Cajanding FINAL MAN Proposal2

THE EFFECTIVENESS OF A STRUCTURED DISCHARGE PLANNING
PROGRAM AMONG FILIPINO PATIENTS WITH ACUTE MYOCARDIAL

INFARCTION ON PERCEIVED FUNCTIONAL STATUS, CARDIAC SELF-
EFFICACY, PATIENT SATISFACTION AND UNEXPECTED HOSPITAL
REVISITS
A Research Proposal
Presented to
The University of the Philippines Open University
Faculty of Management and Development Studies
In Partial Fulfilment
of the Requirements for
N300 Thesis Writing
by
Ruff Joseph M. Cajanding, RN
December 2013
Chapter 1
The Research Problem
Background of the Study
Cardiovascular diseases and its complications remain as the main causes of

morbidity and mortality among Filipinos (Department of Health, 2005). The rates of
ischemic heart diseases and myocardial infarction among Filipino adults have been
increasing exponentially in the past decade. It also constitutes a major disease burden
to the individual, his family, and to society (Bengtsson et al., 2004). The diagnosis of a
cardiac disease affects not only the physiological functioning of an individual, as recent
data shows that the impact of cardiac disease presents with psychological, mental and
social burdens (Petrie et al., 1996). Ultimately, the effect of a cardiovascular disease on
an individual has a lasting implication on his health, well-being and quality of life.
Acute myocardial infarction is responsible for most of the deaths in developed
countries and for a very large number of hospital admissions. Long-term readmission
for recurrent AMI is common in patients discharged for an AMI and is related to the
presence of cardiovascular risk factors. Most of the factors leading to high re-admission
rates, such as non-adherence to treatment and failure to detect signs of
decompensation, can be prevented, and researchers have been trying to find effective
ways to reduce them (Lambrinou et al., 2012). Several studies have shown that these
hospital re-admissions may reflect suboptimal assessment of readiness for discharge,
fragmented discharge planning, a breakdown in communication and information transfer
between hospital-based and community physicians, inadequate post-discharge care
and follow-up, or some combination of these processes (Phillips et al., 2004).
Clinicians and educators are trying to find effective solutions to eliminate the effects of
the disease and the current innovations in research address the introduction of AMI
management programmes which includes nurse-led discharge planning programs for
patients being discharged with a cardiac disease. Majority of these programs, however,
are not implemented in the Philippine context. For instance, structured nurse-led
discharge planning programs/instructions are not routinely practiced in many hospitals
in the country, and should there be one, the content, context, processes and standards
vary from institution to institution, making the evaluation of its effectiveness problematic.
Lastly, search of major databases (CINAHL/Cumulative Index to Nursing and Allied
Health Literature, MedLine PubMed, SAGE, Elsevier Science Direct, EBSCO) reveals a
dearth of literature regarding this topic when placed in the Filipino context. Among
Filipino cardiac patients, this promising concept is underutilized and its use at best is
still unsubstantiated.
Discharge planning is an interdisciplinary approach to continuity of care and a
process that includes identification, assessment, goal setting, planning, implementation,
coordination, and evaluation of care (Lin et al., 2012). The purpose of discharge
planning is to reduce hospital length of stay and unplanned readmission to hospital, to
ensure continuity of quality care between the hospital and the community, and to
improve the coordination of services following discharge from hospital (Shepperd et al.,
2004). Several studies have shown that a comprehensive discharge planning and post-
discharge support may reduce readmission rates and improve health outcomes for
patients with heart conditions such as myocardial infarction and congestive heart failure
(CHF) (Andres et al., 2012; Lambrinou et al., 2012; Phillips et al., 2004). However,
despite evidences supporting the importance of initiating a management program before
patients discharge and the importance of early implementation of discharge planning,
heterogeneity among disease management programs as a result of variation related to
the setting, team composition, nature and intensity of interventions causes difficulties in
recognizing the essential components of a successful and cost-effective management
programme (Lambrinou et al., 2012). Moreover, the efficacy of incorporating discharge
planning with/without transitional care and/or post-discharge management among
Filipino cardiac patients has not been established.
A persons attitudes, abilities, and cognitive skills comprise what is known as the
self-system, and this self-system plays a major role on how individuals perceive
situations and how they behave in response to such situations. Researchers have
suggested that an individuals perceived control over his or her health and beliefs about
his or her own abilities to perform health behaviours will affect how they adjust to their
chronic illnesses (Wu et al., 2004). Self-efficacy plays an essential part of this self-
system. According to Albert Bandura, self-efficacy is the belief in ones capabilities to
organize and execute the courses of action required to manage prospective situations
(1995). In other words, self-efficacy is the persons belief in his or her ability to succeed
in a particular situation. Social cognitive theory explains human behavior in terms of
continuous reciprocal interaction between cognitive, behavioral, and environmental
influences. According to the theory, self-efficacy is enhanced by four factors: mastery
experiences, social modelling, social persuasion, and psychological and emotional
responses. Because it encompasses attention, memory and motivation, social learning
theory spans both cognitive and behavioral frameworks. Social learning theory has
been applied extensively to the understanding of psychological motivation, particularly
in the context of behavior modification (Bandura, 1969). It is also the theoretical
foundation for the technique of behavior modeling which is widely used in education,
health, and training programs.
The construct of self-efficacy has also been shown to be linked to chronic illness
adjustment (Bandura, 1994). The theory of self-efficacy proposes that patients
confidence in their ability to perform certain health behaviors influences their health
outcomes. The construct of self-efficacy has extended far beyond the psychological
arena and has been demonstrated to affect health behaviors and chronic disease
management in many chronic disease settings (Clark & Dodge, 1999; Holden, 1991).
Importantly, self-efficacy is a modifiable characteristic; many health behavior
interventions have been shown to improve patients self-efficacy. Some of these
interventions include self-management education (Lorig & Holman, 2003), exercise
training (Oka et al., 2005), cognitive-behavioral therapy (Schwarzer & Fuchs, 1996), and
structured discharge planning (Tung et al., 2013).
Among patients with cardiovascular disease, studies of self-efficacy have largely
focused on its role in the successful rehabilitation of patients with cardiac disease.
Increases in levels of self-efficacy are correlated with higher confidence in performance
of strenuous activities and physical exercise (Ewart et al., 1983), higher subjective and
objective indices of exercise tolerance, and better participation in cardiac rehabilitation
programmes (Foster et al., 1995). Studies have shown that a low level of self-efficacy is
related to psychological distress, negative affect, and behavioural dysfunction in
patients with chronic medical conditions as well as psychological maladjustment in
elderly people (Melding, 1995). Among patients with coronary heart disease, low
cardiac self-efficacy is associated with poor health status, independent of disease
severity and depressive symptoms (Sarkar et al., 2007).
In this study, the researcher aims to determine the effectiveness of a structured
discharge planning program among Filipino patients with Acute Myocardial Infarction on
their perceived functional status, cardiac self-efficacy, patient satisfaction and
unexpected hospital revisits utilizing the Self-Efficiency Construct of the Social Cognitive
Theory as the theoretical framework. The researcher will implement a nurse-led
structured discharge planning program that is based on the American Heart
Associations patient information modules regarding myocardial infarction
(www.heart.org), My Heart, My Life manual by the Heart Foundation
(www.heartfoundation.org.au) and Discharge Management of Patients with Acute
Coronary Syndromes by the National Prescribing Service by the Australian Government
Department of Health and Ageing (www.nps.org.au). The researcher will determine if
the Structured Discharge Planning initiated primarily by a cardiovascular nurse have
significant effects on the perceived functional status, cardiac self-efficacy, patient
satisfaction and the number or frequency of unexpected hospital revisits of adult Filipino
patients who recently have a myocardial infarction.
To this end, the purposes of this study are (1) to present the current self-reported
perceived levels of functional status, cardiac self-efficacy, and patient satisfaction
among Filipino patients who had myocardial infarction; (2) to determine whether a
nurse-initiated Structured Discharge Planning Program has a significant effect on the
study subjects perceived functional status, cardiac self-efficacy, patient satisfaction and
unexpected hospital revisits; (3) to use the findings in this study to develop
recommendations for future studies regarding the development of interventions to
improve cardiovascular patients perceived functional status, cardiac self-efficacy and
patient satisfaction; and (4) to contribute to the existing body of knowledge regarding
nursing care of Filipino patients who had myocardial infarction.
Statement of the Problem
The study aims to determine the effectiveness of a nurse-initiated structured

discharge planning program among Filipino patients with Acute Myocardial Infarction on
their perceived functional status, cardiac self-efficacy, patient satisfaction and
unexpected hospital revisits. Specifically, the study aims to answer the following
questions:
1. What is the perceived functional status of the AMI clients before and after the
intervention?
1.1. Study group (Nurse-Initiated Structured Discharge Planning Program)
1.2. Comparison group (Standard Patient Care)
2. What is the level of cardiac self-efficacy among the AMI clients before and after
the intervention?
3. What is the degree of patient satisfaction among the AMI clients before and after
the intervention?
4. What is the rate of unexpected hospital revisits among the AMI clients within 2
months after discharge?
5. Is there a significant difference in the perceived functional status of the AMI

clients before and after the intervention?
6. Is there a significant difference in the level of cardiac self-efficacy among the AMI
clients before and after the intervention?
7. Is there a significant difference in the degree of patient satisfaction among the

AMI clients before and after the intervention?
8. Is there a significant difference in the levels of perceived functional status,

cardiac self-efficacy, patient satisfaction and rate of unexpected hospital visits
among those who received the intervention compared to those who did not?
Significance of the Study
This study, which aims to determine the effectiveness of a nurse-initiated

structured discharge planning program among Filipino Acute Myocardial Infarction
patients on their perceived functional status, cardiac self-efficacy, patient satisfaction
and unexpected hospital revisits will benefit:
1. Patients with Cardiovascular Diseases
At present, the rise in the number of individuals afflicted with diseases of the
heart and the blood vessels is alarming, and it is increasing at an unprecedented rate.
There is, however, an apparent dearth in the nursing literature which examines
psychosocial constructs among Filipino cardiac patients. Specifically, studies examining
the effectiveness of AMI management programmes implemented within the Filipino
context are not available or at most unpublished and unexplored. The researcher
deems it essential to examine some of the psychosocial constructs that might affect
cardiac patients psychosocial outcomes in order to develop relevant interventions that
will lead to the better patient outcomes. Moreover, there appears to be a wide variation
in the content, context and processes of implementation of AMI/CHF management
programs across various settings within and among different countries, and between
various institutions within a country or locality. More importantly, a structured discharge
planning program is not practiced and implemented in the researchers own affiliated
institution. Ultimately, the goal of this research is to develop means that will produce
positive client outcomes and improve their over-all psychosocial status and quality of life
after their hospital discharge and return to the community.
2. Nurses and Other Medical Professionals
The findings gathered in this study could serve as an important resource for
practicing cardiovascular nurses as a guide for development of possible nursing
interventions among individuals who had myocardial infarction. In this study, the
researcher aims to determine the effectiveness of a structured discharge planning
program implemented by a cardiovascular nurse practitioner to the patients functional
status, cardiac self-efficacy, health satisfaction and number of unexpected hospital
revisits. The findings generated in the study could be used as a guide to devise means
to improve myocardial infarct patients psychosocial status and ultimately, over-all
quality of life.
3. Nursing Researchers
The research study will fulfil the purpose of expanding the body of knowledge
regarding psychosocial care of myocardial infarct patients within the Filipino context.
For future researchers, this study will help or guide them in selecting research problems
or topics, utilizing it as a reference or springboard for their own studies. In addition, the
study will also aid them in locating more sources of related information and also in
constructing their research designs. Moreover, this study can assist them in making
comparisons with the findings that they will obtain to help them formulate
generalizations or principles to be contributed to the body of knowledge of nursing.
Scope and Limitations of the Study
This study aims to determine the effectiveness of a nurse-initiated structured

