PATiNT EdUCATiON

ANdccm&c,
ELSEVIER Patient Educationand Counseling25 (1995)1-8

Cardiac patient teaching: application to patients undergoing

coronary angioplasty and their partners

Leigh Tooth*, Kryss McKenna

Deparimeni qf Occupational Therapy, University of Queensland, St. Lucia, 4072 Brisbane, Queensland, Australia

Received18 February 1994; revision received 18 May 1994; accepted 27 May 1994

Abstract

Education is accepted as a key component of cardiac rehabilitation for patients following myocardial infarction and
bypassgraft surgery. Recently, there has been a call for rehabilitation to be uniformly offered to partners and families
of cardiac patients, and for the expanding boundaries of rehabilitation to include patients who undergo coronary
angioplasty. This paper aims to highlight patient education strategies for cardiac patients and partners with a focus
on assessmentof their educational needs.The unique needsof patients undergoing coronary angioplasty and their part-
ners will then be discussedwith existing cardiac educational strategies expanded to encompassthis group of patients.

Keywords: Coronary angioplasty; Cardiac rehabilitation education; Learning and coping styles; Cardiac partner

1. Introduction because individuals learn differently and, therefore,

Rehabilitation is accepted as being beneficial to
patients after myocardial infarction (MI) and
coronary artery bypass grafting (CABG). Educa-
tion has been shown to significantly decrease car-
diac mortality [ 11, improve psychological status
[2-41 and quality of life [5-81, enhance compli-
ance [4,9-121 improve satisfaction with medical
care [3,13] and decrease risk factor behaviours
[ 1,5,14- 161 in patients after MI, CABG and valve
replacement surgery.
It is important to tailor education according to
the learning and coping styles of patients [ 1,17-201
* Corresponding author, Tel.: (07)365 3456 or 365 2820; Fax:
(07) 365 1622.
respond optimally to different teaching styles
[i7,19].
This paper reviews the concepts of adult learn-
ing, learning styles, coping styles and tailored educa-
tion, as they have been applied in cardiovascular
research. Using these principles, education of the
cardiac patient will be discussed. Finally, the appli-
cation of these techniques to patients undergoing
coronary angioplasty and their partners will be
outlined.
2. Adult learning
Adults learn differently to children. They prefer
a certain style of learning which is based on pre-
vious experience, and hereditary and environmen-

