the groups on systolic BP, HR, ST, and state anxiety.
However, there were statistically significant differences between groups on
diastolic BP that influenced the MAP.
Trecartin and Carroll 271
After the IR, there were no differences on the study variables between
Group 1 who received SOC and Groups 2 and 3 who received the IR half way
through the ICP. For Group 3 participants, there was significant a reduction
in state anxiety and ST after the PPV.
Discussion
The purpose of this study was to examine the effects of two nursing interventions,
IR and a PPV, on the anxiety of waiting FMs during a loved one’s ICP.
Both psychological and physiologic anxiety measures were used. At baseline, the
groups were similar, with state anxiety levels greater than 40. These scores indicate
a modest amount of state anxiety at baseline. Norms for the state only STAI
in this age group is 35 (Spielberger, Gorsuch, Luchene, Vagg, & Jacobs, 1983).
Normal MAP is approximately 93 mmHg (Shoemaker & Parsa, 2000). At
baseline the groups had a range of 98 to 105 mm Hg for MAP, well above
norm. Given this elevation of MAP, potentially related to the anxiety level in
FMs, these results demonstrate a group that would clearly benefit from nursing
interventions to reduce anxiety and potentially their MAP while waiting.
The statistically significant reduction in ST was not in the hypothesized
direction. We hypothesized that with these two nursing interventions there
would be a decrease in the release of neurotransmitters that would cause
peripheral vasoconstriction and consequently peripheral skin temperature
would be increased. This was not the case. There was a decrease in ST. This
may reflect FM’s reduced level of physical activity while waiting. FMs were
waiting for at least 2 hr, and on average 5.5 hr, in a waiting room where we
were not able to control the ambient temperature.
Table 4. Group 3 Variables Comparing Baseline to Informational Report to
PostProcedure Visit
N = 51 Baseline IR PPV f p
Blood pressure (BP)
Systolic 131 ± 18 129 ± 19 133 ± 21 2.08 .139
Diastolic 83 ± 15 82 ± 13 84 ± 12 0.270 .750
Mean (MAP) 99 ± 14 98 ± 14 99 ± 14 0.341 .341
Heart rate (HR) 72 ± 14 73 ± 14 73 ± 11 0.823 .195
Skin temperature (ST) 86.1 ± 6 84.8 ± 5 83.4 ± 5 6.51 .003
State anxiety 41.4 ± 12 39.9 ± 14 34.2 ± 12 10.06 .0001
Note: IR = informational report, PPV = postprocedure visit.
272 Clinical Nursing Research 20(3)
There was no difference in study variables between groups of FMs that
received an IR and those who received SOC. When asked, FMs report that
information is a top need and FMs want specific information about their
loved one (Molter, 1979; Puntillo & McAdam, 2006). The absence of a significant
difference may reflect the limited information provided in the IR; no
clinical information and only that the procedure time was half complete.
Previous research in the operative setting demonstrated a significant reduction
in FM’s STAI score when the IR contained the patient’s physiologic
status (An et al., 2004).
For Group 3, there were significant reductions in waiting FM’s state anxiety
after a visit to their loved one after the ICP. Providing proximity for FMs
has also been identified as a priority need of FMs (Cunningham, Hanson-
Heath & Agre, 2003). FMs who were able to visit their loved one were able
to be emotionally close, give support, reconnect and transfer feelings of relief
that the ICP was over (Leon & Knapp, 2008). As state anxiety scores lowered
to a normative range, FMs maybe better able to support their FM.
There were limitations in this study. There was a wide range of waiting
times for FMs from 2 to 13 hr that may have influenced the level of anxiety.
Those with previous experience in the waiting area may have been better
prepared and less anxious. We did not control for some FMs receiving procedural
information from the interventional cardiologist and/or primary cardiologist.
The patients in this study were all elective admissions and the majority
of the FMs were White, therefore these results may not be generalized beyond
this group. This study was unable to control the temperature of the waiting
area. Failure to control the temperature could have contributed to the inability
of the FMs to raise their ST that is associated with less vasoconstriction and
relaxation. A number of the FM anecdotally confirmed the ingestion of their
own prescribed cardiac medications, such as beta blockers. This would inhibit
