ISSUES IN CARDIOVASCULAR CARE

A randomized, controlled trial of vicarious

experience through peer support for male
first-time cardiac surgery patients: Impact
on anxiety, self-efficacy expectation, and
self-reported activity
Nicole Parent, MSc, and Fabienne Fortin, PhD, Montréal, Québec, Canada

OBJECTIVES: The purpose of this study was to determine whether vicarious experience, in which for-
mer patients exemplify the active lives they are leading, reduces anxiety and increases self-efficacy
expectation and self-reported activity in patients after cardiac surgery.
DESIGN: A randomized, controlled trial was used to evaluate an intervention that linked volunteers
who had recovered from cardiac surgery in dyadic support with patients about to undergo similar
surgery. The linking was achieved by means of visits during the hospitalization and recovery period.
SUBJECTS: Fifty-six first-time male patients undergoing coronary artery bypass graft (CABG) surgery,
with a mean age of 56.5 years, were randomly assigned to an experimental (n = 27) or control group
(n = 29).
OUTCOME MEASURES: Anxiety was measured at 48 hours and 24 hours before surgery, and again
at 5 days and 4 weeks after surgery. Self-efficacy expectation and self-reported activity were both eval-
uated at 5 days and 4 weeks after surgery.
RESULTS: Only the experimental group showed a significant decrease in anxiety during hospitaliza-
tion. At all measurement times after the first intervention, the experimental group reported significantly
lower levels of anxiety compared with the control group. The experimental group reported significant-
ly higher levels of self-efficacy expectation and self-reported activity for general activities, walking, and
climbing stairs evaluated at 5 days, and for general activities at 4 weeks after surgery.
CONCLUSIONS: Vicarious experience provided through dyadic support is effective in helping patients
undergoing cardiac surgery cope with surgical anxiety and in improving self-efficacy expectations and
self-reported activity after surgery. Dyadic support is a valuable tool for recovery from cardiac surgery
that needs to be maintained and explored through nursing practice and research. (Heart Lung®
2000;29:389-400.)

From Montreal Heart Institute and the Faculty of Nursing, Univer-

sity of Montreal, Quebec.
Reprint requests: Nicole Parent, MSc, Montreal Heart Institute,
Research Center, 5000 Bélanger E., Montreal, Quebec, Canada
H1T 1C8.
C oronary artery bypass graft (CABG) surgery is
one of the major therapeutic approaches to
the treatment of coronary artery disease.
More than 598,000 and 19,000 CABG procedures
This article is based on the first author’s thesis, completed in par- are performed in the United States and Canada,
tial fulfillment of requirements for the master of science degree at respectively, each year.1,2 Despite the fact that car-
the Faculty of Nursing, University of Montreal. The second author diac surgery is known to improve physiological
served as her advisor.
status, 7% to 35% of patients do not resume former
Copyright © 2000 by Mosby, Inc.
0147-9563/2000/$12.00 + 0 2/1/110626 levels of physical activity.3 Moreover, failure to
doi:10.1067/mhl.2000.110626 resume normal activities is not necessarily related