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2 L. Tooth, K. McKennalPatient
tal influences [ 17,19,2 1,221. Age, spousal support,
personality, socioeconomic status, years of educa-
tion and culture can influence how adults prefer to
learn [11,23-271. It has also been contended that
adults seek to learn only that knowledge which they
perceive to be impo~ant and which can be im-
mediately applied to their life situation 1281. Thus,
during an acute cardiovascular event, adult patients
seek that information which will assist them to cope
with the immediate threat of the situation [29]. As
a result of these behaviours, there has been increas-
ing interest in the concept of learning styles in the
health literature.
3. Learning styles and education
Learning style has been defined as the way in
which an individual processes info~ation [ 191 and
organises it into useful knowledge [17]. Different
theories of learning style have been put forward and
well reviewed [30,31]. For the purpose of this paper,
Keefe’s definition of learning style [32] will be
adopted. Keefe described learning style as being in-
fluenced by the interplay of three behaviours: cog-
nitive, for example whether people prefer to learn
visually by reading or aurally, by hearing informa-
tion; affective, for example how motivated people
are; and physiolo~cal, for example, whether peo-
ple need a quiet environment in which to learn in-
dividually or prefer an interactive group situation
[321.
In the literature, cognitive style has often been
used interchangeably with learning style [27]. Cog-
nitive style refers to an individual’s preference in
acquiring information or meaning from the environ-
ment, for example, through written, visual or tac-
tile media [33]. In fact, cognitive style only considers
one of the three components of learning style, ac-
cording to Keefe’s de~nition. Because of this, assess-
ment of cognitive style is more expedient than
learning style, a fact which may account for its
popularity in patient education research. Favour-
ing cognitive style over learning style may reflect the
fact that it is simpler and more realistic for health
practitioners to tailor education according to cog-
nitive style, than it is to attempt to provide the ideal
physical environment and to have the patient in a
perfect affective state to learn.
Educ. Couns. 25 (1995) I-8
However, whilst these terms have been employed
interchangeably, learning style, as well as being
more comprehensive, is also the one more common-
ly used in cardiovascular research and therefore will
be utilised in this review.
Assessment of learning style can assist educators
in determining how patients prefer to learn and
enable the development of individually-tailored
teaching programs [18,23-2534,351. Merritt used
the Patient Learning Style Questionnaire [36] to
assess the learning styles of cardiac patients and
found that the majority preferred individual, as op-
posed to group, learning [25]. Additionally, Mer-
ritt reported that patients with fewer years of
education and in lower socioeconomic groups pre-
ferred less structured methods of learning. This
author reported a generally low preference for read-
ing-based learning in all age groups except for those
65 years and older [25]. This finding was considered
important in light of the amount of written material
used for education of cardiac patients in hospital
settings. Merritt further contended that a patient’s
ability to read did not automatically ensure com-
prehension of information [25]. This study is one
of the only examples of learning style assessment
being utilised with cardiac patients. Surprisingly
though, it was not reported if education was then
tailored according to the results of each patient’s
assessment.
Examples of education tailored to learning style
may be found in research involving school and col-
lege students. Dunn (1984) cited eight studies
whereby students receiving individually-tailored
education achieved significantly better marks in tests
than students receiving non-tailored education. One
such example focussed on the case of students found
to prefer brightly lit environments for learning.
These students were found to perform better in tests
in such an environment than when tested under
dimly lit conditions 1371.
3.1. Self efficucy theory
Learning style has further been linked with a pa-
tient’s belief in his/her own ability. According to self
efficacy theory, if individuals have a high expecta-
tion or belief (high self efficacy) in their ability to
enact a behaviour change, such as smoking cessa-
tion, they are more likely to actually carry it out
 L. Tooth, K. McKenna/Patient
[38]. In support of this, patients after coronary
angioplasty were found to be more likely to engage
in cardiac recovery behaviours if they thought
themselves capable of doing so [39]. This
highlighted the importance of educators spending
more time with individuals with low self efficacy of
their ability to change or modify undesirable risk
behaviours [39].
3.2. Modelling
The concept of modelling suggests that patients
learn best by viewing other patients either undergo-
ing or explaining the procedure as it happened to
them. Modelling relies on the realism of the model,
with patients being more likely to learn if the model
is similar in age, gender and life style and is best
effected by means of videotape, audiotape, pam-
phlet or other written literature [40-421.
4. Informational needs and coping style
4.1. Informational needs
As opposed to learning style, informational needs
refer to what information individuals perceive to be
the most important for them to learn. Patients with
angina, after MI and after re-operative CABG,
generally rate all areas of cardiac teaching to be im-
portant [28,43,44] with information about risk fac-
tors found to be the most desired by patients
[20,28,29,45]. Informational needs equate closely
with coping style, with both requiring consideration
in the delivery of individually-tailored education
1461.
4.2. Coping style
Coping style refers to the degree to which infor-
mation influences anxiety and other psychological
responses [47]. Patient anxiety can contribute to a
prolonged procedure and increased perception of
pain, need for medication and risk of complications,
due to patients’ non-adherence with care instruc-
tions [48,49]. Excessive patient anxiety is not con-
ducive to learning and the problem of patients
forgetting information provided during an acute
hospitalisation period has been repeatedly
highlighted in cardiac rehabilitation literature
[46,50].
Research into coping style has focussed on the
Educ. Couns. 25 (1995) l-8 3
match between the type and amount of information
patients need to cope and the type and amount they
actually receive. The terms ‘blunters’ [51] and
‘repressers’ [52] have been given to those individuals
who seek to deny, underplay, repress or blunt in-
formation in order to cope by not thinking about
it. The terms ‘monitors’ [51] and ‘sensitisers’ [52]
refer to individuals who cope by seeking informa-
tion in order to understand what will happen and
therefore ensure its predictability, Over-educating
a blunter or under-educating a monitor has been
identified with increased anxiety and poor coping
in cardiac patients [ 18,24,47]. This is reportedly due
to an inappropriate level of information interfering
with the patient’s normal coping mechanism.
Considering these results, prior assessment of
coping style could act in a twofold manner. It could
firstly allow tailoring of education to match and
enhance coping style, and secondly, help to iden-
tify those patients at higher risk of complications
or poor psychosocial or medical outcomes after the
procedure [ 18,24,53].
5. Learning and coping styles of cardiac partners
5.1. Learning style
Very few studies on the effect of education and
learning style have included the partner [3]. This is
despite the fact that receipt of information has been
identified as the most important concern .ot$art-
ners and families during an acute hospitalisation
period [54]. Partners retain more knowledge than
patients after involvement in an education session
[3]. A well educated partner may pass on infor-
mation to the patient and, therefore, should be
routinely included in education programs [3].
5.2. Coping style
As with the patient, when the partner does not
receive the information sought, he/she is less likely
to be able to cope (551. Patients and partners have
different informational needs and should be assessed
separately in order to ensure all needs are met in
the educational context [54]. Patients and partners
differ in the importance they place on knowing cer-
