DOI: 10.1111/nuf.

12438

ORIGINAL ARTICLE

The effectiveness of early position change postcardiac

catheterization on patient's outcomes: A randomized
controlled trial

Rashid K. Ibdah MD1 | Wafa'a F. Ta'an PhD, RN2 | Rawan M. Shatnawi RN, MScN3 |
Mohammad M. Suliman PhD, RN4 | Jehad A. Rababah PhD, RN5 | Sukaina I. Rawashdeh1

1
Department of Internal Medicine, Faculty of
Medicine, Jordan University of Science and Abstract
Technology, Irbid, Jordan
2 Background: Nurses play a substantial role in maintaining patient homeostasis
Department of Community and Mental Health
Nursing, Faculty of Nursing, Jordan University postcardiac catheterization. Patients frequently complain of back pain and discomfort
of Science and Technology, Irbid, Jordan
as a result of the prolonged bed rest postcatheterization.
3
Nursing Department, King Abdullah
University Hospital, Irbid, Jordan Aim: This study aims to evaluate the effectiveness of early position change
4
Department of Community and Mental Health postcardiac catheterization on reducing patients' pain and discomfort.
Nursing, Faculty of Nursing, Al al‐Bayt
Settings: The study was conducted at two cardiac units in a university hospital in
University, Mafraq, Jordan
5
Department of Adults Health Nursing, Faculty
Jordan.
of Nursing, Jordan University of Science and Participants: A total of 120 patients were used in the study, 60 patients in each of
Technology, Irbid, Jordan
the two groups—control and intervention.
Correspondence Methods: The randomized controlled trial design was used. Data were initially
Mohammad M. Suliman, PhD, RN, Department
of Community and Mental Health Nursing,
collected 1 hour after sheath removal postcardiac catheterization. After that, the
Faculty of Nursing, Al al‐Bayt University, protocol was applied to the interventional group.
Mafraq 25113, Jordan.
Email: mbarahemah@aabu.edu.jo
Results: Early position change 1 hour after sheath removal after cardiac
catheterization was found to be effective in reducing back pain as compared
with the control group (P < .001). Also, the study intervention was found to be
effective in reducing urinary discomfort (X2 = 50.83, P < .001), and
2
increasing comfort level (X = 120, P < .001). However, although participants in
the intervention group were less likely to have constipation and hematoma than
those in the control group, this outcome was not statistically significant
at P > .05.
Conclusion: Early position change 1 hour after sheath removal postcardiac
catheterization has significant positive effects on patient outcomes by reducing
the intensity of back pain and urination problems and increasing patients'
comfort level without increasing incidents of vascular complications such as
bleeding and hematoma.

KEYWORDS

back pain, cardiac catheterization, nursing care, positioning

Nurs Forum. 2020;1–9. wileyonlinelibrary.com/journal/nuf © 2020 Wiley Periodicals, Inc. | 1