HEART & LUNG VOL. 29, NO. 6 389

Peer support for male cardiac surgery patients Parent and Fortin

to the patient’s physical status; in fact, it may mance during cardiac rehabilitation. Vicarious expe-
reflect psychological influences.4,5 Preoperative rience, a form of learning, takes place when we watch
anxiety and problems with psychological adjust- those similar to ourselves perform a behavior.
ment to the surgical procedure and its outcome Observing another individual mastering situations
can severely impede physical recovery. Social that have been feared can raise one’s own expecta-
withdrawal and difficulties in resuming sexual and tion of mastering such situations.18 Applied to
daily physical activities have been linked to a dif- behavior modification in cardiac rehabilitation, the
ficult behavioral adjustment to the surgical proce- vicarious experience in which a former patient mod-
dure.6,7 els the active life he or she is leading can act as a
Bandura’s social learning theory and its derived source of efficacy information to encourage rehabili-
self-efficacy theory focus on the effect of psycho- tation in the observing patients.
logical and environmental factors on behavior.8 Peer support groups provide opportunities for
Self-efficacy expectation is the perceived self- vicarious experience. In the past decade, growth
confidence to perform a target activity. As an of such groups on a wide variety of health con-
indicator of perceived functional capability, self- cerns has been phenomenal. Despite the preva-
efficacy expectation was found to be a major pre- lence of peer support groups in the community,
dictor of physical activity after a cardiac event.9-11 the available research has produced mixed
For example, self-efficacy expectation in the results. 19,20 Among the reasons postulated for
patient recovering from cardiac surgery was found these mixed effects, it has been reported that
to be positively correlated with activity and was peer support groups may increase negative
predictive of subsequent activity.10 According to downward comparisons when interaction is with
self-efficacy theory, different sources of informa- those who are worse off.19 In contrast, there are
tion can influence a person’s self-efficacy 12: (a) few examples of programs using one-on-one peer
performance accomplishment (the actual perfor- support, and correspondingly little research is
mance of the target activity); (b) verbal persua- available that evaluates the benefits of such inter-
sion (persuasive information from various indi- vention. Ashbury et al21 reported positive evalua-
viduals, such as nurses, physicians, and family); tions of a one-on-one support intervention offered
(c) vicarious experience (modeling of activities by breast cancer survivors to breast cancer
performed by other persons, such as patients patients. Vachon et al22 reported an experimental
recovering from cardiac surgery); and (d) physio- study in which widows received one-on-one sup-
logic and psychological reactions (such as surgical port from other widows who had resolved their
pain and anxiety). Recent studies aiming to influ- own bereavement reactions and had participated
ence patient confidence in carrying out desired in a training session. The differences at 6, 12, and
recovery activities in cardiac rehabilitation have 24 months after bereavement indicated that
used performance accomplishments and verbal those who were randomly assigned to receive
persuasion in the development of inpatient edu- one-on-one support from a widow volunteer
cational programs and telephone monitoring.13-15 achieved landmark stages in the course of adap-
Other studies have used performance accom- tation to bereavement more quickly than the con-
plishments and verbal persuasion, such as trol group. In a descriptive study, Stewart et al23
treadmill exercise testing and a counseling ses- measured the impact of a home visiting support
sion by a physician and nurse, who explained the program offered by experienced peer caregivers
test results to increase postmyocardial infarction for family caregivers of stroke victims. Peer visi-
patients’ self-efficacy for activities similar to tread- tors offered emotional and informational support
mill exercise.16 to 20 family caregivers, twice weekly for 12 weeks.
Psychological reactions after cardiac surgery, such The intervention was found to meet caregivers’
as anxiety, may affect a person’s perceived self-confi- support needs, lessened some of their caregiving
dence about performance capabilities for required demands, and enhanced their confidence and
postoperative activities. Tension/anxiety state mea- ability to cope.
sured after surgery is a major predictor of self- Patients who have had cardiac surgery have
reported general activities, with tension/anxiety received little attention in the literature as a poten-
scores inversely related to self-reported general tial source of motivation and support for current
activity.17 Few studies have used vicarious experi- patients, although some researchers have docu-
ence as a source of information to increase self-effi- mented the interest toward former patients that
cacy expectation and reinforce behavior perfor- new patients have before surgery.24,25 Study sub-

390 NOVEMBER/DECEMBER 2000 HEART & LUNG

Parent and Fortin Peer support for male cardiac surgery patients

jects noted the importance of seeing or hearing included in the sample for both time considerations
about a patient who had previously gone through and issues of sample size feasibility. Older and
the same surgery. The day before cardiac surgery, younger patients were not included, as they may
all patients in these studies had sought out a for- have differed in terms of physiologic recovery.27
mer patient in the hope of finding positive rein- Patients were excluded if they had valve dysfunction,
forcement for their own surgery. Kulik and Mahler26 signs or symptoms of unstable arrhythmias or heart
found that the preoperative patient’s roommate failure, or history of physically disabling illness. No
had a direct influence on preoperative anxiety and patients had a history of, or were receiving treatment
recovery from CABG surgery. In that study, patients for, psychiatric illness. Written, informed consent was
randomly assigned to a room with a postoperative obtained before participation.
roommate were less anxious preoperatively, more The target sample for the study was 70. Calcula-
ambulatory postoperatively, and discharged 1.4 tions were based on a 2-sided alpha of .05 with a
days earlier than patients assigned to a room with power of .80. A sample size was determined that
a preoperative roommate. would allow us to detect between-treatment-group
Although for years it has been widely believed differences in responses of 5 points on the anxiety
that patients benefit from interaction with former scale. A priori, a medium program effect was antic-
patients who have successfully undergone a similar ipated based on previous research in reducing anx-
procedure, the literature review suggests that this iety in patients having cardiac surgery.28 Of the 70
has not yet been adequately shown experimentally. eligible patients admitted during the 4-month
Only crude measurements of the effectiveness of study period, 67 (96%) agreed to participate in the
this particular support intervention are available study.
and an empirical determination of the effective-
ness of peer support given by volunteers to cardiac Intervention
surgery patients is needed. If effective, such an The intervention consisted of 3 supporting visits
approach could reduce medical costs by promoting by a volunteer former patient. This one-on-one
a more rapid recovery and return to normal activi- support intervention provided vicarious experi-
ties. The objective of this study was to test the ence. The former patient provided the study sub-
major hypothesis that vicarious experience, in jects with “living proof” of a successful surgery and
which former patients model the active lives they rehabilitation program. Emotional and information-
are leading, would hasten postsurgical rehabilita- al support given during the visit was intended to
tion. Specific hypotheses were as follows: patients reassure subjects, coach them toward activity, and
in the treatment group, as compared with the control reinforce risk factor reduction. The supportive acts
group, will have (1) less anxiety; (2) higher self-effi- included listening, responding to concerns, affirma-
cacy expectation; and (3) higher self-reported tion, feedback, and social comparisons. The discus-
activity. sions were totally based on questions from the
study subjects. The interventions were tailored to
METHODS the individual patient’s needs. Social comparison
A randomized, controlled trial was designed to opportunities provided by former patients enable
evaluate an intervention linking former patients study subjects to evaluate themselves against indi-
who had recovered from cardiac surgery with indi- viduals who are, in some sense, similar to them-
viduals about to undergo similar surgery. The selves.29 To the extent that coronary patients com-
research protocol was approved by the research pare their own situation exclusively with that of
ethics committee of the Montreal Heart Institute. healthy others, they are likely to experience more
dissatisfaction and anxiety than if they compare
Sample their position to that of individuals with the same
Patients who were having elective CABG surgery problems of adjustment. The model provided by
for the first time and were sequentially hospitalized the former patient of a healthy and active lifestyle
between June 1994 and September 1994 at the was intended to strengthen subjects’ expectancies
Montreal (Quebec) Heart Institute were recruited concerning their capacities to achieve meaningful
for this study by the research coordinator. Criteria behavioral change.
for inclusion in the sample were male gender, ages Three former male patients who had had CABG
40 to 69, and having first-time CABG surgery. At the and were between the ages of 40 and 69 were iden-
time of this study, CABG surgery was performed tified for the intervention. They were selected by
predominantly on men; therefore, women were not the research coordinator on the basis of their abili-