discharge planning program among Filipino patients with Acute Myocardical Infarction
on their perceived functional status, cardiac self-efficacy, patient satisfaction and
unexpected hospital revisits. Using a quasi-experimental, pre-post test non-equivalent
control group design, the researcher will assess whether significant differences exist in
the variable parameters studied among those individuals who had the intervention, from
those who did not receive the intervention and only received standard care. Being a
comparative research, the researcher will utilize quantitative data to present the
variables under study and will be tested for significance using prescribed statistical
techniques.
Using researcher-prescribed inclusion criteria, only those who are eligible for the
study will be included as study subjects. Study participants must be documented to
have acute myocardial infarction as diagnosed by their primary physicians and
documented on their hospital records. Study participants must be an adult, currently
admitted at a tertiary institution and is being treated for myocardial infarction. They
must not be acutely-ill or medically-unstable at the time of data collection or are being
treated for a life-threatening medical condition. Those who have a history of psychiatric
disorder or are being treated for a psychiatric or mental disorder will be excluded in this
study. They must be able to read and understand Filipino and/or English and must
demonstrate an ability to write. Lastly, only those who can provide voluntary consent
will be included in the study.
The actual study will be implemented at the Cardiovascular Unit of a tertiary
hospital equipped with facilities for cardiac monitoring with a limited time frame of 12-16
weeks. Study subjects will be chosen via convenient sampling using a purposive
method approach. Research tools will include a researcher-developed demographic
data sheet (robotfoto) and the instruments will used with permission from the scale
developers whenever applicable. Study subjects who are lost to follow-up will be
considered as study dropouts and their responses will not be included in the final
treatment of data.
Definition of Terms
Perceived Functional Status refers to an individual's ability to perform normal daily

activities required to meet basic needs, fulfill usual roles, and maintain health and well-
being (Wilson & Cleary, 1995). Functional status subsumes related concepts of interest:
functional capacity and functional performance. While functional capacity represents an
individual's maximum capacity to perform daily activities in the physical, psychological,
social, and spiritual domains of life, functional performance refers to the activities people
actually do during the course of their daily lives. In this study, the study subjects
perceived functional status will be measured through the Minnesota Living with Heart
Failure (MLHF) questionnaire (Rector, Kubo & Cohn, 1987).
Minnesota Living with Heart Failure questionnaire (MHLQ) the Minnesota Living
with Heart Failure questionnaire (MLHF) was designed in 1984 to measure the effects
of heart failure and treatments for heart failure on an individuals quality of life (Rector,
Kubo & Cohn, 1987). The content of the questionnaire was selected to be
representative of the ways heart failure and treatments can affect the key physical,
emotional, social and mental dimensions of quality of life without being too long to
administer during clinical trials or practice. To measure the effects of symptoms,
functional limitations, psychological distress on an individuals quality of life, the MLHF
questionnaire asks each person to indicate using a 6-point, zero to five, Likert scale how
much each of 21 facets prevented them from living as they desired. This response
format was chosen to be consistent with the concept of quality of life and allows each
individual to weigh each item using a common scale.
Cardiac Self-Efficacy refers to an individuals judgment of his/her capability to
organize and execute courses of action required to attain designated types of
performances, specifically, those behaviours relevant to the cardiac patients self-
reported physical functional capacity and actions involved in prevention of coronary
risks and rehabilitation (Sullivan et al., 1998). Self-efficacy is a construct from
Banduras Self-Efficacy Theory which reflects the thought process by which one's belief
in his/her own capacity effect behaviour and performance. In this study, the study
subjects degree of cardiac self-efficacy will be measured utilizing the Cardiac Self-
Efficacy Scale developed by Mark D. Sullivan, Andrea Z. LaCroix, Joan Russo & Wayne
J. Katon (1998).
Cardiac Self-Efficacy Questionnaire the Cardiac Self-Efficacy Questionnaire (CSE-

Q, 1998), developed by Sullivan and colleagues, was designed to measure self-efficacy
for physical and role function among patients with coronary heart disease (1998). The
CSE-Q consists of 13 items where patients will be asked to rate their confidence with
knowing or acting on each of the 13 statements on a 5-point Likert scale (0 = not at all
confident, 1 = somewhat confident; 2 = moderately confident, 3 = very confident, and 4
= completely confident). In multiple regression models, the self-efficacy scales
significantly predicted physical function, social function, and family function after
controlling for baseline function, baseline anxiety, and other significant correlates
(Sullivan et al., 1998).
Patient satisfaction refers to the extent by which a patient or an individual perceives

his/her contentment with the care he/she receives during the entire course of
hospitalization. In this study, the study subjects level of patient satisfaction will be
measured through the use of the Short-Form Patient Satisfaction Questionnaire (Ware,
Snyder & Wright, 1976).
Short-Form Patient Satisfaction Questionnaire (SF-PSQ-18) - The SF-PSQ-18,

developed by Ware and colleagues (Ware, Snyder & Wright, 1976) is an 18-item survey
that taps global satisfaction with medical care as well as satisfaction with six aspects of
care: technical quality, interpersonal manner, communication, financial aspects of care,
time spent with doctor, and accessibility of care. In the questionnaire, participants will be
asked to indicate how they feel about the medical care they receive in general, with no
reference to a specific time frame or visit. Responses to each item are given on a 5-
point scale ranging from strongly agree to strongly disagree.
Unexpected Hospital Visit refers to any visit to the clinician, physician, emergency
room department, or out-patient department done within a one-month (30 day) period
that is not scheduled or prescribed as written in their follow-up prescription as
determined by their primary physician or health care provider.
Structured Discharge Planning Program a nurse-led and nurse-initiated

intervention comprising of a series of individualized lecture-discussion, provision of
feedback, integrative problem-solving and action planning that will be implemented by a
cardiovascular nurse to a patient who had myocardial infarction. The intervention will
be implemented for three consecutive daily sessions, with each sessions lasting for 30-
45 minutes. The contents of the intervention are adapted from the American Heart
Associations patient information module on Heart Attack (www.heart.org), My Heart, My
Life manual by the Heart Foundation (www.heartfoundation.org.au) and Discharge
Management of Patients with Acute Coronary Syndromes by the National Prescribing
Service by the Australian Government Department of Health and Ageing
(www.nps.org.au). The content of the program includes a detailed teaching plan and a
negotiated action plan for patients recovering from AMI.
Myocardial Infarction Acute myocardial infarction (AMI) is defined as myocardial cell

death due to prolonged myocardial ischemia. In this study, all patients who present with
angina or angina equivalent, supplemented by an elevation in cardiac biomarkers
and/or ECG changes, and are diagnosed with myocardial infarction by their primary
physician as documented in the patients chart, will be considered an MI patient.
Chapter 2
Theoretical Background
Review of Related Literature and Studies
Acute Myocardial Infarction
Myocardial infarction (MI) is a major cause of death and disability worldwide. The
term myocardial infarction reflects cell death of cardiac myocytes caused by ischemia
which is the result of a perfusion imbalance between supply and demand. MI is defined
in pathology as myocardial cell death due to prolonged ischemia. MI may be the first
manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients
with established disease.
Onset of myocardial ischemia is the initial step in the development of MI and is

the result of an imbalance between oxygen supply and demand. Myocardial ischemia in
a clinical setting can usually be identified from the patients history and from the ECG.
Possible ischemic symptoms include various combinations of chest, upper extremity,
mandibular or epigastric discomfort (with exertion or at rest) or an ischemic equivalent
such as dyspnea or fatigue. The discomfort associated with acute MI usually lasts for
more than 20 minutes. Often, the discomfort is diffusenot localized, nor positional, nor
affected by movement of the regionand it may be accompanied by diaphoresis,
nausea or syncope. However, these symptoms are not specific for myocardial ischemia.
Accordingly, they may be misdiagnosed and attributed to gastrointestinal, neurological,
pulmonary or musculoskeletal disorders. MI may occur with atypical symptomssuch
as palpitations or cardiac arrestor even without symptoms; for example in women, the
elderly, diabetics, or post-operative and critically ill patients.
Myocardial injury is detected when blood levels of sensitive and specific

biomarkers such as cTn or the MB fraction of creatine kinase (CKMB) are increased.
Cardiac troponin I and T are components of the contractile apparatus of myocardial cells
and are expressed almost exclusively in the heart. Although elevations of these
biomarkers in the blood reflect injury leading to necrosis of myocardial cells, they do not
indicate the underlying mechanism. Various possibilities have been suggested for
release of structural proteins from the myocardium, including normal turnover of
myocardial cells, apoptosis, cellular release of troponin degradation products, increased
cellular wall permeability, formation and release of membranous blebs, and myocyte
necrosis (Thygesen et al., 2012). Regardless of the pathobiology, myocardial necrosis
due to myocardial ischemia is designated as MI.
According to the Joint ESC/ACCF/AHA/WHF Task Force for the Universal

Definition of Myocardial Infarction, the term acute myocardial infarction should be used
when there is evidence of myocardial necrosis in a clinical setting consistent with acute
myocardial ischemia. Under these conditions, any one of the following criteria meets
the diagnosis for MI: Detection of a rise and/or fall of cardiac biomarker values
(preferably cardiac troponin, cTnI) with at least one value above the 99 th percentile
upper reference limit (URL) and with at least one of the following: (a) symptoms of
ischemia, (b) new or presumed new significant ST-segment-T wave (ST-T segment)
changes or new left bundle branch block (LBBB), (c) development of pathologic Q
waves in the ECG, (d) imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality, or (e) identification of an intracoronary thrombus by
angiography or autopsy (Thygesen et al., 2012). The term myocardial infarction has
major psychological and legal implications for the individual and society. It is an
indicator of one of the leading health problems in the world and it is an outcome
measure in clinical trials, observational studies and quality assurance programs. These
studies and programs require a precise and consistent definition of MI, hence the
standardized joint definition.
Recent developments in treatment during the acute stage of myocardial infarction

have resulted in improved survival and fewer complications for these patients (Flapan,
1994). However, these gains in the acute phase of the illness contrast with the small
progress that has been achieved in understanding and improving the rehabilitation
phase of the disease (Lipkin, 1991). The difficulties patients face after leaving hospital in
terms of changing their lifestyle and regaining their vocational, sexual, and other
functioning may be considerable. As more patients survive myocardial infarction, this
aspect has become even more important (Petrie et al., 1996).
Much of the available evidence suggests that psychological factors have become
more important than medical factors in directing the recovery process after a myocardial
infarction. Recently, more attention has been directed to how patients cognitive
representations of their illness are associated with adjustment and rehabilitation in
several medical conditions. It is well-known that life-threatening medical conditions
such as myocardial infarction have the potential to be stressful. Myocardial infarction is
a traumatic health event in most patients lives and their families. Patients deal with a
number of experiences, including side effects of medical treatment and changes in their
lifestyles (Hassani et al., 2009). Similarly, patients may show negative psychological
reactions such as fear, anxiety, and depression during the recovery phase of the illness
(Ginzburg, 2006; Al-Hassan & Sagr, 2002).
Clinicians have noted that MI patients may develop quite idiosyncratic ideas
about what has happened to their heart and their likelihood of recoveryan extreme
example is cardiac invalidism (Logan, 1986). Researchers have noted that patients
negative expectations about their illness and future work capacity while in hospital have
been associated with slower return to work and impaired functioning (Maeland & Havik,
1987). Attendance at rehabilitation programmes and adoption of changes in lifestyle are
ongoing issuessome patients do not attend such programmes or they cannot make
the long term changes to diet and lifestyle after them. One recent study found that
patients who were judged by staff to view their illness less seriously were less likely to
attend cardiac rehabilitation (Ades et al., 1992).
In 1995, Petrie and colleagues examined whether patients' initial perceptions of

their myocardial infarction predict subsequent attendance at a cardiac rehabilitation
course, return to work, disability, and sexual dysfunction. It was revealed that patients'
illness perceptions or beliefs after a myocardial infarction are important determinants of
their recovery after discharge from hospital. Illness perceptions measured on admission
were associated with attendance at rehabilitation programmes, speed of return to work,
later sexual difficulty, and recovery of social and domestic functioning. As would be
expected, different illness perception components were related to particular
rehabilitation outcomes (attending a rehabilitation programme, returning to work,
resuming social and domestic duties, and resuming sexual activity). Patients who
strongly believed that their illness was amenable to cure or control were more likely to
attend rehabilitation programmes whereas those who anticipated that their illness would
have major consequences on their life were slower to return to work and regain social
and domestic duties. Patients' initial perception of illness identity, as indicated by the
number of symptoms associated with the illness, was related to later sexual problems
(Petrie et al., 1996).
Post-traumatic responses to life-threatening events, including that of a MI, are