2 |
1 | INTRODUCTION
Coronary artery disease (CAD) is the most common type of cardio-
vascular disease that mostly affects people of productive age.1 As a
result, it tends to harm the workforce and economic productivity.2
According to the latest statistics published by the Jordanian Ministry
of Health (MOH) in November 2015, about 25,000 patients annually
visit governmental clinics complaining of cardiac problems.3 A total of
36.7% deaths in Jordan were because of circulatory heart diseases.3
According to the MOH, the main leading cause of death in the
population in Jordan was ischemic heart disease (11.4%).3
Cardiac catheterization is widely used as a diagnostic and/or
treatment intervention and sometimes considered as a definitive,
routine diagnostic procedure for ischemic heart disease.4 It has
been estimated that approximately 2.2 million patients receive
percutaneous coronary intervention worldwide every year.5 In
such a procedure, the femoral approach to cardiac catheterization
is the most common approach because of the large diameter of this
artery.4 To decrease complications from bleeding, manual or
mechanical compression of a firm pressure above the puncture site
4
is needed. Bed rest in the recumbent (supine) position and
immobilization of the affected leg are also required for such
patients after sheath removal.4
Restricted bed rest and leg immobilization have been considered
essential to reduce the risk of developing complications.4 However,
there is a lack of adequate assessment and management of symptoms
which patients encounter postcardiac catheterization such as back
pain, discomfort, urinary and bowel problems, and stress and anxiety.
Some complication management methods (such as early position
change and early ambulation) were found in previous studies to have
a positive effect in reducing postcardiac complications.6,7 However,
such findings are not applied in Jordanian hospitals. This could be
related to the fact that there is a gap between research and practice
as many research findings and associated knowledge are not
translated into the clinical fields. The lack of an adequate usage of
such available methods could also be attributed to the fact that
healthcare providers are not familiar with such interventions, or the
lack of interventional studies about postcatheterization care.
Changing the patient's position postfemoral cardiac catheter-
ization approach is a protocol that researchers suggested many years
ago should be applied as a standard protocol in cardiac centers
around the world.7 However, in Jordanian hospitals, there are no
guidelines or policies regarding managing symptoms encountered by
patients during the 6‐hour bed rest restriction after a cardiac
catheterization, such as back pain. Thus, this study aimed to test the
effectiveness of early position change postcardiac catheterization on
patients' outcomes by examining the effectiveness of this interven-
tion in relieving postcardiac catheterization symptoms to decrease
back pain, increase comfort, and decrease urinary and bowel
complications, without increasing the risk of vascular complications.
The results of this study are expected to inform policy change
that will be applied to manage symptoms among postcardiac
catheterization patients at cardiac units in Jordan. Also, it is expected
IBDAH ET AL.
that the new protocol will increase patients' comfort, decrease
negative feelings toward cardiac catheterization, reduce the admin-
istration of analgesic medications to reduce pain, decrease cost and
length of stay at the hospital, decrease urinary and bowel problems,
and reduce anxiety and stress levels. Consequently, the new protocol
will increase patients' comfort and satisfaction with their treatment.
In addition, the short bed rest duration may reduce the nursing time
needed to manage patients' back pain by administering analgesics or
back rubs.
2 | METHO DS
2.1 | Study design
A randomized control trial (RCT) was used to test the efficiency of
early positioning of patients postcatheterization vs the routine care
of bed rest in a supine position in the reduction of symptoms.
Randomized controlled trials (RCTs) are designed as experiments with
high internal validity to determine cause‐effect relationships.8
2.2 | Setting
The study took place at a large university hospital in Jordan, which
has approximately 600 beds. The university has a cardiac center
comprising four wards: Intermediate Cardiac Care Unit (IMCU),
Coronary Care Unit (CCU) for postcardiac catheterization patients,
Cardiac Intensive Care Unit (CICU) for open‐heart surgery, and a
catheterization lab. The hospital is considered the only referral
hospital in northern Jordan that provides diagnostic and therapeutic
intervention for cardiac patients who need urgent or elective
catheterization. The researchers included this hospital to represent
the largest number of cardiac patients in the north of Jordan.
2.3 | Sampling
The target population is all patients who underwent cardiac
catheterization. Accessible populations are patients who were admitted
to the CCU and IMCU and were planned for cardiac catheterization.
The inclusion criteria included adult patients (18 years old and
older) who had a femoral approach for the procedure, controlled
blood pressure, no reported complication during the procedure, and
nonurgent catheterization. Also, all participants with a body mass
index (BMI) less than 40 and international normalized ratio (INR) less
than two were invited to participate in this study. Exclusion criteria
included patients who developed bleeding at the catheter insertion
site before sheath removal and patients with a history of chronic
back pain before the procedure.
The samples were chosen by the convenience sampling method, and
participants were randomly allocated into either the control or the