tain types of information [54,56]. In one study, part-
ners were more likely to seek information about the
patient’s psychological reactions and recovery com-
4 L. Tooth, K. McKenna/Patient
pared to patients, who sought information more
about their physical condition and recovery [54].
Partners have been found to prefer information
about community resources, treatment choices
available after discharge, and how to behave with
the patient, for example during a period of depres-
sion or denial [56]. Patients and partners have been
found to differ in their approach to the illness, with
patients reportedly being more positive than part-
ners who tend to be fearful of the future [56].
Another study found patients and partners differed
in their views on the causes of coronary artery
disease (CAD), and on who was responsible for
lifestyle changes and the management of health and
stress [57]. Partners have also been found to seek
information on the best methods of coping, par-
ticularly during stressful periods such as patient dis-
charge [56,58]. Thus, it is important to assessboth
patients’ and partners’ informational needs, in order
to effect an individually-tailored education ap-
proach that best promotes coping [34,54,57,58].
6. Teaching style
Patient education has been described as a shar-
ing process between a health professional and a pa-
tient, not simply the provision of written
instructions to a patient [59]. Flexibility in the
educational approach and the availability of a va-
riety of visual and auditory educational media help
to maximise the impact and effect of teaching
[17,19,23,27].
Information should be simple and relevant to the
patient. It is felt that by focusing attention on the
objective features of the experience, patients are less
likely to be confronted with the unexpected [41].
Providing a combination of procedural and sensory
information is reportedly beneficial in reducing
psychological distress and improving coping strat-
egies [60]. Sensory information refers to the feelings
and physical sensations the patient will experience
when undergoing the procedure, for example, lying
on a cold hard table, experiencing chest discomfort
and hot flushes. Use of the modelling approach,
whereby a ‘real’ patient is shown undergoing a pro-
cedure is effective in disseminating sensory infor-
mation, particularly when presented in the patient’s
own words and in a sequential order [39,41,42]. Pro-
E&c. Couns. 25 (1995) 1-8
cedural information, on the other hand, refers to
the order of the procedure, for example, the site of
catheter insertion will be shaved, washed with an-
tiseptic soap and covered with sterile drapes.
Individuals with heart disease have been found
to prefer structured teaching sessions presented ver-
bally and supplemented with visual aids such as
videos, pictures and models [25,46], the latter allow-
ing active involvement of the patient. The benefit
of providing handouts for the patient to retain has
also been advocated by researchers [46].
6.1. Timing of teaching
Despite calls for thorough assessment of patients’
learning and coping styles, tailored education, and
partners involvement, ever increasing medical care
costs and shortened hospital stays for patients with
CAD have resulted in less opportunity for health
professionals to educate patients and their families
in the hospital setting [44,61]. Due to these factors,
the value of pre-admission assessment and teach-
ing has been highlighted in the literature [2].
Pre-aakission teaching. Advantages of pre-admis-
sion teaching are that patients are less likely to be
faced with the immediate threat of the procedure,
a time considered non-conducive to learning [61].
Further, patients who receive pre-admission teach-
ing are likely to be less anxious, a factor previously
linked to a smoother medical procedure [18,24].
Whilst pre-admission teaching can significantly
improve information retention [2], the ideal time of
teaching (for example 1,2 or 10 days pre-procedure)
is yet to be established [61].
Considering this, and the fact that some studies
have shown it makes no difference whether patients
are educated before admission or not [62], pre-
admission teaching is potentially the most econo-
mical direction of the future. In this way, patient’s
learning and coping styles could be assessed prior
to admission and an individually-tailored program
delivered.
Post-discharge teaching. Post-discharge teaching
is essential for patients in order to supplement
information gaps due to poor recall of information
taught during the stressful phase in hospital
[44,50,63]. Studies of patients and partners after MI
and CABG have found that, as well as requiring in-
formation during the immediate crises of the event,
 L. Tooth, K. McKenna/Potient
education was also desired during the period im-
mediately following the patient’s return home
[29,50,58]. It has been suggested that this might be
the time when patients and partners consider infor-
mation to be important, and are likely to be more
receptive to the reasons for and explanations of their
condition [29,44,50].
6.2. Time spent teaching
The period of time spent teaching has also receiv-
ed attention in the literature. It is considered im-
portant to be aware of the pace of teaching, as not
all patients process information at the same speed
[23]. Additionally, Burke advocated that single edu-
cational sessions are inadequate, due to poor learn-
ing and information retention in patients [64].
Murray concurred that patients require several
educational sessions, both in hospital and after dis-
charge, to effectively remember necessary informa-
tion about their condition and required lifestyle
modifications [46].
Cupples found that patients educated in a single
session 5-14 days before admission for CABG
demonstrated better information recall post-
procedure than those educated in a single session
the night before the procedure. Thus, it can be in-
terpreted that a single session can be effective pro-
vided it is held during a period of low anxiety for
the patient [2].
This suggests that the way teaching time is spent,
rather than total time involved, can be the most im-
portant aspect [l] and further reinforces the need
to provide education tailored to each patient’s re-
quirements.
7. Education for coronary angioplasty patients and
partners
Despite calls for inclusion of patients undergo-
ing coronary angioplasty in cardiac rehabilitation,
very few trials have attempted to systematically eval-
uate the effects of a tailored education session. The
30% incidence of restenosis following successful
angioplasty [65] means that these patients are spe-
cial candidates for intensive education about mon-
itoring of symptoms and early detection of recurring
ischaemia. Further. no studies have considered the
Educ. Couns. 25 (1995) 1-8 5
importance of educating the partner of the patient
undergoing coronary angioplasty.
7.1. Special needs of patients undergoing coronary
angioplasty
In planning for an education session for patients
undergoing coronary angioplasty and their partners,
it is important to consider the special needs of this
group of cardiac patients. Patients undergoing coro-
nary angioplasty may be less motivated to adhere
to risk factor behaviour change because of a per-
ception of being less sick than other cardiac patients
[24,35]. They may believe themselves cured by the
procedure, again impacting on compliance with risk
factor modification [24,35,66]. This population may
also be at risk of a delayed return to work or leisure
due to perceived limitations, when in fact they could
return to these activities more quickly [67]. As well
as this, patients undergoing coronary angioplasty
and particularly their partners, may be disadvan-
taged by the short amount of time that they are ac-
tually in hospital [35,66].
7.2. Educational model
An educational model for the patient undergo-
ing coronary angioplasty and his/her partner would
comprise an individually-tailored, multimedia, flex-
ible approach based on learning and coping style
assessment and delivered prior to hospital admis-
Table I
Educational session content for patients undergoing coronary
angioplasty
Heart anatomy
Pathology of coronary artery disease
Risk factors for development of coronary artery disease
Modification of risk factors
Coronary angioplasty procedure
0 preparation
l catheter laboratory procedure
l procedure complications
Coronary angioplasty recovery and hospital discharge
0 groin or arm care
l physical recovery
l psychological reactions
l home return - guide to resumption of functional ac-
tivities
l resumption of work
Medications
 6 L. Tooth. K. McKenna/ Patient Educ. Couns. 25 (1995) 1-8