not necessarily negative, rather they may result in positive changes (Barakat et al.,
2006). Evidences also suggest that the struggle to deal with negative experiences can
also result in positive changes in patient's life and his/her attitude about oneself and the
world which, in turn, can facilitate the process of adjustment to illness (Linley & Joseph,
2004; Farber et al., 2003). The positive changes are called post-traumatic growth,
stress-related growth, or benefit finding, referring to the positive changes an
individual may experience after a traumatic event (Tedeschi & Calhoun, 2004).
The experience of an acute myocardial infarction has been said to be similar in

many respects to the reported experiences of assault, domestic abuse and combat
survivors, among others (Wilson, 1984), who report high states of arousal in similar
situations or heightened sensitivity, vigilance or readiness to respond to stimuli similar to
the original events (Litz & Keane, 1989).
Behaviors and actions surrounding acute care-seeking are often fraught with
complex social, psychological and emotional processes. Individuals who have had
acute MI can be seen as experiencing a spectrum of post-traumatic disturbances,
ranging from anxiety to post-traumatic stress disorder and alexithymia. These
disturbances contribute to extended care-seeking thereby placing the individuals at
greater risk for AMI and sudden cardiac death. In a study by Alonzo and Reynolds,
effective intervention to address these potential psychosocial derangements requires
three elements (1998). First, knowledge is necessary so that individual and lay others
can correctly label symptoms and signs of an AMI. Second, it is necessary to provide
feasible behaviours that individual and lay others can use to access definitive medical
care. Third, and perhaps most importantly, it is necessary to provide understanding of
and skills to cope with the emotional arousal surrounding both the primary traumatic
experience of symptoms and signs, potential secondary traumatic consequences of AMI
care-seeking and tertiary trauma from the long-term consequences of CHD.
The manner in which patients perceive positive or negative implications of their

illness can influence psychological outcomes (Currier et al., 2009). Traumatic
experiences will not elicit positive change, unless they are perceived as adequately
threatening to ones life and challenge to his/her basic beliefs. Individual, who actively
thinks about and process his/her experience and its implications, if not ruminative
thoughts, most likely will find post-traumatic growth (Greenberg, 1995; Janoff-Bulman
1989).
Readmissions due to Myocardial Infarction
In the United States of America, acute myocardial infarction (AMI) is among the
most common principal hospital discharge diagnoses among Medicare beneficiaries,
and, in 2005, it was the fourth most expensive condition billed to Medicare (Andrews &
Elixhauser, 2007). Readmission rates following discharge for AMI are high. For
example, rates of all-cause readmission at 30 days have been found to range from
11.3% (Barbagelata et al., 2004) to 28.1% (Jonas et al., 1999). These patient
readmissions are often costly and are associated with deleterious consequences. With
an emphasis on cost-containment and improvement of long-term patient outcomes,
measures aimed on the reduction in the incidence and frequency of readmissions, upon
which majority of the causes has been shown to be preventable, have been advocated.
According to a research conducted by the Agency for Healthcare Research and

Quality (AHRQ) of the United States Department of Health and Human Services (US-
DHHS), readmission rates following an acute MI are influenced by the quality of
inpatient and outpatient care, the availability and use of effective disease management
programs, and the bed capacity of the local health care system (The Joint Commission,
2012). Some of the variation in readmissions may be attributable to delivery system
characteristics (Fisher et al., 1994). Also, interventions during and after a hospitalization
can be effective in reducing readmission rates in geriatric populations generally
(Benbassat & Taragin, 2000; Naylor et al., 1999; Coleman et al., 2006) and for AMI
patients specifically (Carroll et al., 2007; Young et al., 2003; Bondestam et al., 1995;
Ades et al., 1992). Moreover, such interventions can be cost saving (Coleman et al.,
2006; Naylor et al., 1999; Ades et al., 1992). Tracking readmissions also emphasizes
improvement in care transitions and care coordination.
Implementing interventions to reduce readmission after AMI require an

understanding of the patient characteristics associated with readmission, as knowledge
of relevant patient characteristics will help physicians stratify AMI patients according to
risk of readmission and assist with tailoring discharge plans. In a 2013 study by
Somalaraju and colleagues, utilizing a chart review, of a total of 118 patients admitted
for an acute MI, 23 (19.4%) were readmitted for all-causes (mean age 85 years, 65.2%
male) within 30 days after discharge. Majority of the readmissions (10/23, 43.5%) were
related to recurrent chest pain or CHF, followed by HCAP/sepsis, thromboembolic
events and bleeding complications secondary to antiplatelet medications. Patients who
were readmitted had a longer duration of index hospitalization (4.6 days vs. 3.8 days)
and the mean interval between index hospitalization and readmission was 9.5 days.
Social factors had minimal contribution to readmission risk stratification in this subset of
population. Multivariate logistic regression analysis reveals that the presence of bundle
branch block (BBB), ST depression on admission ECG, persistent pain at discharge,
WBC > 12 on admission, previous ER/hospital visits within 30 days prior to index
admission were independent predictors of readmission.
In their aims to better guide strategies intended to reduce high rates of 30-day
readmission after hospitalization for heart failure, acute myocardial infarction, or
pneumonia, Dharmarajan and colleagues examined readmission diagnoses,
readmission timing, and the relationship of both to patient age, sex, and race among
Medicare beneficiaries readmitted within 30 days after hospitalization for heart failure,
acute myocardial infarction, or pneumonia (2013). Utilizing chart reviews, they explored
(1) the percentage of 30-day readmissions occurring on each day (030) after
discharge; (2) the most common readmission diagnoses occurring during cumulative
time periods (days 03, 07, 015, and 030) and consecutive time periods (days 03,
47, 815, and 1630) after hospitalization; (3) median time to readmission for common
readmission diagnoses; and (4) the relationship between patient demographic
characteristics and readmission diagnoses and timing. Among cardiac patients, there
were 329,308 30-day readmissions after 1,330,157 hospitalizations for HF (24.8%
readmitted) and 108,992 30-day readmissions after 548,834 hospitalizations for AMI
(19.9% readmitted). Following hospitalization for HF and AMI, readmission was most
often due to HF (35.2% and 19.3% of readmissions, respectively). The percentage of
readmissions due to cardiovascular disease was 52.8% and 53.4% for the HF and AMI
cohorts, respectively. Among patients who are re-admitted for an AMI, the following are
the most common readmission diagnoses: heart failure (19.3%), acute myocardial
infarction (10%), renal disorders including renal failure and fluid, electrolyte, and acid-
base abnormalities (5.3%), arrhythmias and conduction disorders (4.9%), pneumonia
including aspiration pneumonitis (4.9%), chronic angina and coronary artery disease
(4.9%), septicemia and shock (4%), complications of care (3.9%), cardiorespiratory
failure (3.1%), gastrointestinal hemorrhage (3.1%), and acute/transient stroke (2.9%).
Moreover, the diagnoses associated with 30-day readmission are diverse and are not
associated with patient demographic characteristics or time after discharge for older
patients initially hospitalized with HF, AMI, or pneumonia. Although a high percentage of
30-day readmissions occur relatively soon after hospitalization, readmissions remain
frequent during days 1630 after discharge regardless of patient age, sex, or race. This
heightened vulnerability of recently hospitalized patients to a broad spectrum of
conditions throughout the post-discharge period favors a generalized approach to
preventing readmissions that is broadly applicable across potential readmission
diagnoses and effective for at least the full month after hospitalization. Strategies that
are specific to particular diseases or time periods may only address a fraction of
patients at risk for rehospitalization.
Not only do pertinent demographic characteristics have been associated with

recurrent hospital readmissions for AMI. Even patient-related behaviours, specifically,
adherence to their prescribed medical treatments, have been shown to influence the
frequency and occurrence of these hospital readmissions. Adherence to (or compliance
with) a medication regimen is generally defined as the extent to which patients take
medications as prescribed by their health care providers. The word adherence is
preferred by many health care providers, because compliance suggests that the
patient is passively following the doctor's orders and that the treatment plan is not based
on a therapeutic alliance or contract established between the patient and the physician
(Osterberg & Blaschke, 2005).
Patients recovering from acute MI are often challenged with the demand of taking
several medications aimed at altering the course of the disease and preventing
deleterious sequelae. In almost all cases, adherence to the regular intake of these
medications is challenging given the fact that the prescription is often confounded with
troublesome dosing, demanding schedules, unfamiliar nomenclatures and indications,
or just the lack of information about the common side effects of the drugs. Research on
adherence has typically focused on the barriers patients face in taking their
medications. Common barriers to adherence are under the patient's control, so that
attention to them is a necessary and important step in improving adherence. In
responses to a questionnaire, typical reasons cited by patients for not taking their
medications included forgetfulness (30%), other priorities (16%), decision to omit doses
(11%), lack of information (9%), and emotional factors (7%); 27% of the respondents did
not provide a reason for poor adherence to a regimen (Cramer, 1991). Physicians
contribute to patients' poor adherence by prescribing complex regimens, failing to
explain the benefits and side effects of a medication adequately, not giving
consideration to the patient's lifestyle or the cost of the medications, and having poor
therapeutic relationships with their patients. Within the Filipino context, even the
procurement of the medications offer a significant challenge for the patient, his family
and his caregiver.
In the field of healthcare, the importance of patients adherence to their

prescribed regimen cannot be overemphasized. Literature reveals inverse correlation
between adherence and re-admissions. For instance, Wei and colleagues investigated
patients' adherence to statin treatment prescribed following their first myocardial
infarction (MI) and estimated the effect of adherence to statins on recurrence of MI and
all cause mortality utilizing a cohort study using a record linkage database. Patients
who experienced their first AMI and are admitted in a private UK hospital were included
in the study. Percentage of statin use and adherence to statins by patients after an MI
and the relative risk of hospitalisation for recurrent MI were used as outcome measures.
Similarly, the effect of adherence on all cause mortality was also examined. The
covariates used were age, sex, socioeconomic deprivation, serum cholesterol
concentration, diabetes mellitus, cardiovascular drug use, and other hospitalisations.
Results reveal that out of 5590 patients who experienced an incident MI, 717 (12.8%)
experienced at least one further MI during the six-year follow-up study. Only 7.7% of
patients used statins after an MI during the study period, signifying poor compliance.
Compared with those not taking statins, those who had 80% or better adherence to
statin treatment had an adjusted relative risk of recurrent MI of 0.19 (95% CI 0.08 to
0.47) and all cause mortality of 0.47 (95% CI 0.22 to 0.99). It was concluded that
despite the infrequent use of statin during the study period, good adherence to statin
treatment was associated with lower risk of recurrent MI.
Hospital readmissions have been shown to be a marker of poor health quality

and efficiency. One way to prevent hospital readmissions is to address the problem of
patient non-adherence. Methods that can be used to improve adherence can be
grouped into four general categories: patient education; improved dosing schedules;
increased hours when the clinic is open, and therefore shorter wait times; and improved
communication between physicians and patients (Osterberg et al., 2005). Within the
nursing context, educational interventions involving patients, their family members, or
both can be effective in improving adherence. Interventions that enlist ancillary health
care providers such as pharmacists, behavioral specialists, and nursing staff can
improve adherence. Most methods of improving adherence have involved combinations
of behavioral interventions and reinforcements in addition to increasing the convenience
of care, providing educational information about the patient's condition and the
treatment, and other forms of supervision or attention. Successful methods are complex
and labor intensive, and innovative strategies will need to be developed that are
practical for routine clinical use. Given the many factors contributing to poor adherence
to medication, a multifactorial approach is required, since a single approach will not be
effective for all patients.
Discharge Planning
Discharge planning is an interdisciplinary approach to continuity of care; it is a