HEART & LUNG VOL. 29, NO. 6 391

Peer support for male cardiac surgery patients Parent and Fortin

ty to verbalize their enthusiasm, to stimulate moti- rate their present anxiety on a scale ranging from
vation, and to share their successful rehabilitation 1 to 4, with 1 indicating no anxiety and 4 indicat-
after cardiac surgery. As a group, the 3 former ing high anxiety. Total anxiety scores range from
patients were given 6 hours of training by the 20 to 80. Bergeron et al30 established construct
research coordinator on interaction principles (how validity, concurrent validity, and test-retest relia-
to listen empathically and to reflect the patient’s bility for this inventory using graduate students
feelings) and on cardiovascular disease and treat- and other medical patients. In the current study,
ment. The former patients were given opportuni- the alpha coefficients over the 4 measurement
ties to practice their skills through role play activi- times were .90 to .93.
ties and practice sessions with a patient, under the Self-efficacy expectation. The Jenkins Self-
supervision of the research coordinator. Efficacy Expectation Scales31 for selected cardiac
recovery behaviors were used to assess postoper-
Procedure ative self-efficacy expectation at 5 days and at 4
Consenting subjects were recruited and ran- weeks after surgery. The instrument measured
domized before surgery to an experimental or patients’ confidence in their ability to perform 3
control group by flipping a coin. During the hospi- activity categories: general activities (daily life
talization, both experimental and control groups activities), walking (varying distances), and climb-
were given routine information on surgery and ing stairs (varying numbers of steps). Subcate-
recovery by health professionals that is consid- gories within each activity category included a
ered standard therapy. Subjects in the experi- progressive range of activities from simple to dif-
mental group also received 3 supporting visits ficult. The general activity checklist has 17 activi-
from a volunteer former patient: the first 24 hours ties, the walking checklist has 14 activities, and
before surgery, the second on the fifth postopera- the climbing stairs has 7 activities. The instrument
tive day, and the third 4 weeks after surgery. Each was translated into the French version for this
consecutive supporting visit was given by the study, using back translation.32 Patients used an
same former patient in the hospital setting. The 11-point confidence scale (0 = not at all, to 10 =
last supporting visit took place with the subject as total confidence) to rate their confidence in their
an outpatient. Each volunteer former patient visit- ability to carry out the activity. Mean strength
ed approximately the same number of patients. scores (ranging from 0-10) for self-efficacy expec-
Anxiety, self-efficacy expectation, and self-report- tation for each activity were obtained by adding
ed activity were the 3 dependent variables mea- the numerical responses and dividing the total by
sured. Experimental and control patients were the total number of subcategories contained in
tested for anxiety 4 times: at 48 and 24 hours each respective scale. Higher mean scores indi-
before surgery, and again at 5 days and at 4 weeks cate a more positive self-efficacy expectation. In
after surgery. Self-efficacy expectation and self- the current study, the alpha coefficients over the 2
reported activity were measured in both groups measurement times were .70 to .96.
twice: at 5 days and at 4 weeks after surgery. The 3 Self-reported activity. Patients used the Jenkins
variables were tested by the research coordinator Activity Checklists to report their behavior perfor-
on the same day for both groups and scheduled mance of the same walking, climbing stairs, and
within an hour period after the support visit for general activities assessed in the Jenkins Self-
the experimental group. The most rapid gains in Efficacy Scales at 5 days and at 4 weeks after
recovery occur during the first 4 to 6 weeks after surgery. The checklists were designed to be used
surgery, at which time most individuals are able to after the administration of the self-efficacy expec-
resume presurgical activity levels of functioning.15 tation scales. In these 3-point scale checklists, the
Therefore, the window of opportunity for effective patient rated as “yes,” “no,” or “not applicable” the
behavioral change was chosen to be 4 weeks with carrying out of each physical activity in the previ-
an early intervention, to maximize patients’ car- ous 24 hours. For each checklist, the number of
diac rehabilitation. “yes” responses was summed to provide a total
activity score. Scores can range from 0 to 14 for
Instruments walking and from 0 to 7 for climbing stairs. Higher
Anxiety. Anxiety was evaluated with the state total activity scores indicate a higher reported per-
form of the State-Trait Anxiety Inventory’s French formance of physical activity. Total activity scores
version.30 This self-reporting instrument consists for general activities were expressed in percent-
of 20 short statements that allow participants to ages (from 0 to 100), as some activities were not