the participant’s ability to increase their HR with anxiety.
Clinical Implications
FMs are an important part of the illness experience and the recovery process.
This study adds evidence for nursing practice by demonstrating the effect of
nursing interventions that diminish the FM’s anxiety associated with a patient’s
ICP. By implementing and encouraging nursing interventions to reduce
anxiety, FMs can be more involved and supportive to the patient and a contributing
member of the patient’s health care team. These nursing interventions
ultimately satisfy and fulfill the needs of both patient and family.
Trecartin and Carroll 273
Conclusions
Family visitation at the bedside post ICP significantly decreased FM’s anxiety.
Nurses in the ICP area or other procedural areas have the opportunity to
establish the initial tone for the hospitalization by including the family as a
part of the health care team.
Further research on adequate assessment of waiting FMs’ desire for information
needs to be further explored as there are those FMs who may have a
lower preference for information. Future research will need to assess the ability
to collect reliable data and to control for environmental factors that can
influence the data measured.
Traditionally, nurses have focused primarily on the patient, but in recent
years, nurses have expanded their view beyond the patient to include the
family in an effort to maintain and promote family integrity. Each family
unit is unique to the patient and is defined by the patient. As the family unit
becomes separated during the hospitalization, similar emotions can be experienced
by all members. Both units are concerned with the other, and yearn
to be reunited.
The inclusion of family in patient care has been influenced by hospital
environment, and the traditional focus of caring for the patient in a technically
driven environment. The waiting period during procedures has been
reported to be the most anxiety-producing time for those family members
who accompany patients to the hospital. Nursing interventions to provide
information and proximity for FMs are critical to reducing emotions that prevent
the family from being a part of the patient’s health care team.
Acknowledgments
The authors would like to thank Nicole Spano-Niedermeier, RN, Diana Ploss, ANP-BC,
RN and the staff of the Knight Center for Interventional Cardiovascular Therapy for
their support and assistance during this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Yvonne L. Munn Nursing Research
Award, Patient Care Services, Massachusetts General Hospital, Boston, MA.
274 Clinical Nursing Research 20(3)
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Bios
Kelly Trecartin, ACNP-BC, RN, is a staff nurse/nurse practitioner, Knight Center
for Interventional Cardiovascular Therapy, Department of Cardiology, Massachusetts
General Hospital.
Diane L. Carroll, PhD, RN, FAAN is the Yvonne L. Munn nurse researcher in the
Yvonne L. Munn Center for Nursing Research, Institute for Patient Care, Massachusetts
General Hospital.

) Complete the required readings including reading the Trecartin & Carroll (2011) research article and review the Statistical Analysis Handout with presentations. After doing such, complete the following exercises. Discuss this topic.
This discussion will be an opportunity for you to complete an in-depth analysis of the statistical presentation in the Trecartin & Carroll (2011) research article.

2) After reviewing the research article, address the following questions that are based on tables in the Trecartin &Carroll (2011) research article:
Table 1 questions:
a) Descriptive statistics were used to “describe” the demographic data found in this table. Explain the age findings in the table and whether or not there is a significant difference noted.
Table 2 questions:
b) What statistical test was completed to provide thevalues in thef column
c)Why do you think this statistical test was completed?
d) Are there any results in Table 2 that are significant at the P<0.05 level? If so, explain what a significant finding means from this table.
Table 3 questions:
e) In Table 3 what statistical test completed?
f) In Table 3, are there any results in Table 3 that are not significant at the p<0.05 level? Explain.
Last set of questions:
g) What was the purpose of this study?
h) Were there any significant effects noted? Explain.

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