process that includes identification, assessment, goal setting, planning, implementation,
coordination, and evaluation and is the quality link between hospitals, community-based
services, nongovernment organizations, and carers (NSW Department of Health, 2005;
The Association of Discharge Planning Coordinators of Ontario, 1997). Based on the
individual needs of the patient, effective discharge planning supports the continuity of
health care between the health-care setting and the community; it is described as the
critical link between treatment received in hospital by the patient, and post-discharge
care provided in the community (NSW Department of Health, 2005). The purpose of
discharge planning is to ensure continuity of quality care between the hospital and the
community. In addition, the aim of discharge planning is to reduce hospital length of stay
and unplanned readmission to hospital, as well as to improve the coordination of
services following discharge from hospital (Shepperd et al., 2004).
The process of discharge planning includes the following: (1) early identification
and assessment of patients requiring assistance with planning for discharge; (2)
collaborating with the patient, family, and health-care team to facilitate planning for
discharge; (3) recommending options for the continuing care of the patient and referring
to accommodations, programs, or services that meet the patients needs and
preferences; (4) liaising with community agencies and care facilities to promote patient
access and to address gaps in service; and (5) providing support and encouragement to
patients and families during the stages of assessment from the hospital (Canadian
Association of Discharge Planning and Continuity of Care, CADPACC, 1995).
Researchers have used various outcome indicators to evaluate how well

discharge planning has ensured the quality and continuity of care between the hospital
and the community (Dai et al., 2003). Length of hospital stay, rate of unplanned
readmission, rate of nursing home placement, and level of patient satisfaction have
been identified as indicators for evaluating the effectiveness of discharge planning.
Many studies showed that discharge planning may increase patient satisfaction, and
some studies showed reduced hospital length of stay and reduced readmission to
hospital which translates to reduced health-care costs (Naylor et al., 1999; Naylor,
1990). A structured discharge planning tailored to the individual patient has been shown
to reduce hospital length of stay and readmission rates for older people admitted to
hospital with a medical condition, and the impact of discharge planning on mortality,
health outcomes, and cost are currently being investigated.
In a study by Naylor (1990), the impact of comprehensive discharge planning

protocol specific to the elderly and implemented by a gerontological nurse specialist in
terms of (1) Patient Outcomes (length of initial hospitalization; post-discharge morbidity;
post-discharge health services; functional status; mental status; satisfaction with
care; self-esteem; patient's perception of health status; and stress level); (2) Family
Related Outcomes (primary care giver's functional status; mental status; care giving
demands; stress level and family functioning); (3) Cost of Care Outcomes (charges for
initial hospitalization, rehospitalizations, post-discharge health services; family related
costs; and gerontological nurse specialist costs), was examined. Using a randomized
clinical trial with a total of 280 elderly (2 groups of 140), it was shown that discharge
planning for the elderly can potentially reduce patient length of hospital stay, prevent
rehospitalization, enhance patient outcomes and lessen the burden of care on the
families.
In a follow-up study, Naylor and colleagues examined the effectiveness of an

advanced practice nurse-centered discharge planning and home follow-up intervention
for elders at risk for hospital readmissions (1999). A randomized clinical trial consisting
of 363 elderly were recruited in this study, and patient readmissions, time to first
readmission, acute care visits after discharge, costs, functional status, depression,
and patient satisfaction were used as main outcome measures. Results show that an
advanced practice nurse-centered discharge planning and home care intervention for
at-risk hospitalized elders reduced readmissions, lengthened the time between
discharge and readmission, and decreased the costs of providing health care. There
were no significant group differences in post-discharge acute care visits, functional
status, depression, or patient satisfaction. The intervention demonstrated great
potential in promoting positive outcomes for hospitalized elders at high risk for
rehospitalization while reducing medical-related costs.
Discharge Planning Programs have been utilized by nurse clinicians and

educators to address the multifaceted needs of patients with cardiac conditions who are
being discharged from a medical institution. In an effort to rationalize the need for an
effective discharge planning program among patients who had acute MI, Newby and
Calliff (1996) identified patient risk factors inherent in cardiac patients which can serve
as the basis for the implementation of such programs. According to Newby and Calliff,
risk stratification of such patients, combined with data about effective therapies,
provides the basis for developing rational guidelines for patient care that can improve
efficiency while maintaining quality of care. To be most effective in guiding hospital
course and early discharge planning, risk stratification strategies must be applied early
in a patient's course with continuous updating. The process of identifying risk in a
patient with acute chest pain occurs in two segments: assessing the risk of acute MI at
presentation, and subsequently assessing the morbidity and mortality risk of patients
diagnosed with acute MI. For patients with acute MI, baseline characteristics,
complications, and laboratory and diagnostic testing help define the risk of morbidity
and mortality and guide management through the immediate post-MI phase and long
term. In conclusion, risk stratification models can facilitate early discharge planning,
potentially reducing hospital stay, improving resource utilization, and reducing costs.
Recent studies on the effectiveness of comprehensive discharge planning among

patients with a cardiac condition, specifically acute myocardial infarction and congestive
heart failure, have been discussed in current literature. A meta-analysis by Phillips and
colleagues in 2004 evaluated the effect of comprehensive discharge planning plus post-
discharge support on the rate of readmission, all-cause mortality, length of stay (LOS),
quality of life (QOL), and medical costs among patients admitted with a CHF. A
database search of randomized clinical trials that described interventions to modify
hospital discharge for older patients with CHF (mean age 55 years), delineated clearly
defined inpatient and outpatient components, compared efficacy with usual care, and
reported readmission as the primary outcome was performed in this study. Eighteen
studies representing data from 8 countries randomized 3304 older inpatients with CHF
to comprehensive discharge planning plus postdischarge support or usual care. During
a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention
patients were readmitted compared with controls (555/1590 vs 741/1714). Analysis of
studies reporting secondary outcomes found a trend toward lower all-cause mortality for
patients assigned to an intervention compared with usual care, similar initial length of
stay, greater percentage improvement in QOL scores compared with baseline scores,
and similar or lower charges for medical care per patient per month for the initial
hospital stay, administering the intervention, outpatient care, and readmission. The
meta-analysis shows that a comprehensive discharge planning plus postdischarge
support for older patients with CHF significantly reduced readmission rates and may
improve health outcomes such as survival and QOL without increasing costs.
In 2012, a meta-analysis was undertaken to estimate the effect of a heart failure

management programme (HF-MP) with a nurse-driven pre-discharge phase on the
outcomes of HF and all-cause re-admission (Lambrinou et al., 2012). A systematic
search of databases was performed to locate randomised controlled trials (RCTs),
published in English language, which implemented any HF-MP with discharge planning
carried out by a nurse. The researchers hypothesized that nurse-oriented HF
management programmes, initiated before patients discharge, will have a positive
effect on patients re-admission rates. Nineteen RCTs were selected for the meta-
analysis. The overall pooled effect (relative risk, RR) of the intervention group compared
with the control group was estimated by using a random effects analysis (95%
confidence interval (CI)) for the outcomes of HF-related re-admission and all-cause re-
admission. Analysis of results show that the overall RR of HF re-admissions was 0.68,
95% CI (0.53, 0.86), p < 0.05 and of all-cause re-admission was 0.85, 95% CI (0.76,
0.94), p < 0.05 favouring the intervention. Metaregression analysis was performed while
trying to explain the observed heterogeneity but none of the factors (environment,
duration of followup, origin and complexity) were significantly related with the RR. The
results of the current meta-analysis highlight the potential of HF-MPs with nurse-driven
pre-discharge interventions to reduce hospital re-admissions. Essential characteristics
or components of a successful HF-MP are still to be determined; thus more studies are
required to solve this issue.
In 2013, Cherlin and colleagues identified hospital discharge processes that may
be associated with better performance in hospital AMI care through a qualitative study
of 14 US Hospitals to come up with the essential features of high quality discharge
planning for patients following acute myocardial infarction. Using in-depth interviews
guided by the grounded theory approach, the researchers identified five broad
discharge processes that distinguished higher and lower performing hospitals: 1)
initiating discharge planning upon patient admission; 2) using multidisciplinary case
management services; 3) ensuring that a follow-up plan is in place prior to discharge; 4)
providing focused education sessions for both the patient and family; and 5) contacting
the primary care physician regarding the patient's hospitalization and follow-up care
plan. The researchers concluded and recommended that a comprehensive and more
intense discharge processes that starts on admission, and continuing during the
patient's hospital stay, and follow up with the primary care physician within 2 days post-
discharge, may be critical in reducing hospital risk-standardized mortality rate (RSMR)
for patients with AMI.
Self-Efficacy and Programs for Cardiac Patients
Traditional patient education programs have focused on patients changing their

behavior based on current recommendations for their health status (Katch & Mead,
2010). However, studies have shown that if patients do not believe in their own ability to
improve their health status through behavior change, the association between healthful
behaviors and health status change is weak (Lorig & Holman, 2003). Further studies
have shown that an important mechanism in improving health status for participants in
self-management programs is patient self-efficacy, or a patients engagement and belief
in his or her ability to carry out or change behavior necessary to the desired goal. By
engaging patients in problem-solving and tailoring disease management skills to their
particular challenges, self-management programs can improve patient self-efficacy.
Lorigs work shows that engaging patients in their disease management and increasing
self-efficacy are critical in linking disease management to improved clinical outcomes
(2003).
Studies have also demonstrated that patient engagement and self-efficacy are
important factors of disease management in patients with CVD. The literature
demonstrates that patients own perceptions of their ability to self-manage their CVD
improve health behaviors and clinical outcomes.
In 2007, Sarkar and colleagues examined the relationship between cardiac self-
efficacy and health status, including symptom burden, physical limitation, quality of life,
and overall health, among outpatients with stable coronary heart disease (CHD). A
cross-sectional study of 1024 outpatients with CHD who were recruited between 2000
and 2002 for the Heart and Soul Study was done. The researchers administered a
validated measure of cardiac self-efficacy, assessed cardiac function using exercise
treadmill testing with stress echocardiography, and measured depressive symptoms
using the Patient Health Questionnaire. Health status outcomes (symptom burden,
physical limitation, and quality of life) were assessed using the Seattle Angina
Questionnaire, and overall health was measured as fair or poor (versus good, very
good, or excellent). The results reveal that after adjustment for CHD severity and
depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy
score was independently associated with greater symptom burden (adjusted odds ratio
(OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of
life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive
symptoms and poor treadmill exercise capacity were also associated with poor health
status, but left ventricular ejection fraction and ischemia were not. It appears that
among patients with CHD, low cardiac self-efficacy is associated with poor health
status, independent of CHD severity and depressive symptoms. The researchers
recommended that further study be done to examine if self-efficacy constitutes a useful
target for cardiovascular disease management interventions.
Similarly, Sullivan and colleagues (1998) examined the role of specific forms of
self-efficacy in the physical and role function for patients with coronary heart disease
after controlling for the effects of anxiety and depression. A 6-month prospective cohort
study was conducted after cardiac catheterization of 198 HMO members demonstrating
clinically significant coronary disease. Coronary disease severity was assessed through
cardiac catheterization; physical function, role function, anxiety, depression, and self-
efficacy were assessed through questionnaires. Utilizing the Cardiac Self-Efficacy
Scale, the self-efficacy scales significantly predicted physical function, social function,
and family function after controlling for baseline function, baseline anxiety, and other
significant correlates. The researches posited that self-efficacy to maintain function and
to control symptoms helps predict the physical function and role function, after
accounting for coronary disease severity, anxiety, and depression in patients with
clinically significant coronary disease. Interventions to improve self-efficacy may have a
broader applicability in the heart disease population than was previously appreciated.
In 2010, a comprehensive, systematic review of disease self-management

programs for patients with cardiovascular disease (CVD), looking specifically at those
with self-efficacy as a key component to the effectiveness of such programs on CVD
management and outcomes was conducted by Katch & Mead. The researchers
performed a review of effective strategies promoting patient involvement and
engagement in the self-management of CVD. To narrow the scope of the review, the
reviewers defined strategies that were empirically tested and showed a measurable and
positive impact on outcomes that reflect improved self-management (eg, medication
adherence or patients perceived management skills) and/or improved clinical outcomes
(eg, lower blood pressure or reduced hospitalization). They were able to identify five
disease management programs focusing on self-efficacy that had been rigorously
evaluated by multiple studies in varying patient populations (Chronic Disease Self-
Management Program by Lorig et al., 1999; Taking Control of Your Health by Lorig et.
al., 2003; Women Take PRIDE by Clark et al., 1992; CR on Exercise Self-Efficacy by
Bock et al., 1997; & Disease Management Program for Low Literacy Patients with HF
by deWalt et al., 2004). Each of these programs were shown to be effective in
increasing patients engagement and involvement in the management of their disease
by demonstrating improvement in self-efficacy while developing patients self-
management skills. They also were shown to improve clinical outcomes for patients,
such as lower blood pressure and reduced hospitalizations. The studies that they
reviewed demonstrated the importance of including self-efficacy as a key component in
CVD self-management programs. These programs should be multidisciplinary in
approach, should be tailored to the needs of the patients, and should have a theoretical
foundation of behavior change. More research was recommended so as to investigate
the causal link between self-efficacy, self-management and clinical outcomes among
patients with CVD.
Self-Efficacy Construct of the Social Cognitive Theory
Self-efficacy refers to perceived capabilities for learning or performing actions at

