Nicole O'Neil
University of San Francisco
July 4th, 2014
NURS 639: Summer 2014
Introduction
In the article titled “Randomized Controlled Trial of a Psychoeducation Program for the
Self-Management of Chronic Cardiac Pain” from the Journal of Pain and Symptom
Management, Coyte et al. (2008) further evaluated the need for secondary approach prevention
plans to address cardiac pain arising from chronic stable angina (CSA). This trial evaluating the
impact of a low-cost six week psychoeducation program on angina, called The Chronic Angina
Self-Management Program (CASMP), helps to address possible future prevention strategies and
ways to improve one’s overall health (Coyte et al, 2008, p. 1). The key research question in this
study addresses a specific treatment or therapy intervention that will ultimately result in better
health outcomes and prevent even more adverse negative effects on one’s health.
The study consisted of 117 individuals where baseline information was gathered initially,
as well as three months into the study. General health-related quality of life (HRQL) was
evaluated using the Medical Outcomes Study 36 Item Short form (SR-36) as well as the
disease-specific Seattle Angina Questionnaire (SAQ) (Coyte et al, 2008, p. 1). The average age of the
individuals was 68 years of age with 80% being male. Through this randomized controlled trial,
the effectiveness of a standardized psychoeducational program was created to assess the
improvements noted on health-related quality of life (HRQL), self-efficacy, and resourcefulness
of those diagnosed with CSA in the community. Here, we will further evaluate the effectiveness
of this research trial.
Substantive Value
Cardiac pain related to CSA is characterized by pain in the chest; shoulder; back; arm or
jaw; and is a significant, well-documented, health-related problem that can majorly impact one’s
life (Coyte et al, 2008, p. 2). Not only is one at higher risk of cardiovascular death and recurrent
significant impact on functional capacity and quality of life (Scirica, B, 2009.) In 2005, it was
reported that 445,687 deaths occurred just in the United States due to coronary heart disease. In
addition, there are 1,260,000 new and recurrent coronary attacks per year, killing about 37% of
those people who experience a coronary attack. The CSA that results can be life shattering with
an estimated 10 million people in the US presently suffering from this medical condition
(Healthcare Professionals Network, 2009.) Therefore, based on these statistics, there is currently
a proven clinical relevance to this research trial.
Presently, treatment options predominantly are available to those in the post-acute period
after a cardiac event and/or coronary artery bypass, but not for those suffering from chronic pain
related to CSA (Coyte et al, 2008, p. 2). As a result, there is a lack of secondary prevention
strategies for the population suffering from CSA, leaving the individual at greater risk of further
health related problems due to the lack of options available to the public. Therefore, there is a
clear need for further research on programs designed to improve one’s HRQL, self-efficacy, and
resourcefulness of those diagnosed with CSA. Since much evidence from well-designed
randomized controlled trials of psycho-education have shown to be effective for improving one’s
self-management skills, HRQL, self-efficacy and or resourcefulness of people with chronic pain,
nurses can begin to include some of these psycho-educational interventions in the discharge
summary. Nurses can give these specific instructions on how to effectively manage one’s
emotional and physical well-being while suffering from CSA in their daily life to prevent any
unnecessary suffering and diminishing of one’s quality of life. (Coyte et al, 2008, p. 2.) Not only
would this model help one to manage their CSA better, but the more information and support
nurses provide on this model, the less re-admission rates into local emergency departments, as
artery disease is largely related to unhealthy lifestyles in combination with genetic factors, many
of these patients are suffering from CSA related to unhealthy behaviors and noncompliance.
Therefore, nurses can use this model as a multimodal, self-help treatment intervention to use
information in combination with cognitive behavioral strategies to obtain changes in their
knowledge and behavior for more effective self-management at home. The more studies done on
this topic, the more these interventions will become best practice in the nursing field.
Methodologic Rigor
For this randomized controlled trial, the researchers chose to use 80% of male individuals
in this study with an average age of 68 (Coyte et al, 2008, p. 1.) According to Laurence O’Toole,
the author of the article “Chronic Stable Angina,” from the US National Library of Medicine
National Institutes of Health, CSA affects up to 16% of men and 10% of women aged 65–74
years, therefore their method of selecting the right participants is accurate to the current high-risk
statistical findings (O’Toole, 2008.) The method used to begin participant recruitment was
arranged by highly qualified clinicians at certain hospital recruitment sites that were most
appropriate for group selections resulting in. To increase the validity of results, the principal
investigator was certified as a “master trainer” to ensure all participants of the program were in
compliance set forth by a standard CDSMP education format (Coyte et al, 2008, p. 3). To ensure
appropriate consistency in program delivery, a facilitator manual was provided to all groups so
the interpretation of results was reliable and consistent (Coyte et al, 2008, p. 3). However, in
future trials it could be more beneficial to include multiple facilitators to prevent any possible
bias.