392 NOVEMBER/DECEMBER 2000 HEART & LUNG

Parent and Fortin Peer support for male cardiac surgery patients

applicable shortly after surgery. In the current any intervention by a former patient (Table II).
study, the alpha coefficients over the 2 measure- Despite this initially higher anxiety level compared
ment times were .72 to .95. with the control group, the anxiety level of the
experimental subjects dropped significantly after
Data Analysis the first visit by the former patient and remained
Statistical analyses were carried out using SPSS significantly lower compared with the controls at 24
for Windows (version 9.0).33 A series of repeated hours before surgery, at 5 days after surgery, and
measures analysis of variance with 2 factors (time again at 4 weeks after surgery.
and group) and their interactions were conducted The anxiety level in the experimental group
separately for each dependent variable, anxiety, showed a significant decrease from 48 to 24 hours
self-efficacy expectation, and self-reported activity. before surgery. The anxiety level showed no further
Significant interactions were then explored using significant decrease from 24 hours before surgery
Bonferonni t tests34 to compare the means involved to 5 days after surgery, and from 5 days after
in the interactions. All comparisons using Bonfer- surgery to the fourth week. In comparison, the anx-
onni t tests were planned in advance. All tests were iety level of the control group did not change sig-
2-tailed, and a P value of .05 or less was considered nificantly over each successive evaluation during
statistically significant. Two-sided hypothesis tests the hospitalization period, from 48 to 24 hours
were chosen over a 1-sided test, as the treatment before surgery and from 24 hours to 5 days after
difference could go in either direction. surgery. A significant decrease in the anxiety level
in the control group was only found from 5 days to
RESULTS 4 weeks after surgery.
Of the 36 patients randomly assigned to the
treatment group, 4 (11%) had postoperative com- Self-efficacy expectation
plications (pulmonary edema, peripheral embolism, A significant interaction between time and
intestinal reocclusion), 1 (3%) was discharged group was observed for self-efficacy expectation
before completion of the outcome assessment, and for each activity category, namely for general activ-
4 (11%) were absent at the final assessment. Of the ities, for walking, and for climbing stairs (Table III).
31 patients randomly assigned to the control Therefore, groups were compared at each mea-
group, 2 (6.5%) had postoperative complications surement time, and the effect of time was exam-
(pulmonary edema). The final sample for the study ined within each group through the use of Bonfer-
consisted of 56 patients who had received a roni t tests.
first-time CABG surgery and who had completed The experimental group reported significantly
outcome assessments at all time periods, with 29 higher levels of self-efficacy expectation for general
subjects in the control group and 27 in the experi- activities, for walking, and for climbing stairs than
mental group. A flow diagram (Fig 1) provides infor- the control group at discharge (Table III). Both
mation about the progress of patients throughout groups, however, showed significant increases in
the design. Table I shows the demographic and self-efficacy expectations over time, and by 4 weeks
physiologic characteristics of the final sample. The after surgery the group difference was no longer sig-
2 groups were comparable in mean age, occupa- nificant (Fig 3).
tions, smoking status, number of previous myocar-
dial infarctions, and number of bypass grafts. There Self-reported activity
were no statistically or clinically significant differ- A significant interaction between time and group
ences in any measures of baseline demographics, was observed for 2 activity categories, namely, for
physiologic characteristics, or anxiety scores general activities and for walking (Table IV). For
between the dropouts and those who completed these activity categories, groups were compared at
the study. each measurement time, and the effect of time was
examined within each group. No significant interac-
Anxiety tion was observed for climbing stairs.
A significant interaction between the time and The experimental group reported significantly
group factors (F[1,54] = 12.63, P = .001) was higher levels of self-reported activity for general
observed (Fig 2). Results of multiple comparisons activities and for walking compared with the control
tests revealed that the anxiety level of the experi- group at discharge (Table IV). Although both groups
mental group was significantly higher at the first increased their behavior performance from dis-
evaluation than that of the control group, before charge to 4 weeks after surgery for every activity

HEART & LUNG VOL. 29, NO. 6 393

Peer support for male cardiac surgery patients Parent and Fortin

Fig 1 Flow diagram.