designed levels (Bandura, 1997). Self-efficacy has been shown to be a powerful
influence on individuals motivation, achievement, and self-regulation. Since Bandura
introduced the construct of self-efficacy to the psychological literature, researchers have
explored its role in various domains including education, careers, health and wellness.
Researchers have investigated the operation of self-efficacy among different individuals,
developmental levels, and cultures.
Social cognitive theory is primarily based on a social learning theory construct in

which people learn by observing what others do in a social context. Additionally,
reinforcement and punishment observed or experienced immediately following
imitatively learned acts either fosters the reoccurrence or deterrence of a behavior.
Individuals use cognitive processes to perceive situations and initiate behavioral
operationsa combination of psychological operations and environmental stimuliin
this case, the reinforcement observations.
Social cognitive theory encompasses three domainsthe environment, personal

factors and cognition, and overt behavior, referred to as a triadic reciprocal determinism,
which forms the foundation of the social cognitive theory. In this model of reciprocal
causation, the environment, personal factors, and behavior interact reciprocally by
influencing each other. Social cognitive theory views individual behavior as determined
by interactions among environmental and personal factors as well as cognitive
operation. What people believe, think, and feel affects how they behave given a
particular case scenario.
According to the social cognitive theory, while the environment may influence an
individuals engagement in a particular behaviour, the ultimate decision making of how
people will behave depends on the individuals self-control skills. As a construct in the
social learning theory, the concept of self-efficacy has been developed and
operationalized.
Self-efficacy reflects thought process by which one's belief in capacity effect

behavior and performance. People who have a sufficient self-efficacy are likely to
engage in utilizing capacities, which lead them to a higher chance of accomplishing their
goals. However, people who do not exercise their self-efficacy by exerting capacities
consistently do not have a tendency to pursue and achieve goals, which also, in turn,
provoke deteriorating self-efficacy. Therefore, enhanced self-efficacy tend to cause
people involved in making efforts to develop and achieve pursuing goals, which can
lead to positive performance outcome. Self-efficacy development is important in life
because it is a process of learning and mastering self-control which enable individuals
to empower themselves.
In social cognitive theory, self-efficacy is hypothesized to influence behaviors and

environments and, in turn, to be affected by them. Bandura postulated that people
acquire information to gauge their self-efficacy from interpretations of actual
performances, vicarious (e.g., modelled) experiences, forms of social persuasion, and
physiological indexes. How individuals interpret their actual performances should
provide the most reliable information for assessing self-efficacy because these
interpretations are tangible indicators of ones capabilities. Performance interpreted as
successful should raise self-efficacy; those interpreted as failures should lower it,
although an occasional failure or success after many successes or failures should not
have much impact.
Individuals can acquire much information about their capabilities through
knowledge of how others perform. Similarity to others is a cue for gauging ones self-
efficacy. Observing similar others succeed can raise observers self-efficacy and
motivate them to try the task because they are apt to believe that if others can do it they
can as well. A vicarious increase in self-efficacy, however, can be negated by
subsequent performance failure. Persons who observe similar peers fail may believe
they lack the competence to succeed, which can dissuade them from attempting the
task. Because people often seen models with qualities they admire and capabilities to
which they aspire, models can help instill beliefs that will influence the course and
direction of ones life.
Individuals also create and develop self-efficacy beliefs as a result of social

persuasions (e.g., I know you can do it) they receive from others. Persuaders play an
important part in the development of an individuals self-efficacy. But social persuasions
are not empty praise or inspirational statements. Effective persuaders must cultivate
peoples beliefs in their capabilities while at the same time ensuring that the envisioned
success is attainable. Although positive feedback can raise individuals self-efficacy, the
increase will not endure if they subsequently perform poorly. Just as positive
persuasions may work to encourage and empower, negative persuasions can work to
defeat and weaken self-efficacy.
Individuals can also acquire self-efficacy information from physiological and

emotional states such as anxiety and stress. People can gauge their self-efficacy by
the emotional state they experience as they contemplate an action. When they
experience negative thoughts and fears about their capabilities (e.g., feeling nervous
thinking about speaking in front of a large group), those affective reactions can lower
self-efficacy and trigger additional stress and agitation that help ensure the inadequate
performance they fear. One way to raise self-efficacy is to improve physical and
emotional well-being and reduce negative emotional states. Individuals have the
capability to alter their thoughts and feelings, so enhanced self-efficacy can influence
their physiological states.
The sources of self-efficacy information are not directly translated into judgments
of competence. Individuals interpret the results of events, and these interpretations
provide the information on which judgments are based. The types of information people
attend to and use to make self-efficacy judgments and the rules they employ for
weighting and integrating them form the basis for such interpretations. The selection,
integration, interpretation, and recollection of information influence judgments of self-
efficacy.
Furthermore, Bandura made it clear that self-efficacy is not the influence on

behaviour. No amount of self-efficacy will produce a competent performance when
individuals lack the needed skills to succeed. Individuals values (perception of
importance and utility of learning) also can affect behaviour. Also important are
outcome expectations, or beliefs about the anticipated outcomes of actions. Individuals
typically engage in activities that they believe will result in positive outcomes and avoid
actions that they believe may lead to negative outcomes. Assuming requisite skills and
positive values and outcome expectations, self-efficacy is a key determinant of
individuals motivation, learning, self-regulation, and achievement.
Self-efficacy is predicted to enhance human accomplishment and well-being in

many ways. Self-efficacy can influence the choices people make and the courses of
action they pursue. Individuals tend to select tasks and activities in which they feel
competent and confident and avoid those in which they do not. Unless people believe
that their action will produce the desired consequences, they have little incentive to
engage in those actions.
Self-efficacy also helps determine how much effort people will expend on an
activity, how long they will persevere when confronting obstacles, and how resilient they
will be in the face of adverse situations. People with a strong sense of efficacy are apt
to approach difficult tasks as challenges to be mastered rather than as threats to be
avoided. They set challenging goals and maintain strong commitment to them, heighten
and sustain their efforts in the face of failure, and more quickly recover their sense of
self-efficacy after setbacks. Conversely, people with low self-efficacy may believe that
things are more difficult than they really area belief that can foster anxiety, stress,
depression, and a narrow vision of how best to solve a problem. Self-efficacy can
influence ones ultimate accomplishments and lead to a self-fulfilling prophecy in which
one accomplishes what one believes one can accomplish.
Will I be able to do strenuous exercise?....to return to work?...to control feelings

of chest pain? These kinds of questions reflect practical concerns of many patients
after myocardial infarction or other major coronary events (Berkhuysen et al., 1999).
The subsequent judgments that these patients make about their capabilities to actually
perform one of these tasks or behaviors has been designated by Bandura as their
perceived self-efficacy. Care of individuals who had myocardial infarction, or cardiac
rehabilitation, has largely evolved as a multifactorial service, assisting patients in
resuming and maintaining life as normally as possible. Rather than exercise
conditioning only, rehabilitation programs today include interventions also aimed at
psychosocial counseling, and modifications of coronary risk factors and behaviors.
In the recent past, numerous studies have been conducted to evaluate positive
effects of these programs. As a result, cardiac rehabilitation has gained widespread
support as an important component of the care plan for coronary patients. Most often,
effects of cardiac rehabilitation have been documented in terms of functional capacity,
clinical or behavioral characteristics, psychosocial well-being, subjective health status,
or returning to work. Self-efficacy as an outcome measure has received considerably
less attention thus far. However, from at least two perspectives, self-efficacy is an
important outcome measure in cardiac rehabilitation. The first perspective refers to the
predictive value of self-efficacy on recovery behaviors and outcomes. According to
Bandura's self-efficacy theory, decisions that people make about whether or not to
attempt certain courses of action and about how long to pursue them, are to an
important extent determined by judgments of personal efficacy. It is well established that
these judgments of capabilities consistently predict subsequent health related outcomes
(e.g. smoking, pain management, exercise). The predictive value of self-efficacy has
also been demonstrated in the area of recovery from coronary events. Self-efficacy
estimates were shown to be better predictors of return to work, physical functional
status and use of pain medication, than was age or medical status. Thus changes in
self-efficacy beliefs stimulate changes in desired recovery behaviors that benefit
patients and, as such, they are important outcomes of cardiac rehabilitation.
The second perspective supporting the need to include self-efficacy as an

outcome measure is that, in fact, most cardiac rehabilitation programs explicitly employ
strategies enhancing patients' self-efficacy which calls for a subsequent evaluation of its
effect. Self-efficacy theory, briefly, asserts that personal efficacy is based on four major
sources of information: performance accomplishments, social modeling, verbal
persuasion by a respected authority, and internal feedback from one's physiological
state. Relying on the extensive literature on coronary patients, investigators have
described how nurses or other cardiac rehabilitation practitioners can utilize self-efficacy
theory to achieve predetermined rehabilitation goals. Jeng and Braun even explicitly
suggested that self-efficacy theory might serve as a theoretical framework in cardiac
rehabilitation programs (Jeng & Braun, 1994). Similarly, Ewart stated that the four
sources of self-efficacy information are key components of a well-designed cardiac
rehabilitation program and may constitute the most important benefit the program
provides (Ewart, 1989).
The social cognition theory aims to provide the theoretical underpinnings to

define the study interventions directed at recovery behavior after MI. Behavior change
results from the individual's belief that they are able to perform a behavior (self-efficacy)
combined with a belief that the behavior will lead to a desired outcome. Therefore self-
efficacy is concerned not with the skills one has but with the judgments of what one can
do with whatever skills one possesses. Self-persuasion regarding self-efficacy relies on
the cognitive processing of sources of self-efficacy information that are conveyed
enactively, vicariously, socially, and physiologically. Enactive performance or mastery is
the actual performance of a specific behavior, while vicarious experience is seeing a
credible role model perform a behavior one wants to achieve. Social or verbal
persuasion can be used to persuade others that they have the capabilities to mobilize
greater effort while strategies can be identified that reduce physiologic arousal that can
cause symptoms and negative emotional responses.
Theoretical and Conceptual Framework
Self-Efficacy Construct of the Social Cognitive Theory, Albert Bandura (1994)
Perceived self-efficacy is defined as people's beliefs about their capabilities to

produce designated levels of performance that exercise influence over events that affect
their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves
and behave. Such beliefs produce these diverse effects through four major processes.
They include cognitive, motivational, affective and selection processes (Bandura, 1994).
A. Cognitive Processes
The effects of self-efficacy beliefs on cognitive processes take a variety of forms.