intervention group. The sample size was calculated using G‐power with a
IBDAH ET AL.
type I error rate of 5% (95% CI) and a type II error rate of 20%
(80% power), and a medium effect size. Accordingly, 64 patients in the
interventional group and 64 patients in the control group were required.
To prevent attrition, the plan was to include 130 to 150 patients.
2.4 | Recruitment procedure
Considering the size of the study sample, a period of 5 months (March
to August 2018) was allocated to collecting the data. One of the
researchers met the patients who were scheduled for cardiac
catheterization and who were admitted to the CCU/IMCU wards the
day before the procedure. The trial's purpose, protocol, risk factors,
and the time that the protocol would take place were explained to all
patients, and they were assured that, if they experienced any negative
outcomes such as bleeding or hematoma as a result of our interven-
tion, all of their treatment would be free and dispensed from the
hospital. Also, they were informed that the study protocol had been
checked and ethically approved by the hospital and the university.
They were also told that they could withdraw from the study any time
they wanted without affecting the quality of care provided to them.
According to the study protocol, patients were only approached
after ensuring that they were eligible to participate in the study
based on the inclusion and exclusion criteria listed above. Then, the
participants were asked to sign a consent form. After reading
the information sheet and having their questions answered, they
were also asked to give the researcher permission to publish the
results of the study anonymously.
The total number of patients assessed for eligibility was
150 patients over the 5‐month data collection period. Nine patients
refused to participate in the study (response rate = 94%). After data
collection started, 15 patients were excluded due to having chronic
back pain, dependence on analgesics, uncontrolled blood pressure, or
inability to participate in this study. By the end of the 5‐month
period, 126 patients were randomly and equally allocated to the
intervention or control group (63 in each group). In the intervention
group, three patients were lost to follow up: two had chest pain after
cardiac catheterization and needed to take morphine intravenously,
and one had hematoma at the catheterization site before sheath
removal. In the control group, three patients were also lost to follow
up: two patients did not receive percutaneous transluminal coronary
angioplasty due to obstruction in the abdominal aorta and the other
had an anaphylactic reaction to the contrast agent during the
catheterization. Therefore, the final number of patients remaining
after the assessment of eligibility and used in the final analysis was
120 patients (60 in the intervention and 60 in the control group).
2.5 | Intervention protocol
The study used the protocol that was used previously by Bakhshi
et al.9 Patients in the intervention group were position changed from
a supine position to a 15° head of bed elevation; in the second hour,
| 3
patients were in the semirecumbent position with the bed head
elevated 30°; in the third hour, patients were instructed to put
pressure over the catheterization site with their hand, then to roll
themselves into a lateral position opposite to the puncture site as
one piece, then a supportive pillow was placed at their back for
further stability. From the fourth to sixth hours, patients were free to
change their position to either supine with the bed head at 30° or a
lateral position. Six hours after sheath removal, patients were able to
leave their beds under the supervision of the researcher or the
trained research assistant or nurses in that unit. Patients were also
advised to walk around the room and use the bathroom if they
wanted. Finally, patients were asked to get back into bed and the site
of the catheterization was checked at 8 AM the next day for bleeding
and hematoma. In the control group, patients did not receive any
intervention; patients received routine care in which they were
instructed to undergo bed rest in a supine position for two and a half
to three hours before sheath removal and then a minimum of 6 hours
after sheath removal.
2.6 | Research instruments
All patients' demographical data were collected from their
hospital files, which included patients' characteristics (age, gender,
educational level, career, marital status, chronic disease, medications,
BMI, INR value, any vascular disorder, and any chronic back pain).
Also, the unit where the patient was admitted and the date of data
collection were recorded.
A Visual Analogue Scale was used to measure the levels of back
pain. A patient determined back pain level on a scale of 0 to 10 were
0 means no pain and 10 means severe pain. This scale is frequently
used to assess subjective feelings. In addition, the validity and
reliability of this instrument have been examined and approved in
different previous studies.10
A two‐dimensional ruler with 1 cm² precision was used to measure
the amount of bleeding and hematoma. A palpation technique was
used to determine the borders of the hematoma and then it was
measured by the ruler. To measure the amount of bleeding, the
dressing over the catheterization site was observed, then the surface
area of bleeding on the dressing was measured using this ruler. The
reliability of this measurement was established using the interrater
method; the correlation coefficient was equal to 0.96, according to
Rezaei‐Adaryani et al.11 The patients were asked about comfort,
urinary discomfort, and bowel problems during the study as subjective
questions and the answers to these questions were either yes or no.
2.7 | Data analysis
Statistical Package for Social Science (SPSS), version 22 for Windows at
an α level of .05 was used for data analysis. Descriptive statistics were