Table I
Characteristics of patients randomized to experimental or control group

Control (n = 29) Experimental (n = 27)

Age, y (mean ± SD) 55.9 (7.8) 57.6 (7.4)

40-49 (%) 28 11
50-59 (%) 36 48
60-69 (%) 36 41
Occupations (%)
Professional (%) 8 4
Managerial (%) 39 44
Skilled worker (%) 21 19
Retired (%) 32 33
Current smokers 6 4
Previous myocardial 36 37
infarction
Number of bypass grafts
2 (%) 50 41
3 (%) 32 37
4 (%) 14 15
5 (%) 4 7

category, by 4 weeks after surgery, the group differ- DISCUSSION

ences remained significant for general activities
and for climbing stairs (Fig 4). The experimental Vicarious experience provided through a one-on-
group reported a significantly higher level of self- one support intervention reduces anxiety, improves
reported walking compared with the control group, self-efficacy expectation, and accelerates recovery
but only at discharge. after CABG surgery. The experimental group

394 NOVEMBER/DECEMBER 2000 HEART & LUNG

Parent and Fortin Peer support for male cardiac surgery patients

Fig 2 Mean anxiety scores over time. (■) Experimental group; (●) control
group; *P< .01; †P< .05.

Table II
Effect of the intervention on state anxiety

Control Experimental
Variable (n = 29) (mean ± SD) (n = 27) (mean ± SD)

48 hours before surgery *

NS 39.8 ± 10.6 *
46.6 ± 14.0
*
24 hours before surgery NS 38.8 ± 10.0 29.2 ± 8.7 NS
5 days after surgery *
‡ 36.1 ± 9.0 † 25.2 ± 5.2
NS
4 weeks after surgery 31.4 ± 8.6 25.3 ± 5.4

NS, Not significant.

Anxiety scores range from 20 to 80.
*P < .01.
†P < .05.
‡P < .10.

showed a significant decrease in anxiety during the for another patient for information before surgery.24
hospitalization period, whereas the anxiety level of The possible influence of this confounding variable
the control group stayed constant for the same time was assessed within each group. A similar number
of measurement. Our findings support the potential of subjects in each group acknowledged such inter-
value of this type of approach for patients undergo- actions, which were described for some as not ben-
ing cardiac surgery. eficial or even harmful.
After randomization, both groups were homoge- Only the experimental group showed a signifi-
neous regarding physiologic characteristics, past cant decrease in anxiety from 48 hours to 24 hours
history of cardiovascular illness, and for sociode- before surgery, a time known for high anxiety for
mographic characteristics. This homogeneity con- cardiac surgery patients. Admission 48 hours
tributes to the internal validity of the study. Possi- before surgery was common medical practice when
ble interactions of the subjects with other patients the study was conducted, making it possible to
during hospitalization or after discharge could have assess anxiety in the early periods. This decreased
represented a competitive event to the indepen- anxiety level may reflect the beneficial influence
dent variable, as up to 80% of patients usually look before surgery of the supportive intervention by a

HEART & LUNG VOL. 29, NO. 6 395

Peer support for male cardiac surgery patients Parent and Fortin

Fig 3 Mean self-efficacy expectation scores by groups over time. (■) Experimental
group; (●) control group; *P < .01.

Table III
Effect of the intervention on self-efficacy expectation

Control Experimental F
Variables (n = 29) (mean ± SD) (n = 27) (mean ± SD) (df 1,54) P

General activities
5 days after surgery 5.4 ± 1.7 * 7.5 ± 2.1 10.50 .002
4 weeks after surgery * 9.1 ± 1.1 NS 9.6 ± 0.7 *
Walking
5 days after surgery 4.6 ± 2.3 * 7.4 ± 2.0 19.53 .001
4 weeks after surgery * 9.5 ± 0.8 NS 9.7 ± 0.8 *
Climbing stairs
5 days after surgery 5.2 ± 2.4 * 7.1 ± 2.1 6.36 .015
4 weeks after surgery * 9.1 ± 1.1 NS 9.4 ± 1.0 *

NS, Not significant.

Note: Self-efficacy scores range from 0 to 10.
*P < .01.

former patient or may be a result related to the Researchers have identified the hospitalization
patient’s higher anxiety before surgery. No further period after cardiac surgery as the most critical and
decrease in anxiety was observed in the experi- complex period of recovery. This period coincides
mental group at each successive measurement with the aggressive aspects of the medical and
time, from 24 hours before surgery to 4 weeks after nursing regimen.36 Patients are in the process of
surgery. Anxiety may have reached a floor level coping with multiple physical and emotional
after the first visit. In contrast, the anxiety level of demands. These demands include preoccupation
the control group stayed constant during the hos- with bodily state and function, requirements to
pitalization period but decreased significantly after ambulate, and emotional reorganization in facing
discharge. Our study corroborates the work of oth- the implications of their heart surgery. Anxiety was
ers who used supportive interventions to decrease noted in relation to physical care procedures and
anxiety surrounding cardiac surgery.28,35 the individual’s tolerance of them. The most sig-

396 NOVEMBER/DECEMBER 2000 HEART & LUNG

Parent and Fortin Peer support for male cardiac surgery patients

Fig 4 Mean self-reported activity scores by groups over time. (■) Experimental group;
(●) control group; *P < .01; †P < .05; ‡P < .10.