Much human behavior, being purposive, is regulated by forethought embodying valued
goals. Personal goal setting is influenced by self-appraisal of capabilities. The stronger
the perceived self-efficacy, the higher the goal challenges people set for themselves and
the firmer is their commitment to them.
Most courses of action are initially organized in thought. People's beliefs in their
efficacy shape the types of anticipatory scenarios they construct and rehearse. Those
who have a high sense of efficacy, visualize success scenarios that provide positive
guides and supports for performance. Those who doubt their efficacy, visualize failure
scenarios and dwell on the many things that can go wrong. A major function of thought
is to enable people to predict events and to develop ways to control those that affect
their lives. Such skills require effective cognitive processing of information that contains
many ambiguities and uncertainties. In learning predictive and regulative rules people
must draw on their knowledge to construct options, to weight and integrate predictive
factors, to test and revise their judgments against the immediate and distal results of
their actions, and to remember which factors they had tested and how well they had
worked.
B. Motivational Processes
Self-beliefs of efficacy play a key role in the self-regulation of motivation. Most

human motivation is cognitively generated. People motivate themselves and guide their
actions anticipatorily by the exercise of forethought. They form beliefs about what they
can do. They anticipate likely outcomes of prospective actions. They set goals for
themselves and plan courses of action designed to realize valued futures.
There are three different forms of cognitive motivators around which different
theories have been built. They include causal attributions, outcome expectancies, and
cognized goals. The corresponding theories are attribution theory, expectancy-value
theory and goal theory, respectively. Self-efficacy beliefs operate in each of these types
of cognitive motivation. Self-efficacy beliefs influence causal attributions. People who
regard themselves as highly efficacious attribute their failures to insufficient effort, those
who regard themselves as inefficacious attribute their failures to low ability. Causal
attributions affect motivation, performance and affective reactions mainly through beliefs
of self-efficacy.
C. Affective Processes
People's beliefs in their coping capabilities affect how much stress and
depression they experience in threatening or difficult situations, as well as their level of
motivation. Perceived self-efficacy to exercise control over stressors plays a central role
in anxiety arousal. People who believe they can exercise control over threats do not
conjure up disturbing thought patterns. But those who believe they cannot manage
threats experience high anxiety arousal. They dwell on their coping deficiencies. They
view many aspects of their environment as fraught with danger. They magnify the
severity of possible threats and worry about things that rarely happen. Through such
inefficacious thinking they distress themselves and impair their level of functioning.
Perceived coping self-efficacy regulates avoidance behavior as well as anxiety arousal.
The stronger the sense of self-efficacy the bolder people are in taking on taxing and
threatening activities.
D. Selection Processes
People are partly the product of their environment. Therefore, beliefs of personal
efficacy can shape the course lives take by influencing the types of activities and
environments people choose. People avoid activities and situations they believe exceed
their coping capabilities. But they readily undertake challenging activities and select
situations they judge themselves capable of handling. By the choices they make, people
cultivate different competencies, interests and social networks that determine life
courses. Any factor that influences choice behavior can profoundly affect the direction of
personal development. This is because the social influences operating in selected
environments continue to promote certain competencies, values, and interests long
after the efficacy decisional determinant has rendered its inaugurating effect.
Locus of control is defined as an individuals generalized expectancies regarding

the forces that determine rewards and punishments. Individuals with an internal locus
of control view events as resulting from their own actions. Persons with an external
locus of control view events as being under the control of external factors such as luck
(Marsh & Weary, 1995). For example, a person with an internal locus of control will
attribute the failure to meet a desired goal to poor personal preparation, whereas, one
with an external locus of control will attribute failure to circumstances beyond the
individuals control. The way individuals interpret such events has a profound affect on
their psychological well-being. If people feel they have no control over future outcomes,
they are less likely to seek solutions to their problems. The far-reaching effects of such
maladaptive behaviors can have serious consequences, which has led many social
psychologists to examine the origin of locus control and its impact on the social world.
Bandura (1986) examined aspects of the self that influence self-regulation. His
research examined the effects of self-efficacy beliefs, or the expectations that people
hold about their abilities to accomplish certain tasks. Whether or not they will undertake
a particular activity, attempt to do a particular task, or strive to meet a particular goal
depends on whether or not they believe we will be efficacious in performing those
actions. In other words, if individuals believe they have control over future events, then
they will attempt to exert that control in order to achieve a positive outcome. It does not
matter whether an outcome is or is not attainable, the perception of control determines if
one will try to attain it. Therefore, locus of control has a significant impact on Banduras
self-efficacy theories, and how individuals expectations shape the goals they set for
themselves (Wise, 1999).
In sum, perceived self-efficacy is concerned with people's beliefs in their

capabilities to exercise control over their own functioning and over events that affect
their lives. Beliefs in personal efficacy affect life choices, level of motivation, quality of
functioning, resilience to adversity and vulnerability to stress and depression. People's
beliefs in their efficacy are developed by four main sources of influence. They include
mastery experiences, seeing people similar to oneself manage task demands
successfully, social persuasion that one has the capabilities to succeed in given
activities, and inferences from somatic and emotional states indicative of personal
strengths and vulnerabilities. Ordinary realities are strewn with impediments,
adversities, setbacks, frustrations and inequities. People must, therefore, have a robust
sense of efficacy to sustain the perseverant effort needed to succeed. Succeeding
periods of life present new types of competency demands requiring further development
of personal efficacy for successful functioning. The nature and scope of perceived self-
efficacy undergo changes throughout the course of the lifespan (Bandura, 1994). The
theoretical framework of Banduras Self-Efficiency Theory is depicted in Figure 1
(below).
Cognitive processes
Vicarious experience
Performance of/
Self-Efficacy Engagement in certain
Judgments behaviors
Social persuasion
Physiological and
emotional states
Figure 1. Theoretical framework of Banduras Self-Efficiency Theory (1994) as a
construct of the Social Cognitive Theory.
Conceptual Framework
The conceptual framework for this study (Figure 2) was derived using constructs
from the Self-Efficacy Theory by Bandura (1994). The main predictors of an individuals
engagement in a particular behaviour are personal factors and cognition. Self-efficacy
reflects thought process by which one's belief in capacity effect behavior and
performance. In the model, elements of cognitive, affective, motivational and selective
domains are operative agents which affect people's behaviors through self-efficacy
(Bandura, 1989). A positive reinforcement, in the form of an intervention targeting self-
efficacy, is postulated to increase an individuals level of self-efficacy so that his
confidence to muster the behaviour needed to produce positive outcomes will be
enhanced.
Cognitive processes
Vicarious experience
Self-Efficacy Positive psychosocial
Judgments outcomes
Social persuasion
Physiological and
emotional states
Positive
Reinforcement by a
Nurse
Figure 2. Conceptual framework showing the relationships between various

determinants of self-efficacy to the positive outcomes of an acute myocardial infarction
with an Intervention as a moderating variable.
Conceptual Paradigm/Hypothesized Model
In this study, it is hypothesized that a nurse-initiated structured discharge

planning program will lead to an increase in the study subjects levels of perceived
functional status, cardiac self-efficacy and patient satisfaction, while decreasing the
incidence and frequency of unexpected hospital revisits. Utilizing the self-efficacy
construct, the researcher will determine whether the Intervention which targets
individual self-efficacy will produce positive outcomes to the population of interest as will
be measured by the outcome parameters. Hence, this study will attempt to elucidate
the existence and the magnitude of the effect of the intervention among the variables of
interest, guided by Banduras Social-Cognitive Theory.
Perceived Functional
Status
Cardiac Self-Efficacy
Filipino Patients with
Structured Discharge
Acute Myocardial
Planning
Infarction
Patient Satisfaction
Unexpected Hospital
Partnership Model Revisits
under Self-Efficacy
Theory
Figure 3. Conceptual paradigm showing the relationship between the locus of control
and self-efficacy among the psychosocial outcomes of post-MI patients.
Research Hypothesis
HO1: There is no significant difference in the perceived functional status of the AMI
clients before and after the intervention.
HO2: There is no significant difference in the level of cardiac self-efficacy of the AMI
clients before and after the intervention.
.HO3: There is no significant difference in the degree of patient satisfaction among the
AMI clients before and after the intervention.
HO4: There is no significant difference in the levels of perceived functional status,
cardiac self-efficacy, patient satisfaction and rate of unexpected hospital visits among
those who received the intervention compared to those who did not.
Chapter 3
Research Methodology
Research Design
For this study, the researcher will use a quantitative approach, utilizing a
prospective, experimental method through the use of a quasi-experimental
research design to examine the specific psychosocial constructs under study. A quasi-
experiment is one where the treatment variable is manipulated but the groups are not
equated prior to manipulation of the independent variable. Like true experiments, quasi-
experiments involve an intervention; however, quasi-experimental designs lack
randomization, the signature of a true experiment.
In this study, the researcher will utilize the non-equivalent control group
before-after (or pre- post-test) design, which involves an experimental treatment and
two groups of subjects observed before and after its implementation. Despite the fact
that quasi-experimental comparisons are much farther from an ideal counterfactual than
true experimental comparisons, the design is nevertheless strong because appropriate
analysis of the baseline data can allow the researcher to determine whether the study
subjects had similar conditions prior to the intervention/s. If the comparison and the
experimental groups are similar at baseline, the researcher could be relatively confident
inferring that any post-test difference in the variables under study was the result of the
intervention.
A quasi-experimental, quantitative, prospective design is the appropriate

research design for this study because the researcher is interested in examining the
effect of an intervention on two subsets of subjects with conditions that are extremely
difficult for the researcher to control. While the researcher can randomize the study
subjects between the experimental and the comparison group using stringent statistical
methods, there are particular patient characteristics that the researchers can not
exclusively manipulate to create an equivalent experimental and comparison group.
The employment of two groups of study subjects is the researchers attempt to provide
an effective counterfactual. As a means to maintain equivalence between the two
groups, several stringent controls will be employed by the researcher to ensure that the
study subjects are comparable in most regards and are homogeneous in terms of
individual subject characteristics (e.g., gender, age range, etc.) through the use of strict
eligibility criteria.
Research Locale
The data collection will be conducted in the Cardiovascular Unit of a

comprehensive tertiary hospital in the Philippines (University of Santo Tomas Hospital).
The Cardiovascular Unit is the main telemetry unit of the hospital and is a 16-bedded
capacity unit that is equipped with cardiac telemetry for round-the-clock monitoring of
arrhythmias. The Cardiovascular Unit contains 16 individually-bedded and roomed
units where patients with suspected or confirmed diagnosis of ACS/AMI are admitted.
All CVU rooms allow the presence of 1-2 visitors, and is suitable for individualized
instructions without undue distraction. The CVU is equipped with cardiac monitors that
are well-suited for monitoring of all cardiac cases irrespective of diagnosis. On the
average, the CVU admits around 20-30 patients with AMI on a monthly basis.
Study Population
The target population for this study includes all Filipinos who are diagnosed with
acute myocardial infarction. The accessible population, however, consists of all Filipino
AMI patients who are currently admitted in the research site during the process of data
collection.
Using power analysis, the number of study subjects needed to complete a
longitudinal study where the outcome is a measurement was computed and estimated.
Using the following formula:
Where:
z = researcher-specified significance level (adjusted for sidedness) of 0.025
(95%, 0.05 alpha level, two-tailed);
p = 50%, and;
E = 15% maximum allowable (margin of) error:
A minimum of 43 patients needs to be recruited to this longitudinal study. To

anticipate for possible subject attrition, a target study sample of 75 will be used.
The sample for this study will include 75-100 AMI patients who are currently
admitted in the research locale during the data collection procedure. Using researcher-
prescribed inclusion criteria, only those who are eligible for the study will be included as
study subjects. Study participants must be documented to have myocardial infarction
as diagnosed by their attending physician and documented in the patients chart. Study
participants must be an adult, currently admitted at a tertiary institution and is being
treated for myocardial infarction. They must not be acutely-ill or medically-unstable at
the time of data collection or are being treated for a life-threatening medical condition.
Those who have a history of psychiatric disorder or are being treated for a psychiatric or
mental disorder will not be excluded in this study. They must be able to read and
understand Filipino and/or English and must demonstrate an ability to write. Lastly, only
those who can provide voluntary consent will be included in the study. Only those who
will meet the specific eligibility criteria will be included in the study.
Sampling Design
The researcher will utilize both convenient and purposive sampling techniques to
select study subjects for this study. A purposive sample is one which is selected by the
researcher subjectively. In purposive sampling, the researcher attempts to obtain a
sample that appears to him to be representative of the population and will usually try to
ensure that a range from one extreme to the other is included. Convenience sampling,
on the other hand, is when a sample is drawn on the basis of opportunity.
The study sample will include all eligible subjects who are currently admitted in
the Cardiovascular Unit in a tertiary hospital in Manila. Study subjects who are present
on actual day of the data collection and who consented to the study will automatically be
included in the sample. They will be purposively selected based on the eligibility criteria.
The research protocol will be briefly explained to the study subjects and the research
questionnaires will be individually distributed. Individuals who do not meet the
requirements will be eliminated until the researcher has accumulated a minimum total of
75 completed questionnaires.
Research Instrument and Tools
The research subjects will be given a researcher-developed demographic and