used to describe the basic features of the data that provide descriptive
summaries about the sample and variables of interest (means, standard
4 |
deviations, and frequencies), frequency for groups and departments,
mean and standard deviation (SD) for continuous variables (age, BMI,
pain score, INR, the number of cigarettes, income). All the continuous
variables were checked for the normal distribution, and all those vari-
ables were normally distributed. Differences between the two groups of
the study (control group and intervention group) were examined to
assess the homogeneity of the two groups. χ2 and Fisher's exact tests
were conducted to compare the categorical demographic and clinical
characteristics of the study participants between the intervention and
control groups. A mixed design of analysis of variance (ANOVA) was
conducted to examine the differences in pain scores over time in the
intervention and control groups.
2.8 | Ethical considerations
Before the beginning of data collection and sample recruitment, the
approval was sought from the Human Research Ethics Committee at
the researcher's hospital. A formal letter was sent to the hospital
seeking permission to conduct the study at the site; the researcher
received a letter of approval from the hospital. A full research proposal
along with the study tool, protocol, and other documents (information
letter and consent form) were sent to the hospital for full approval.
3 | RESULTS
3.1 | Participants' demographical characteristics
A sample of 120 participants completed the study, half of them (n = 60)
were in the intervention group and the other half (n = 60) were in the
control group. Participants were recruited from two units: the CCU
(n = 76, 63.3%) and the ICU (n = 44, 36.7%). All participants underwent
cardiac catheterization in the hospital and completed the study
questionnaire after completing the cardiac catheterization procedure.
Most participants (n = 105, 87.5%) were male. The mean age of the
study participants was 51.9 years (SD = 7.3). Among the study parti-
cipants, 40 (33.3%) were employed in governmental or private in-
stitutions, 46 (38.3%) were self‐employed (ran their own business), and
34 (28.3%) were retired. One hundred and nine participants were
smokers (90.8%), and the mean number of cigarettes smoked per day
was 32.96 (SD = 18.67). The mean of participants' monthly income was
436.29 JD (SD = 164.55). The mean of participants' BMI was 29.39
(SD = 22.40). The mean INR of the study participants was 1.05
(SD = 0.11). Most of the participants were married (n = 112, 93.3%),
while only four were divorced (3.3%), three (2.5%) were single, and one
was widowed (0.08%). Regarding the education level, about half of the
participants had a bachelor's degree (n = 59, 49.2%), 40 (33.3%) had a
diploma, and 21 (17.5%) had postgraduate degrees. Under half of the
participants were on thrombolytic medications (n = 54, 45%). Most of
the participants (n = 117, 97.5%) reported that they did not have an
allergy to any medication or food, while three participants (2.5%) had
an allergy to seafood. A total of 42 participants (34.2%) had diabetes,
IBDAH ET AL.
23 (19.2%) had hypertension, only nine participants (7.5%) had both
diabetes mellitus (DM) and hypertension (HTN), and four participants
(3.3%) had other chronic diseases. The sample characteristics are
summarized in Table (1).
3.2 | Comparison of participants' characteristics
A χ2 test was conducted to compare the categorical demographic and
clinical characteristics of the study participants between the inter-
vention and control groups. χ2 Test was employed when at least 80%
of the cells had an expected count of five or more, and no cell had an
expected count of less than one.12 Alternatively, Fisher's exact test
was conducted when this assumption was violated. Variables com-
pared between the groups were gender, chronic disease, allergy,
marital status, educational level, employment, ward, having DM, HTN,
or other diseases, and medications used. The results revealed that only
“medications used” differed significantly between the intervention and
control groups (X2 = 5.97, P = .05), as participants in the intervention
group were more likely to use thrombolytic medications (n = 31, 52%)
compared with those in the control group (n = 23, 38%).
3.3 | Effectiveness of early position change on
comfort, urinary retention, bowel problems, and the
incidence of hematoma
χ2 Tests were conducted to compare the categorical patient
outcomes of the study participants between the intervention and
control groups when at least 80% of the cells had an expected count
of five or more at least, and no cell had an expected count of less
than one.12 Alternatively, Fisher's exact test was conducted when
this assumption was violated. Thus, a χ2 test was conducted to
compare three patient outcomes (comfort, urinary retention, and
hematoma) between the intervention and comparison groups, while
Fisher's exact test was used to compare other one patient outcome
(bowel movement) since this variable has two cells with an expected
count of less than five. Regarding comfort, the results revealed that
participants in the intervention group were more likely to be
comfortable compared with those in the control group, X2 = 120,
P < .001. The results revealed that the participants in the
intervention group were less likely to have dysuria compared with
those in the control group, X2 = 50.83, P < .001. However, although
participants in the intervention group were less likely to have
constipation and hematoma than those in the control group, this
outcome was not significant (P > .05) (see Table 2).
3.4 | Effectiveness of early position change on pain
scores
A repeated measured ANOVA, namely mixed ANOVA, was
conducted to examine the differences in pain scores over time in
IBDAH ET AL. | 5