Table IV
Effect of the intervention on self-reported activity

Control Experimental F
Variables (n = 29) (mean ± SD) (n = 27) (mean ± SD) (df 1,54) P

General activities
5 days after surgery 29.5 ± 18.4 * 50.6 ± 18.6 10.50 .002
4 weeks after surgery * 76.1 ± 14.9 † 84.3 ± 12.8 *
Walking
5 days after surgery 4.2 ± 1.5 * 5.5 ± 1.8 19.53 .000
4 weeks after surgery * 12.9 ± 1.8 NS 12.5 ± 2.8 *
Climbing stairs
5 days after surgery 0.1 ± 0.6 NS 0.4 ± 1.5 6.36 .015
4 weeks after surgery * 5.4 ± 1.2 ‡ 6.0 ± 1.3 *

NS, Not significant.

Note: Self-reported activity scores are expressed in percentages for general activities, ranging from 0 to 14 for walking, and
from 0 to 7 for climbing stairs.
*P< .01.
†P< .05.
‡P< .10.

nificant stressors reported by others included the control group only after discharge may reflect
family worrying, having to depend on others, the absence of the stressors related to the hospi-
sleeping in a strange or uncomfortable bed, and tal environment.
not having things within easy reach. 37 Most of Initial randomization was performed in this
these stressors are related to the hospital envi- study, but experimental subjects showed a signifi-
ronment. After discharge, these stressors are cantly higher level of anxiety as compared with the
gone. In the present study, the anxiety level of the control subjects before any intervention. This dif-
control group stayed constant during the hospital- ference could have been caused by the experi-
ization period but decreased significantly after mental subjects knowing of their group status and
discharge. This significant decrease in anxiety for the correspondent intervention. Despite this initial

HEART & LUNG VOL. 29, NO. 6 397

Peer support for male cardiac surgery patients Parent and Fortin

higher anxiety level for the experimental subjects, visit at 4 weeks. When subjects were questioned on
a significant decrease in anxiety was observed after the usefulness of this intervention, 97.3% respond-
the first intervention. As a result, the anxiety level ed with 4 (very much) on a 4-point Likert scale and
of the experimental subjects was significantly lower 3.7% responded with 3 (moderately). When ques-
compared with the control subjects 24 hours pre- tioned on the extent to which they would recom-
operatively and at both measurement times post- mend such an intervention, all subjects (100%)
operatively. responded with a maximal score of 4 on the scale.
Higher self-efficacy expectation and self-reported Patients found this intervention useful and strong-
activity scores were observed in the experimental ly recommended such a support intervention for
group when compared with the control group. future patients undergoing CABG surgery.
These results support the results of other studies
that used information such as verbal persuasion Limitations
and performance accomplishment to increase self- In this study, both the subjects and the inter-
efficacy expectation and self-reported activity. For viewer were aware of the group to which the subject
example, an inpatient education program and had been assigned. It is difficult in such a study to
hospital-initiated telephone monitoring after dis- provide double-blind conditions, as the study sub-
charge were found to enhance perceptions of efficacy jects need to know their group status. To ensure a
and reported activity in a group of male cardiac uniform approach to data collection, we used struc-
patients at 4 and 8 weeks after surgery.14-16 In the tured information to address the subjects. However,
present study, no significant differences were because the study subjects could not be blinded to
observed between groups on self-efficacy expecta- their group status, some placebo effect may have
tion for general activities, walking, and climbing come into play. The knowledge of being included in
stairs at 4 weeks after discharge. Also, no significant the treatment group may have been sufficient to
differences were observed for self-reported activi- cause some subjects to change their behavior,
ty for walking at the same time period. Additional thereby magnifying the effect of the treatment.
differences might have been found between the Replication of this study with both psychological
groups if the patients had been tested at 2 weeks. and physiologic outcome variables, and not exclu-
Fewer differences were found at 4 weeks; however, sively self-reports, is suggested to overcome this
the experimental group might have achieved their effect. Physiologic conditions could include vari-
relative success sooner. ables such as complications of the surgical proce-
As anticipated, self-efficacy expectation and dure, length of stay in the hospital, or rehospitaliza-
self-reported activity for every activity category tion rates.
were increased in both groups from discharge to 4 Another limitation pertains to the construct
weeks after surgery. This result reflects the pro- validity of the intervention, that is, exactly what was
gressive healing and confidence that patients gain manipulated. It was anticipated that the supporting
during rehabilitation. Self-efficacy expectation intervention by a volunteer former patient provid-
and self-reported activity measured at discharge ed opportunities for vicarious experience, using
reflect the fragile physical status of patients in the supportive acts such as affirmation, feedback, and
immediate postoperative period. Another study social comparison. Although the key component
has shown that altered comfort, pain, activity was the model providing “living proof”of a success-
intolerance, and sleep pattern disturbance were ful surgery or past experience as a CABG survivor,
among the major complaints of patients in the first other potentially effective components may have
few weeks after surgery.38 As the healing progress- been at work in this intervention. For example, it
es, patients’ confidence gradually rises. The might have been the increased information about
increases in self-efficacy expectation and self- postsurgical symptoms, pain status, and what to
reported activity in this study support the findings expect during recovery, or the verbal persuasion
reported in other studies of recovery after cardiac provided through feedback from the volunteer.
surgery.16,39 Obviously, it would be difficult logistically to sepa-
rate or dissociate such components. Vicarious
Patients’ personal acknowledgments experience involves a mix of all these components.
of the support intervention Future studies would need to consider some type
Direct appreciation of the intervention was of intervention for the control group, such as non-
assessed through a brief questionnaire adminis- specific volunteers, to distinguish the effect of a
tered to the experimental subjects after the last volunteer former patient from any volunteer