informational sheet (robotfoto) which will contain the socio-demographic data and the
contact information of the participants (name, age, gender, marital status, medical
history, highest educational attainment, employment data, contact information, etc., see
Appendix 1). A written consent is attached to the other side of the patient data sheet
(Appendix 2). The following research instruments/tools will be used for this study:
Minnesota Living with Heart Failure questionnaire (MHLQ)
The Minnesota Living with Heart Failure questionnaire (MLHF) was designed in
1984 to measure the effects of heart failure and treatments for heart failure on an
individuals quality of life (Rector, Kubo & Cohn, 1987). The content of the questionnaire
was selected to be representative of the ways heart failure and treatments can affect
the key physical, emotional, social and mental dimensions of quality of life without being
too long to administer during clinical trials or practice. To measure the effects of
symptoms, functional limitations, psychological distress on an individuals quality of life,
the MLHF questionnaire asks each person to indicate using a 6-point, zero to five, Likert
scale how much each of 21 facets prevented them from living as they desired. This
response format was chosen to be consistent with the concept of quality of life and
allows each individual to weigh each item using a common scale.
In a study by Rector (2005), the total MLHF score can be highly reliable as
demonstrated by estimates of the correlation (r) between repeated baseline
assessments and even measures of internal consistency such as Cronbachs alpha
coefficient (). In a pooled reliability tabulation measure across five studies done from
1992 to 2003 totalling at least 2,000 participants (n=152-1,136), reliability scores
ranging from =0.92-0.95 was documented. More recently, the reliability coefficient was
estimated to be 0.86 using structural equation models of repeated measurements from
the Valsartan Heart Failure Trial (unpublished). Similarly, high internal consistency
(0.56-0.81) suggests that the total MLHF score measures a single construct
presumably interrelated effects of heart failure on an individuals quality of life.
Cardiac Self-Efficacy Questionnaire
The Cardiac Self-Efficacy Questionnaire (CSE-Q, 1998), developed by Sullivan

and colleagues, was designed to measure self-efficacy for physical and role function
among patients with coronary heart disease (1998). The objective of the CSE is to
examine the role of self-efficacy in the physical and role function for patients with
coronary heart disease after controlling for the effects of anxiety and depression. The
initial Cardiac Self-Efficacy Questionnaire consisted of 16 items. Patients were asked to
rate their confidence with knowing or acting on each of the 16 statements on a 5-point
Likert scale (0 = not at all confident, 1 = somewhat confident; 2 = moderately confident,
3 = very confident, and 4 = completely confident). Patients could also rate an item as
nonapplicable. Three items were rated as nonapplicable by more than 25% of the
sample and were omitted from additional analyses: "Lose weight (if you are
overweight)"; "Stop smoking (if you do smoke)"; and "Change your diet (if your doctor
recommended this)."
The Cardiac Self-Efficacy Scale has two factors (Control symptoms and Maintain
function) with high internal consistency and good convergent and discriminant validity.
Cronbach alphas for the two factors were 0.90 and 0.87, respectively. The Control
Symptoms factor consists of eight items and the Maintain Function factor consists of the
remaining five items. The score for each of these sub-scales is the mean of the items
for the scale except for any items rated as Nonapplicable. Three outcomes were
assessed at 6-month follow-up: SF-36 physical functioning scale and the two Sheehan
disability scales. In multiple regression models, the self-efficacy scales significantly
predicted physical function, social function, and family function after controlling for
baseline function, baseline anxiety, and other significant correlates (Sullivan et al.,
1998).
Short-Form Patient Satisfaction Questionnaire (SF-PSQ-18)
The SF-PSQ-18, developed by Ware and colleagues (Ware, Snyder & Wright,
1976) is an 18-item survey that taps global satisfaction with medical care as well as
satisfaction with six aspects of care: technical quality, interpersonal manner,
communication, financial aspects of care, time spent with doctor, and accessibility of
care. In the questionnaire, participants will be asked to indicate how they feel about the
medical care they receive in general, with no reference to a specific time frame or visit.
Responses to each item are given on a 5-point scale ranging from strongly agree to
strongly disagree.
Previous studies have shown that all PSQ-18 subscales have acceptable internal
consistency reliability scores (0.64-0.77, r=0.83-1.00). Furthermore, the tool has been
shown to be applicable to a variety of patient population, with studies testing the tool
among populations with diabetes, hypertension, heart disease, symptoms of depression
and low-income, minority women with HIV (Burke et al., 2000; Ware et al., 1976).
Independent sample t-tests, exploratory and confirmatory factor analysis, and scale
reliability has shown that the PSQ III and SF-PSQ is comparable to other measures of
satisfaction and quality of life. PSQs established psychometric properties mean that
results are generalizable to other populations; and its good overall reliability mean that
results are predictable and items can be averaged into one multidimensional result.
The researcher will use the aforementioned instruments to measure the
constructs under study because of the instruments supported high validity and reliability
indices. Since the constructs under study are generally latent and subjective in nature,
the use of self-report scales gives the study subjects the opportunity to self-introspect
and assess their own levels of perceived functional status, cardiac self-efficacy, and
patient satisfaction, and provide honest responses that are based on their self-
perception and appraisal. Similarly, the concepts of interest are inherently impervious to
external observation and thus, any other means or methods of gathering information
(i.e., observation or biophysiologic measures) will be inappropriate and ineffective.
Study Design
A two-group non-equivalent quasi-experimental pre-, post-test research design

with one-month follow-up from baseline will be conducted in a tertiary hospital in Manila,
Philippines. The study will be done in a Cardiovascular Unit catering to clients with
myocardial infarction. The Structured Discharge Planning Program will be delivered in
three consecutive daily sessions. Assessment of the psychosocial parameters will be
done at baseline and after the intervention period, specifically the Cardiac Self-Efficacy
and Patient Satisfaction measures prior to discharge, and the Perceived Functional
Status one-month after discharge.
Using researcher-prescribed inclusion criteria, only those who are eligible for the
study will be included as study subjects. Study participants must be documented to
have myocardial infarction as diagnosed by their attending physician and as
documented in the patients chart. Study participants must be an adult, currently
admitted at a tertiary institution and is being treated for myocardial infarction. They
must not be acutely-ill or medically-unstable at the time of data collection or are being
treated for a life-threatening medical condition. Those who have a history of psychiatric
disorder or are being treated for a psychiatric or mental disorder will be excluded in this
study. They must be able to read and understand Filipino and/or English and must
demonstrate an ability to write. Lastly, only those who can provide voluntary consent
will be included in the study.
Research Protocol
Study subjects who meet the inclusion criteria will be purposively selected during
the four-week recruitment period. Those who will give written informed consent will be
randomly allocated to the control group or the experimental group using SPSS 9
random number allocator. The control group will not receive the Structured Discharge
Planning Program and will only be given routine standard care. The experimental group
will receive the intervention in addition to routine standard care. Seventy-five (75)
subjects will be needed for this study, with 35 subjects allocated to the control group
and 40 subjects to the experimental group. More subjects will be allocated in the
experimental group in order to anticipate possible subject drop-out and/or attrition in the
latter group.
All study participants will be assessed at baseline for the demographic data and
the psychosocial parameters namely, (1) Perceived Functional Status, (2) Cardiac Self-
Efficacy, and (3) Patient Satisfaction utilizing appropriate instruments. Statistical
treatment using single-factor ANOVA and Independent Students t-test will be utilized to
determine if the study subjects from both groups are comparable, or whether a
statistically significant difference in the parameters variables already exist even at
baseline.
The control group will not receive the intervention and will only receive routine
standard care. The experimental group will be given the intervention for three
consecutive days. After the last day of the intervention, or on the 5 th hospital day, prior
to their hospital discharge, both subjects in each group will be assessed for their self-
reported levels of (1) Cardiac Self-Efficacy and (2) Patient Satisfaction. One month
after discharge, all study subjects will be contacted to measure their levels of (1)
Perceived Functional Status and to determine the (2) number or frequency of
Unexpected Hospital Revisits during the first 30 days following their discharge. The
proposed flow of the study is shown below (Figure 4).
Eligible patients
Assessment of psychosocial
parameters
a. Perceived Functional Status;
b. Cardiac Self-Efficacy;
c. Patient Satisfaction
Randomization
Treatment Group (N=40) Control group (N=35)
Session 1:
MY HEART
Session 2:
MY RECOVERY
Session 3:
MY ACTION PLAN
Prior to discharge
(Hospital day 5)
parameters
a. Cardiac Self-Efficacy;
b. Patient Satisfaction
One month (30-
days) after
discharge
parameters
a. Perceived Functional Status;
b. Unexpected Hospital Revisits
Figure 4. Proposed flow of study.
Methods of Data Collection
A. Preparatory
Prior to the actual data collection, the face, content and construct validity of the
research instruments will be validated by the following individuals who are experts in
their respective fields: Prof. Socorro S. Guan Hing, RN, MAN, a professor of psychiatric
nursing from the University of Santo Tomas, Dra. Debbie Liquete, MD, a neurologist-
psychiatrist from the University of Santo Tomas Hospital, and Prof. Nenita Cervantes,
RGC, MA, a psychologist-psychometrician from the University of Santo Tomas. A semi-
structured questionnaire consisting of open-ended questions regarding the face validity,
content validity and appropriateness of the tool in the Filipino context will be given to the
aforementioned experts. This is aimed on assessing the applicability and
appropriateness of the instruments to be used in this study towards the intended study
subjects and to make necessary revisions whenever appropriate.
After the initial validation, the measurement scales, with the permission of the
scale developers will be translated to Filipino through the translation services offered by
Sentro ng Wikang Filipino, University of the Philippines, Manila.
A pre-testing and pilot study will be done 2 months prior to the actual data
collection. This will be accomplished through an actual implementation of the research
protocol in a subset of population who are admitted in the research site. The responses
will be tabulated through descriptive statistics. Preliminary results will likewise be
interpreted and inferences made through inferential statistics.
For the actual data collection, a letter addressed to Dr. Eduardo Caguioa,
Medical Director of the University of Santo Tomas Hospital and Dr. Wilson Tan De
Guzman, Chair of the Continuing Education Committee of the University of Santo
Tomas Hospital, will be sent through Mrs. Alicia Estiller, RN, MAN, Chief of the
Department of Nursing Services of the University of Santo Tomas Hospital, to inform
them of the researchers interest in conducting the study at their institution. The
research proposal will be submitted to the hospitals institutional review board for clinical
and ethical review. This will allow the researcher and the administrators/reviewers to
peruse the research protocol and discuss the necessary concerns involving the data
collection procedures and the ethical considerations that must be observed when
implementing the study protocol to the study subjects. The researcher will explain the
research protocol to the staff of The Cardiovascular Unit to gain entre and to elicit
participation prior to the actual data collection.
B. Actual Data Collection
The actual data collection will be done in the Cardiovascular Unit of the
University of Santo Tomas Hospital. The researcher will briefly explain the objectives of
the study to the study subjects at the time of admission. The researcher will then
distribute the questionnaire packet consisting of the cover letter, consent for
participation form, subject information sheet, Minnesota Living with Heart Failure
questionnaire, Cardiac Self-Efficacy Questionnaire and Short-Form Patient Satisfaction
Questionnaire for the subjects to accomplish. The researcher will remain in the room to
address any concern or to answer the study subjects queries. The researcher will then
collect the questionnaire packet after the respondents have answered all the questions
in the form.
The subjects will then be allocated to either the control group or the intervention
group through simple random allocation using SPSS . The subjects who are allocated
to the Experimental Group will receive the intervention. The Structured Discharge
Planning Program comprise a series of individualized lecture-discussion, provision of
feedback, integrative problem-solving, goal-setting and action planning that will be
implemented by a cardiovascular nurse practitioner to a patient who had myocardial
infarction. The intervention will be implemented for three consecutive daily sessions,
with each session lasting only for 30-45 minutes. The contents of the intervention is
adapted from the American Heart Associations patient information modules regarding
myocardial infarction (www.heart.org), My Heart, My Life manual by the Heart
Foundation (www.heartfoundation.org.au) and Discharge Management of Patients with
Acute Coronary Syndromes by the National Prescribing Service by the Australian
Government Department of Health and Ageing (www.nps.org.au). The modules will be
given to the study subjects after the intervention.
For the first day of the intervention, an individualized discussion of the module on
MY HEART will be implemented. The module contains information regarding the
following topics: epidemiology of cardiovascular diseases, causes of heart attack,
symptoms of an impending or occurring heart attack, brief pathophysiology of heart
attack, how to avoid heart attack, and what to do in cases of heart attack. After the
discussion, opportunities for question and answer about the discussed topic will be
provided to the study subject. The session will end once the researcher finishes the
content of the module and the study subject has exhausted all his/her questions.
For the second day of the intervention, the second individualized discussion of
the module on MY RECOVERY will be implemented. The module contains
information regarding the following topics: usual psychosocial concerns of patients who
had heart attack, what lifestyle changes must be implemented by the patient who just
had a heart attack, and what precautions must be observed by the cardiac patient.
Similarly, after the discussion, opportunities for question and answer about the
discussed topic will be provided to the study subject. The session will end once the
researcher finishes the content of the module and the study subject has exhausted all
his/her questions.
For the third day of the intervention, a goal-setting session utilizing integrative
problem-solving and partnership approach will be done to the study subject. The
session comprise of accomplishing the following action plans mutually set by the patient
and the health care provider: My Risk Factor Readings, Smoking Action Plan, Nutrition
Action Plan, Alcohol Action Plan, Physical Activity Action Plan, Healthy Weight Action
Plan, and Psychological and Social Health Action Plan. The Action Plans will be given
to the study participants after the 3-day intervention to be brought home after discharge.
A sample Action Plan (Physical activity action plan) is shown on Figure 5 (below).
Figure 5. Sample action plan. Physical Activity Action Plan (from My Heart, My Life: A
Manual for Patients with Coronary Disease, from the Heart Foundation)
For the Control Group, the study subjects will not receive any intervention and
will only receive standard nursing care.
After the intervention period (at 5th hospital day), the levels of Cardiac Self-
Efficacy and Patient Satisfaction will be measured through the self-reported
questionnaires (Cardiac Self-Efficacy Questionnaire and Short-Form Patient
Satisfaction Questionnaire (SF-PSQ-18). The respondents will be followed-up one
month (30-day) after discharge through a phone or a follow-up interview for the
measurement of their Perceived Functional Status (Minnesota Living with Heart Failure
questionnaire) and to inquire the number or frequency of their Unexpected Hospital
Revisits. The quantitative data will then be treated utilizing descriptive and inferential
statistics.
Statistical Treatment
Research data regarding the study subjects characteristics will be presented and
analyzed through descriptive and inferential statistics. Demographic data will be
presented in frequency distribution tables with means standard deviation or SEM
values whenever appropriate. Assumption of normality will be presumed for all
quantitative data and parametric statistics will be used. Independent Students t-test
and Single Factor ANOVA will be utilized to detect statistical differences in the pre-test
scores of the control and study groups. Pre- and post-intervention scores will be
computed using paired Students t-test. All statistical tests will be tested at 95%
significance ( level of 0.05, two-tailed) and a P value < 0.05 will be considered
significant.
Ethical Considerations
The researcher understands the special and distinctive needs of the study
subjects in his aim to study certain phenomena with whom he is interested in.
Cognizant of the human rights of his study subjects, all ethical principles will be
stringently adhered to in the performance of the procedures in this research endeavor.
The researcher will ascertain that all administrative and logistic protocols will be
applied to and implemented in all steps of this research process. The specific
guidelines set by the respective institutions regarding protection of client privacy,
confidentiality and anonymity will be adhered to inasmuch as applicable. Because the
research protocol involves research on human subjects, the researcher will adhere to
the guidelines stated by the World Medical Associations Declaration of Helsinki in the
Ethical Principles for Medical Research Involving Human Subjects
(http://www.wma.net/en/30publications/10policies/b3).
During the actual research study, only those who consent to the study will be
included in the sample. No patient chart will be perused by the researcher without
administrative and/or individual subjects consent. No actual name or identifying
answers will be linked to the actual participants of the study. Answers to questionnaire
fields are non-obligatory, and no data collected from this research study will be divulged,
shared, revealed or disclosed in any manner except for the purpose of research
utilization.
Debriefing sessions after the data collection will be done by the researcher to
address the study subjects complaints, concerns or grievances.
Appendices
Appendix 1: Cover Letter
Ginoo/Ginang/Binibini:
Magandang Araw!
Ako po si Ruff Joseph M. Cajanding, mag-aaral ng Unibersidad ng Pilipinas, Open