T A B L E 1 The demographic characteristics of the study participants

Variable Category Frequency Percent Mean SD

Age 51.90 7.30

Income 436.29 164.55

BMI 29.39 22.40

Cigarettes/day 32.96 18.67

INR 1.05 0.11

Gender Male 105 87.5

Female 15 12.5

Marital status Single 3 2.5

Married 112 93.3
Divorced 4 3.3
Widowed 1 .8

Education Bachelor's degree 59 49.2

Diploma 40 33.3
High degree 21 17.5

Employment Free business 46 33.3

Retired 34 28.3
Employed 40 33.3

Department Coronary Care Unit 76 63.3

Intermediate Cardiac Unit 44 36.7

Medications Thrombolytic 54 45
Other medications 17 14.2
Noun 49 4.8

Allergy Allergic 3 2.5

None 117 97.5

Diabetes Diabetic 42 34.2

Not diabetic 79 65.8

Hypertension Hypertensive 23 19.2

Not hypertensive 97 80.8

Other diseases Yes 4 3.3

No 116 96.7

Abbreviation: BMI, body mass index.

T A B L E 2 Differences in comfort, urinary retention, bowel problems, and the incidence of hematoma between the study groups
Intervention Control
Variables Category group (n = 60) group (n = 60) P

Comfort Comfortable 60 0 <.001

Uncomfortable 0 60

Urinary discomfort Normal 51 12 <.001

Dysuria 9 48

Bowel movement Active 50 47 .487

Constipation 10 13

Hematoma None 60 55 .057

Soft discoloration/hematoma 0 5
6 | IBDAH ET AL.