398 NOVEMBER/DECEMBER 2000 HEART & LUNG

Parent and Fortin Peer support for male cardiac surgery patients

involvement, therefore controlling for increased 2. Heart and Stroke Foundation of Canada. The Changing Face of
Heart Disease and Stroke in Canada 2000. Ottawa, Canada:
attention, social support, and companionship. The Foundation; 1999, p. 54.
Finally, another limitation pertains to the gen- 3. King KB, Parrinello KA. Patient perceptions of recovery from
eralizability of the research findings. Although this coronary artery bypass grafting. Heart Lung 1988;17:708-15.
4. Mayou R, Bryant B. Quality of life after coronary artery surgery.
was an extremely promising intervention, our Q J Med 1987;62(239):239-248.
sample was small and consisted exclusively of 5. Gundle MJ, Reeves BR, Tate S, Raft D, McLaurin LP. Psychoso-
male patients at a single hospital who were under- cial outcome after coronary artery surgery. Am J Psychiatry
1980;137(12):1591-4.
going coronary bypass. No women were involved, 6. Carr JA, Powers MJ. Stressors associated with coronary bypass
and younger and older subjects were excluded. surgery. Nurs Res 1986;35(4):243-46.
The need for replication then should be clear, 7. Dracup K, Meleis A, Baker K, Edlefsen P. Family-focused car-
diac rehabilitation. A role supplementation program for car-
including both women and men using gender- diac patients and spouses. Nurs Clin North Am 1984;19(1):
match dyads. 113-25.
In the present study, experimental subjects 8. Bandura A. Social foundations of thought and action: a social
cognitive theory. Englewood Cliffs, New Jersey: Prentice-Hall;
exposed to vicarious experience demonstrated 1986.
lower anxiety, higher efficacy expectation, and 9. Allen JK, Becker DM, Swank RT. Factors related to functional
higher self-reported activity than did control sub- status after coronary artery bypass surgery. Heart Lung 1990;
19(4):337-43.
jects. The results of this study are significant for 10. Jenkins LS, Gortner SR. Correlates of self-efficacy expectation
recovery after cardiac surgery. They indicate that and prediction of walking behavior in cardiac surgery elders.
one-on-one support given by former cardiac Ann Behav Med 1998;20(2):99-103.
11. Oka RK, Gortner SR, Stotts NA, Haskell WL. Predictors of
patients to current surgery patients may be effec- physical activity in patients with chronic heart failure sec-
tive in helping the latter deal with their experience. ondary to either ischemic or idiopathic dilated cardiomyopa-
This study has contributed to the acknowledgment thy. Am J Cardiol 1996;77(2):159-63.
12. Bandura A, Adams NE. Analysis of self-efficacy theory of
of this potential source of information for behavior behavioral change. Cognit Ther Res 1977;1:287-308.
modification in cardiovascular programs. 13. Gillis CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA, Tomp-
One-on-one peer support represents a valuable kins C. A randomized clinical trial of nursing care for recovery
from cardiac surgery. Heart Lung 1993;22(2):125-33.
perspective on recovery from cardiac surgery that 14. Gortner SR, Gillis CL, Shinn JA, Sparacino PA, Rankin S, Leav-
could provide clinicians with a further rationale for itt M, et al. Improving recovery following cardiac surgery: a
designing nursing interventions. For example, randomized clinical trial. J Adv Nurs 1988;13:649-61.
15. Gortner SR, Jenkins LS. Self-efficacy and activity level follow-
because it has been shown that heart surgery has a ing cardiac surgery. J Adv Nurs 1990;15:1132-38.
particular impact on the patient’s spouse,40,41 one- 16. Ewart CK, Taylor B, Reese LB, DeBusk RF. Effects of early post-
on-one support given to that spouse by the spouse myocardial infarction exercise testing on self-perception and
subsequent physical activity. Am J Cardiol 1983;51:1076-80.
of a former patient should be studied. Further 17. Ruiz BA, Dibble SL, Gillis CL, Gortner SR. Predictors of gener-
research is needed to examine the influence, in al activity 8 weeks after cardiac surgery. Appl Nurs Res
terms of learning, on the former patient, as both 1992;5(2):59-65.
18. Bandura A. Social learning theory. Englewood Cliffs, New Jer-
parties of the dyad may benefit from the learning sey: Prentice-Hall; 1977.
process. As helping professionals, nurses must 19. Helgeson V, Choen S, Schulz R, Yasko J. Education and peer
encourage and explore one-on-one peer support discussion group interventions and adjustment to breast can-
cer. Arch Gen Psych 1999;56(4):340-47.
relationships through practice and research. This 20. Molchany CA, Peterson KA. The psychosocial effects of sup-
should enhance the quality of life for patients hav- port group intervention on AICD recipients and their signifi-
ing cardiac surgery and their families and con- cant others. Prog Cardiovasc Nurs 1994;9(2):23-9.
21. Ashbury FD, Cameron C, Mercer SL, Fitch M, Nielsen E. One-
tribute to the growth of knowledge for the practice on-one peer support and quality of life for breast cancer
of nursing. patients. Patient Educ Couns 1998;35(2):89-100.
22. Vachon MLS, Lyall WAL, Rogers J, Freedman-Letofsky K, Free-
The authors thank Stanley Nattel, MD, and Nancy man SJJ. A controlled study of self-help intervention for wid-
Frasure-Smith from the Montreal Heart Institute and ows. Am J Psychiatry 1980;137(11):1380-84.
Evelyn Adams from the University of Montreal for their 23. Stewart MJ, Doble S, Hart G, Langille L, MacPherson K. Peer
critical review of the manuscript. The contributions of visitor support for family caregivers of seniors with stroke. Can
J Nurs Res 1998;30(2):87-117.
Camille Koury, Gérald Laplante, and Richard Larouche 24. Rakoczy M. The thoughts and feelings of patients in the wait-
(as former patients who participated in the support ing period prior to cardiac surgery: a descriptive study. Heart
interventions) are also gratefully acknowledged. Lung 1977;6(2):280-7.
25. King KB. Measurement of coping strategies, concerns, and
emotional response in patients undergoing coronary artery
bypass grafting. Heart Lung 1985;14(6):579-86.
REFERENCES 26. Kulik JA, Mahler HIM. Effect of preoperative roommate assign-
ment on preoperative anxiety and recovery from coronary-
1. Heart and Stroke Statistical Update for 1996. American Heart bypass surgery. Health Psychol 1987;6(6):525-43.
Association, Dallas, Texas, 1999. 27. Vaca KJ, Lohmann DP, Moskoff ME. Cardiac surgery in the