Table 2 for tailoring a program to best suit an individual’s

Media of education cognitive style (or preference for receiving informa-
tion). It is also important to be aware of the affec-
Video
Pamphlets information booklets tive and physiological components of an individual’s
Slides learning style to ensure that education is optimally
Demonstration models: tailored.
- heart model showing coronary arteries The choice of which learning style assessment to
- mode1 of balloon catheter
use poses a problem. Whilst there are a number of
Patient discharge information kit containing written informa-
tion and illustrations about: learning style assessments available, not all are
- coronary angioplasty reliable or valid [30]. An assessment used with car-
- groin or arm care diac patients was the Patient Learning Style Ques-
- coronary risk factors and risk factor modification tionnaire [25]. Other assessments that have been
- guidelines for return to functional activities used with school and college students include the
- psychological recovery
- medications Learning Styles Inventory [37] and the Witkin’s
- contact number for follow-up advice Group Embedded Figures Test [ 171.

8. Conclusion
sion. Following the procedure, continuing educa-
Cardiac patient education has received con-
tion and discussion about risk factor modification
siderable attention in the literature. Assessing leam-
should occur, with post-discharge information also
ing and coping styles prior to education allows the
offered. The content of educational sessions should
provision of individually tailored education pro-
be similar to that taught to patients after MI or
grams, which have the benefits of enhancing knowl-
CABG, but with consideration of the previously
edge and psychological status and promoting
mentioned unique requirements. Indeed angioplasty
compliance to risk factor modification.
patients may not require involvement in a full 8- 12-
Education of cardiac patients cannot be consid-
week cardiac rehabilitation program as traditionally
ered complete without the inclusion of their part-
offered to individuals after MI and CABG. The
ners, due to the high degree of anxiety they
degree and depth of information provided should
experience and the important role they play in car-
be based on evaluation of what information patients
ing for the cardiac patient.
and partners perceive to be important and their risk
There now exists a need to determine the educa-
of future cardiac problems [67].
tion needs of angioplasty patients as opposed to
The suggested content of this education and the
those after angina, MI or CABG and to assesshow
media to be utilised are presented in Tables 1 and
effective current rehabilitation programs are in
2. Manipulation of different aspects of the multi-
meeting these needs.
media approach to education provides the means
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