T A B L E 3 Analysis of interaction between time and group
membership
F P η 2
Within time (overall sample) 1224.86 <.001 .985
Interaction 995.00 <.001
Within time (intervention group) 201.71 <.001 .958
Within time (control group) 1425.56 <.001 .994
the intervention and control groups. The pain scores were
measured over seven points (at the end of the first, second, third,
fourth, fifth, and sixth hours of sheath removal, and the next
morning postcardiac catheterization). The results (Table 3)
indicated a significant difference in the mean scores of pain over
time. The differences in pain scores were statistically significant
for the group by time interaction (P < .001). Thus, in addition, to
analyze the main effects, an additional analysis was conducted
including simple main effects of changes in pain score over time in
each group and differences in pain score between the intervention
and control groups at each time point (see Table 4). For the
intervention group, there was a significant reduction in the mean
pain scores over time from T1 to T6 (6.15, 4.85, 2.95, 1.53, 0.78,
and 0.22, respectively), F = 201.71, P < .001, η = 0.96. The 2
follow‐up comparisons were conducted using a pairwise difference
adjustment by Bonferroni correction for multiple comparisons.
The pairwise difference in the intervention group showed that
each pairwise difference was significant at P < .05, with a decrease
in pain scores over time, suggesting that early position changes
decreased participants' pain level over time.
Regarding the control group, there was a significant increase in pain
scores over time from T1 to T6 (5.17, 5.80, 6.72, 7.65, 8.20, 8.88, re-
spectively) and a significant decrease in pain scores over time from T6 to
T7 (8.88, 0.00), respectively, F = 1425.56, P < .001, η2 = 0.99. The follow‐
up comparisons were conducted using a pairwise difference adjustment
by Bonferroni for the multiple comparisons. The pairwise difference in
the control group indicated that each pairwise difference was significant
at P < .05, with an increase in pain scores over time during the first day
T A B L E 4 Changes in pain scores over time in the intervention and
control groups
postcardiac catheterization (T1‐T6) and a reduction in pain scores the
next morning after cardiac catheterization (see Table 4), suggesting that
remaining in a supine position the first day after cardiac catheterization
increases participants' pain level over time.
Although the total pain score 1 hour after sheath removal was
significantly higher in the intervention group compared with the control
group at P < .05 (Table 4), it reduced to become significantly lower than
the control group during the intervention, P < .05. However, there was
no significant difference in pain score between the two groups the next
morning (P = .315), as the mean pain scores were zero in the control
group and close to zero in the intervention group.
4 | D IS C U S S I O N
The present study aims to compare the effectiveness of early posi-
tion change postcardiac catheterization on patients' outcomes as a
comfort and safety protocol in reducing postcardiac catheterization
patients' physiological responses during the recovery period as
compared with remaining in a supine position as routine care post-
cardiac catheterization. According to the results of this study, making
early position change postcardiac catheterization was significantly
more effective in managing patients' outcomes compared with
standard care. Patients' outcomes included decreasing back pain,
decreasing urinary discomfort, and increasing comfort without in-
creasing the risk of hematoma and bleeding.
The findings of this study show no significant differences
between participants' demographic and clinical characteristics, which
were: gender, chronic disease, allergy, marital status, educational
level, employment, ward, having DM, HTN, or other diseases, and
medications used. The results revealed that only "medications used"
differed significantly between the intervention and control groups, as
participants in the intervention group were more likely to use
thrombolytic medications compared with those in the control group.
This means that the differences between the intervention and con-
trol groups are related to our intervention not to any variation in
demographic characteristics between the two groups.
According to the patient outcomes, the groups differed
significantly on back pain, urinary discomfort, and comfort level,
whilst there were no significant differences in bowel problems and
hematoma. Back pain, urinary discomfort, and discomfort were re-