University, para sa kursong Master of Arts in Nursing. Kayo po ay naimbitahan bilang
parte ng aking pananaliksik na pinamagatang Ang Epekto ng Structured Discharge
Planning sa mga Pasyenteng may Sakit sa Puso sa Kanilang Estadong
Pangkakayahan, Cardiac Self-Efficacy, Kasiyahan at Bilang Nang Hindi
Inaasahang Pagka-admit sa Ospital.( The Effectiveness Of A Structured Discharge
Planning Program Among Filipino Patients With Acute Myocardial Infarction On
Perceived Functional Status, Cardiac Self-Efficacy, Patient Satisfaction And Unexpected
Hospital Revisits) Ang layon ng aking pananaliksik ay alamin ang epekto nang isang
Programa na naglalayong mapabuti ang kakayahang pansarili o self-efficacy ng mga
pasyenteng nagka-atake sa puso upang maiwasan ang mga komplikasyon ng sakit na
ito.
Bilang parte ng pananaliksik na ito, kayo po ay maaring sumailalim sa isang

programang may layon na mapabuti ang inyong pagsunod sa mga planong medikal
dulot ng inyong sakit sa puso. Ito ay tatagal ng isang linggo. Sa kurso ng pag-aaral na
ito, maaari po kayong magpasya na ihinto ang pagsali sa pagsusuri. Wala po kayong
gagastusin sa pagsali sa pag-aaral na ito.
Maaari po ninyo akong tawagan, Ruff Joseph M. Cajanding, sa teleponong 0917-

8199783 sa anumang oras na kayo ay may katanungan tungkol sa pagsisiyasat.
Ang inyong partisipasyon sa pananaliksik na ito ay boluntaryo, at hindi kayo

magkakaroon ng anumang parusa kung kayo ay magdesisyon na hindi sumali o kaya
huminto sa pagsali.
Ang paglagda sa dokumentong ito ay nagpapahiwatig na ipinaliwanag sa inyo nang

mabuti ang pananaliksik na ito at kayo ay boluntaryong sumasang-ayon na sumali sa
pananaliksik.
_____________________________ ____________
Lagda ng kasali Petsa
_____________________________
Lagda ng saksi
Appendix 2: Personal Data Sheet
Pangalan (Name, optional): ______________________________________

Edad (Age): ___________________________________________________
Kasarian (Gender): ____________________________________________
Tirahan (Address): ____________________________________________
Telepono (Telephone Number): ___________________________________

Cellphone Number: ___________________________________
E-mail address: __________________________________
Marital Status: ________________________________________________

Trabaho (kung mayroon) (Occupation, if any): _______________________
Pinakamataas na antas na natapos (Highest educational attainment):
__________________________________________________
Kita sa loob ng isang taon (Average annual income): ___________________
Edad nang unang nalamang may sakit sa puso (Age first diagnosed with a heart
condition): ____________________________________
Edad nang unang nagka-atake sa puso (Age at first myocardial infarction):

___________________________________________
Ibang mga sakit o karamdaman (Other medical conditions:) __________________

Appendix 3: Instruments/Tools
MINNESOTA LIVING WITH HEART FAILURE QUESTIONNAIRE

CARDIAC SELF-EFFICACY QUESTIONNAIRE
(Sullivan et al., 1998)
Kindly rate your confidence with knowing or acting on each of the 13 statements on a 5-
point Likert scale (0 = not at all confident, 1 = somewhat confident; 2 = moderately
confident, 3 = very confident, and 4 = completely confident).
How confident are you that you know or can:
1. Control your chest pain by changing your activity levels

2. Control your breathlessness by changing your activity levels
3. Control your chest pain by taking your medications
4. Control your breathlessness by taking your medications
5. When you should call or visit your doctor about your heart disease
6. How to make your doctor understand your concerns about your heart
7. How to take your cardiac medications
8. How much physical activity is good for you
9. Maintain your usual social activities
10. Maintain your usual activities at home with your family
11. Maintain your usual activities at work
12. Maintain your sexual relationship with your spouse
13. Get regular aerobic exercise (work up a sweat and increase your heart rate)
SHORT FORM PATIENT SATISFACTION QUESTIONNAIRE
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THE EFFECTIVENESS OF A STRUCTURED DISCHARGE PLANNING

PROGRAM AMONG FILIPINO PATIENTS WITH ACUTE MYOCARDIAL

The Research Problem

Background of the Study

Cardiovascular diseases and its complications remain as the main causes of

The study aims to determine the effectiveness of a nurse-initiated structured

5. Is there a significant difference in the perceived functional status of the AMI

7. Is there a significant difference in the degree of patient satisfaction among the

8. Is there a significant difference in the levels of perceived functional status,

Significance of the Study

This study, which aims to determine the effectiveness of a nurse-initiated

1. Patients with Cardiovascular Diseases

2. Nurses and Other Medical Professionals

Scope and Limitations of the Study

This study aims to determine the effectiveness of a nurse-initiated structured

Perceived Functional Status refers to an individual's ability to perform normal daily

Cardiac Self-Efficacy Questionnaire the Cardiac Self-Efficacy Questionnaire (CSE-

Patient satisfaction refers to the extent by which a patient or an individual perceives

Short-Form Patient Satisfaction Questionnaire (SF-PSQ-18) - The SF-PSQ-18,

Structured Discharge Planning Program a nurse-led and nurse-initiated

Myocardial Infarction Acute myocardial infarction (AMI) is defined as myocardial cell

Review of Related Literature and Studies

Acute Myocardial Infarction

Onset of myocardial ischemia is the initial step in the development of MI and is

Myocardial injury is detected when blood levels of sensitive and specific

According to the Joint ESC/ACCF/AHA/WHF Task Force for the Universal

Recent developments in treatment during the acute stage of myocardial infarction

In 1995, Petrie and colleagues examined whether patients' initial perceptions of

Post-traumatic responses to life-threatening events, including that of a MI, are

The experience of an acute myocardial infarction has been said to be similar in

The manner in which patients perceive positive or negative implications of their

Readmissions due to Myocardial Infarction

According to a research conducted by the Agency for Healthcare Research and

Implementing interventions to reduce readmission after AMI require an

Not only do pertinent demographic characteristics have been associated with

In the field of healthcare, the importance of patients adherence to their

Hospital readmissions have been shown to be a marker of poor health quality

Discharge planning is an interdisciplinary approach to continuity of care; it is a

Researchers have used various outcome indicators to evaluate how well

In a study by Naylor (1990), the impact of comprehensive discharge planning

In a follow-up study, Naylor and colleagues examined the effectiveness of an

Discharge Planning Programs have been utilized by nurse clinicians and

Recent studies on the effectiveness of comprehensive discharge planning among

In 2012, a meta-analysis was undertaken to estimate the effect of a heart failure

Self-Efficacy and Programs for Cardiac Patients

Traditional patient education programs have focused on patients changing their

In 2010, a comprehensive, systematic review of disease self-management

Self-Efficacy Construct of the Social Cognitive Theory

Self-efficacy refers to perceived capabilities for learning or performing actions at

Social cognitive theory is primarily based on a social learning theory construct in

Social cognitive theory encompasses three domainsthe environment, personal

Self-efficacy reflects thought process by which one's belief in capacity effect

In social cognitive theory, self-efficacy is hypothesized to influence behaviors and

Individuals also create and develop self-efficacy beliefs as a result of social

Individuals can also acquire self-efficacy information from physiological and

Furthermore, Bandura made it clear that self-efficacy is not the influence on

Self-efficacy is predicted to enhance human accomplishment and well-being in

Will I be able to do strenuous exercise?....to return to work?...to control feelings

The second perspective supporting the need to include self-efficacy as an

The social cognition theory aims to provide the theoretical underpinnings to

Self-Efficacy Construct of the Social Cognitive Theory, Albert Bandura (1994)

Perceived self-efficacy is defined as people's beliefs about their capabilities to

The effects of self-efficacy beliefs on cognitive processes take a variety of forms.

Self-beliefs of efficacy play a key role in the self-regulation of motivation. Most