HEART & LUNG VOL. 29, NO. 6 399

Peer support for male cardiac surgery patients Parent and Fortin

octogenarian: nursing implications. Heart Lung 1994;23(5): 34. Perlmutter J, Myers JL. A comparison of two procedures for
413-422. testing multiple contrasts. Psychol Bull 1973;79(3):181-84.
28. Christopherson B, Pfeiffer C. Varying the timing of information 35. Beckie T. A supportive-educative telephone program: impact
to alter preoperative anxiety and postoperative recovery in on knowledge and anxiety after coronary artery bypass graft
cardiac surgery patients. Heart Lung 1980;9(5):854-61. surgery. Heart Lung 1989;18(1):46-55.
29. Festinger L. A theory of social comparison processes. Hum 36. Jillings CR. Phases of recovery from open heart surgery. Heart
Relations 1954;2:117-40. Lung 1978;7:987-94.
30. Bergeron J, Landry M, BJlanger D. The development and vali- 37. Best DG. The perceptions of stressors in coronary artery
dation of a French form of the State-Trait Anxiety Inventory, In: bypass graft patients. Can J Cardiovasc Nurs 1992;3(2-3):5-12.
Spielberger R, Diaz-Guerrero, editors. Cross-cultural anxiety. 38. Tack BB, Gilliss CL. Nurse-monitored cardiac recovery: a
New York: Halsted Press/Wiley; 1976. p. 41-50. description of the first 8 weeks. Heart Lung 1990;19(5):491-9.
31. Jenkins LS. Self-efficacy expectation scales and activity check- 39. Guluanick M. Is phase 2 cardiac rehabilitation necessary for
lists for selected cardiac recovery behaviors. University of Wis- early recovery of patients with cardiac disease? A randomized
consin-Milwaukee; 1989. p. 1-18. controlled study. Heart Lung 1991;20(1):9-15.
32. Robichaud-Ekstrand S, Haccoun, Millette. Une methode pour 40. Webber KS. The role of a health care professional in the evo-
faire valider la traduction d’un questionnaire. Can J Nurs Res lution of a self-help group. Can J Cardiovasc Nurs 1994;5(2):
1994;26(3):77-87. 30-3.
33. SPSS Inc. SPSS for Windows, release 9.0. Chicago: SPSS, 41. Winterhalter JG. Group support for families during the acute
Inc; 1993. phase of rehabilitation. Holist Nurs Pract 1992;6(2):23-31.

RECEIVE TABLES OF CONTENTS BY E-MAIL

To receive the tables of contents by e-mail, sign up through our web site at
http://www.mosby.com/hrtlng
Choose E-mail Notification.
Simply type your e-mail address in the box and click the Subscribe button.
Alternatively, you may send an e-mail message to
[email protected].
Leave the subject line blank and type the following as the body of your message:
subscribe hrtlng_toc.
You will receive an e-mail to confirm that you have been added to the mailing list.
Note that table of contents e-mails will be sent out when a new issue is posted
to the web site.

400 NOVEMBER/DECEMBER 2000 HEART & LUNG