Intervention group Control group ported by the present study participants as a significant problem
Pain scores M (SD) M (SD) P* postcardiac catheterization. This is congruent to many other studies
that identified that prolonged bed rest postcardiac catheterization is
First hour (T1) 6.15 (1.33) 5.17 (1.14) <.05
associated with increased patient back pain, urinary retention, and
Second hour (T2) 4.85 (1.44) 5.80 (0.88) <.05
discomfort. Similar to those in other studies, patients in the control
Third hour (T3) 2.95 (1.27) 6.72 (0.90) <.05 group in this study complained of urinary retention, discomfort, and
Fourth hour (T4) 1.53 (0.77) 7.65 (0.95) <.05 back pain, and asked the nurses to allow them to change their po-
sition, and give them analgesics, and sometimes a Foley catheter had
Fifth hour (T5) 0.78 (0.56) 8.20 (0.71) <.05
to be inserted.6,9,13
Sixth hour (T6) 0.22 (0.42) 8.88 (1.42) <.05
Comfort level was measured in this study by patients' self‐
Next day (T7) 0.02 (0.13) 0.00 (0.00) .315 report at the end of the 6 hours after sheath removal and before
*Adjustment for multiple comparisons: Bonferroni. the ambulation for both groups. It was noticed that all patients in
IBDAH ET AL.
the intervention group reported that they felt relaxed and com-
fortable after changing their position. This was especially the
case for those patients who had not previously experienced
cardiac catheterization. In contrast, patients in the control group
reported that they felt uncomfortable regarding the procedure of
cardiac catheterization because they had to be in a supine
position for 6 hours at least. Staying in a supine position
made patients feel they had difficulty in implementing some daily
activities such as urination and evacuation, in addition to the
back pain that developed due to the long bed rest. This explains
that the result of our study about the comfort level showed
that 100% of the intervention group felt comfortable after
cardiac catheterization, and 100% of the control group felt
uncomfortable after cardiac catheterization.
Urinary retention in addition to back pain is a major complaint that
was noticed by nurses and physicians in patients postcardiac cathe-
terization using a femoral approach. Before the sheath removal, all
patients in the control and intervention groups reported difficulty in
urination in the supine position related to different reasons such as
religious beliefs, culture, and sometimes feeling too shy to ask nurses to
help them to use a bedpan or urinal. Patients in the intervention group
reported that being in the 30° head of bed elevation made urination
easier than being in a supine position. Males reported that the pre-
ferable position for urination is the lateral position, while females
preferred head of the bed elevation rather than a lateral position.
The incidence of the urinary problem in this study differed sig-
nificantly between the two groups. Patients in the intervention group
experienced less urinary discomfort compared with the control group.
This finding is supported by evidence from Hosseini et al14 and Hansen
et al,15 which shows that patients who undergo cardiac catheterization
may develop urinary retention due to various reasons such as lack of
preoperation teaching regarding emptying of the bladder before the
operation. Urinary retention can be transient but if it is not treated, it
could cause damage to the urinary system. However, other studies
conducted by Neishabory et al16 reported that there were no sig-
nificant differences between intervention and control groups regard-
ing the urinary retention problem, which is not congruent to our study
6
finding. Abdollahi et al, in a study on changing positions, compared
the control and experimental groups with a different protocol from
this study and found that there were no significant differences be-
tween the two groups in terms of complications of urinary retention,
which is also not consistent with our study.
Five patients in our study suffered from soft discoloration that
did not exceed 3 × 3 cm at the catheterization site in the control
group compared with none in the interventional group, which gives
strong evidence that our protocol is safe and effective in alleviating
patients' negative outcomes postcardiac catheterization. Positioning
postcardiac catheterization strategies such as the head of bed
elevation or lateral position opposite to the catheterization site were
found to have no significant changes in vascular complications
such as bleeding and hematoma. The findings of this study are
consistent with a low incidence of bleeding and hematoma from early
9,11,17
positioning change cited in earlier studies.
| 7
As far as we are aware, no previous literature has taken the
bowel problem (constipation) that we included into consideration.
There was one study that reported that patients complained about
difficulty with evacuation when they were in a supine position but
not about constipation; this could be related to the fact that
constipation needs more than 1 day to be established.18
5 | C O N CL U S I O N
In this study, findings show that making the early position change
1 hour after sheath removal postcardiac catheterization has sig-
nificant positive effects on patient outcomes by reducing the in-
tensity of back pain and urination problems and increasing patients'
comfort level without increasing the incidence of vascular compli-
cations such as bleeding and hematoma. However, there is still a
need for further assessment and reporting of any long‐term adverse
events because it is important to confirm the safety of this protocol.
The present findings add a new scope of knowledge regarding
postcardiac catheterization care among patients, and using different
methods and encouraging patients to participate in applying and
providing care for themselves. It also makes it easy for other
researchers to investigate other applicable methods for promoting