To assist in the minimization of individuals withdrawing from the study and possible
confounding variables, telephone reminders and flexibility in CASMP program offerings were
al, 2008, p. 3). Also, during the analysis period, researchers utilized a multivariate analysis of
variance (MANOVA), to avoid Type I error related to the different levels within the Medical
Outcomes Study 36-item Short Form (SF-36) instrument that’s designed to capture multiple
indicators of one’s functional capabilities, behavioral functions, distress, and overall wellbeing
(Coyte et al, 2008, p. 6). The MANOVA was done initially prior to the SF-36 as well as analysis
of variance (ANOVA) to note the differences accurately and prevent invalid results related to the
multi levels present in the SF-36 (Coyte et al, 2008, p. 6). This research intervention also helps to
yield the most accurate results and appropriate method. Also, to produce the most participant
retention, an attendance record was used to properly evaluate the number of sessions attended by
individuals; out of the possible 6, the average for this study was 5.8, yielding more accurate
findings (Coyte et al, 2008, p. 10). The study’s main methods used to decrease biases and any
potential error include a power analysis; centrally controlled randomization; valid and reliable
measures; blinding of data collectors; as well as evaluation of any possible cohort intervention
effects, which are all an appropriate research method to collect the most accurate data (Coyte et
al, 2008, p. 11).
The research yields some appropriate methods; however, there are some significant
limitations that should be noted that can ultimately lead to an insufficient amount of evidence,
which in the end, may not be substantial enough to justify an evidence based change. For
instance, other score results that weren’t significantly improved at post-test include SAQ
treatment satisfaction; disease perception and physical limitation; and resourcefulness, which are
some of the main goals with the anticipated research outcomes. Also, six of the nine total SAQ
items examine some of the known activities that can increase one’s myocardial oxygen demand
groceries; lifting or moving heavy objects; and participating in sports to name a few; yet, as the
pilot in this study suggests, most CSA patients will learn to avoid these physical activities related
to their constant fear of recurrent pain (Coyte et al, 2008, p. 11). Therefore, it can be determined
that more strenuous activities assessed by the SAQ scale may not even be relevant to the CSA
patients. This leads to a likely result too small to create any substantial evidence and the
evidence that does result from this scale, is too weak and inconclusive to warrant an evidenced
based change.
Another limitation in this study is the unavailability of any future comparisons as this is
the first trial conducted that has shown significant improvements in one’s quality of life through
this educational model. Therefore, it would be recommended for future CSA
psycho-educational trials to be performed for more comprehensive and reliable findings for future
comparisons. Another potential factor interfering with the validity of the findings, is the different
classes of reported angina. Since this program included those with Classes I-III angina, and the
study utilizes SF-36 subscales that may not be sensitive to some of the angina-induced
limitations, the accuracy of the results may possibly be tarnished. Also, with the utilization of the
SF-36 multi-scaled program, a longer term evaluation period may be necessary to see the most
accurate results (Coyte et al, 2008, p. 11). For future purposes, to create better quality evidence,
researchers should prolong the pilot test period to effectively evaluate the research outcomes.
Also, one other counterfactual variable present in the study, is the inability to blind participants
in the group setting to prevent any potential biases.
Interpretative Analysis
The data interpretation analysis segment of this research trial included assessments of
their findings and discussions of possible study limitations as mentioned above. The
defensible inferences by presenting concluded evidence from the study using reasoning and logic
to illustrate the results. For instance, to illustrate potential limitations, the researchers included
the inability to blind participants in the socially based interventions provided, therefore, resulting
in a performance bias that cannot be ruled out (Coyte et al, 2008, p. 12). However, the
researchers may have failed to provide the reader with the importance of this trial to the
healthcare field and the magnitude of the possible result if this trial was never initiated; which
can be considered one major limitation to this trial. The researchers interpreted the data
accurately, but didn’t defend the results and prove to the reader why this trial is necessary to
improve healthcare outcomes and the results for nursing practice. The researchers also didn’t
emphasize the meaning of the results or stress the need for future research. They did, however,
illustrate the credibility and accuracy of the results by including several statistically proven data
collection systems as methods to gather the necessary information. In short, the researchers
effectively analyzed the study’s methods of choice and potential limitations and strengths by
pointing out areas of improvements, potential inconclusive results, and any areas of data
collection that could lead to inaccuracy of results.
Conclusion
In conclusion, the article presents evidence that yield significant improvements in
treatment group physical functioning, general health, angina pain symptoms, and self-efficacy,
but failed to provide any evidence that supports improvements in other areas such as
resourcefulness. As mentioned, a longer pilot test period would be beneficial to allow for a more
long-term evaluation phase to diminish any potential limitations to the data collected. To
improve this evidence trial, more specific desired outcomes should be established to result in
more precise results that can be applied to nursing practice to ultimately improve patient’s
this trial should be further emphasized showing the impact it could have on the nursing
profession. After careful analysis, the interpretation of this research trial concluded data showing
the credibility of the results and implications for future research to be established. However, the
lack of recognition of the magnitude of the effects, underlying meaning, relevance to nursing
practice, and lack of generalizability shows a need for better quality evidence. This results in an
overall insufficient amount of research base to warrant an evidence based change to nursing
References
Coyte, P., Graham, A., LeFort, S., McGillion, M., Stevens, B., & Watt-Watson, J. (2008). Randomized Controlled Trial of a Psychoeducation Program for the Self-Management of Chronic Cardiac Pain. Journal of Pain and Symptom Management.
Healthcare Professionals Network. (2009). Angina by the Numbers - Mortality, Incidence, Prevalence, and other Angina Statistics. Retrieved from
http://www.hcplive.com/articles/angina_statistics
O’Toole, L. (2008). Angina (Chronic Stable). U.S. National Library of Medicine National Institutes of Health. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907993/
Scirica, B. (2009). Chronic Angina: Definition, Prevalence, and Implications for Quality of Life. U.S. National Library of Medicine National Institutes of Health. Retrieved from