patients' comfort with less cost and complications and fewer efforts.
6 | STRE NGTH AND LIMIT ATIONS
Using an RCT design with restricted inclusion and exclusion criteria for
participants was useful to control the study and minimize biases. Also,
the process of applying the protocol and study intervention was
controlled to reduce confounders. The sample size of 60 patients in
each group is higher than other RCTs conducted previously on
position change interventions, which is a major strength of this study.
One of the limitations of this study was that the majority of the
participants were male; this might be related to the fact that males are
more prone to cardiovascular diseases than females.19 Thus, it was
difficult to determine if there were any differences between males and
females in response to early position change in their outcomes. Also,
the two variables of bleeding and hematoma were obtained by
palpation and observation technique, but despite the high interrater
reliability for the measurement, the occurrence of bias is probable. The
comfort level, urinary discomfort, and the bowel problem were
obtained by patients' self‐report, not by an objective measure.
7 | IM P L I C A T I O N S
7.1 | Implications for research
The findings of this study can be used by nursing and medical teams in
all cardiac departments as a guideline for further investigation of such
issues related to postcardiac catheterization care methods. Additional
8 |
comparative studies are needed to compare routine nursing care and
other postcardiac catheterization care methods with larger samples and
from diverse settings to enhance the generalizability of the result.
7.2 | Implications for education
Nurses, patients, and healthcare teams should be informed and educated
about the efficacy of early position change protocol in enhancing
care postcardiac catheterization procedure on patients' outcomes.
Clinicians should also be informed about the effectiveness of applying
nonpharmacological methods to alleviate and decrease patients'
undesired outcomes, their importance, consequences, and complications.
7.3 | Implications for practice
Nurses are caring for the patient as a whole. They are concerned
about what they are experiencing after they receive medical care.
Thus, the impact of physiological discomforts such as back pain and
urinary retention on patients' physical and psychological status needs
to be taken into consideration. The present findings emphasize
the need to demonstrate and apply the new protocol among cardiac
departments to decrease these physiological discomforts and
enhance the quality of medical care.
7.4 | Implications for policy
Stakeholders, nursing administrators, and policymakers need to design
and establish policies and guidelines to improve the use and application of
the protocol used in this study. This is because the protocol takes into
consideration the negative outcomes that patients may encounter post-
cardiac catheterization. Managing patients' symptoms of postcardiac ca-
theterization will promote patients' satisfaction and increase their
physiological and psychological health.
OR CID
Wafa'a F. Ta'an http://orcid.org/0000-0002-4381-8772
Mohammad M. Suliman http://orcid.org/0000-0001-6457-9304
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AU TH OR B IO GRA P H IES
Rasheed K. Ibdah is an assistant professor and assistant dean at the
faculty of medicine/Jordan University of Science and Technology
and is a consultant interventional cardiology in King Abdullah
University Hospital (KAUH) 2014– till now. Dr. Ibdah was internal
medicine resident at KAUH 2005–2010 and teaching assistant at
JUST 2009–2010. Dr. Ibdah was an Interventional cardiology fellow
2010–2013 at Tubingen university hospital/Germany.
Wafa'a Ta'an is an Assistant Professor at the Community and
Mental Health Nursing Department, Faculty of Nursing, Jordan
University of Science and Technology. Dr. Ta'an received Ph.D.
from Arthur Labatt Family School of Nursing, Western
University, Canada. For her distinguished Academic and research
IBDAH ET AL.
contribution, she has received several national and international
grants and scholarships. She worked on research in the areas of
mental health and nursing administration.
Rawan M. Shatnawi is a clinical nurse specialist at Coronary Care
Unit/King Abdullah University/Jordan. Ms. Shatnawi has an MSN
degree in 2019 from Jordan University and Science and
Technology in Nursing Service Administration and she is
interested in cardiopulmonary nursing research.
Mohammad M. Suliman is an associate professor and Chairman
of community and mental health department/Faculty of nursing
at Al al‐Bayt University/Jordan. Dr. Suliman has a Ph.D. in
nursing from Case Western Reserve University/USA in 2015. His
specialty is nursing leadership and management. Dr. Suliman has
many publications in patient safety and quality of care, nursing
leadership and management, and patient's care in general.
Jehad A. Rababah is an assistant professor at the Adult Health
Nursing Department, Jordan University of Science and Technol-
ogy. He has a Ph.D. in nursing from Kent State University.
| 9
Dr. Rababah has more than 15 years of experience as a
registered nurse and nurse educator. His current research
interest covers health promotion, self‐care, behavior modifica-
tion, and health literacy.
Sukaina I. Rawashdeh is an assistant professor at the faculty of
medicine/Jordan University of Science and Technology and is a
consultant in clinical cardiology in King Abdullah University
Hospital (KAUH) 2014– till now. Dr. Rawashdeh has a High
specialty certificate of internal medicine from Jordan University
of science and technology; has Jordanian board in internal
medicine.
How to cite this article: Ibdah RK, Ta'an WF, Shatnawi RM,
Suliman MM, Rababah JA, Rawashdeh SI. The effectiveness of
early position change postcardiac catheterization on patient's
outcomes: A randomized controlled trial. Nurs Forum.
2020;1–9. https://doi.org/10.1111/nuf.12438