Commentary on Smith J &amp; Liles C (2007) Information needs before hospital discharge of myocardial infarction patients: a comparative, descriptive study. <i>Journal of Clinical Nursing</i> 16, 662–671

As Smith and Liles (2007) highlight in this well-written report, the subject of patient education has been thoroughly discussed within nursing academic literature over the past three decades and indeed a plethora of literature exists on the specific topic of cardiac patient information needs. This may lead the reader to question the particular relevance and importance of this study. However, in setting out the rationale for the study, the authors rightly point out that the issue of age-related information needs and the influence of employment status are professed omissions from the literature in question. With many recent contributions to the literature (Hughes 2000, Timmins & Kaliszer 2003), including a comprehensive literature review on the topic (Scott & Thompson 2003), the identification of these gaps ultimately warranted the addition of this contribution to the growing body of literature on the topic. However, in light of criticisms of previously used instruments and approaches (Hughes 2000, Scott & Thompson 2003, Timmins & Kaliszer 2003), it may be useful to examine the paper further with reference to its distinct contribution to the evidence base for practice in this area, and its ultimate ability to close the identified gaps within in the literature. As pointed out by the authors, there is very little empirical evidence that examines information needs from the perspective of age-related information needs, and in particular from the perspective of the older person. However, from the bulk of literature that does exist, clearly an individualised needs-based approach is advocated (Scott & Thompson 2003), which would of necessity take into account the differing needs, related to age or other variables. This recommendation for person-centred cardiac patient teaching abounds in the literature. However, the extent to which this recommendation is mere rhetoric or is undertaken in practice is unclear. In one sense, the paper by Smith and Liles adds very little to this plea for such an approach, although it might appear that, in their case, a more traditional approach to education may be in use. In addition, it appears that older persons are largely excluded from cardiac rehabilitation, which raises ethical issues that need to be addressed, but which are beyond the scope of this commentary. The study is firmly contextualised within a UK context, which is somewhat limiting with regard to this particular field, where there is much international collaboration and agreement on key issues. In their review of international literature, it is unclear why the findings some older key studies, but not others, are not referred to. Important omissions include the work of Karlik and Yarcheski (1987), Ashton (1997) and Chan (1990), or the seminal work of Gerard and Peterson (1984). Furthermore, it is somewhat puzzling why the authors’ theoretical framework used in the study predates the search period outlined (Mirka 1994). Scott and Thompson (2003) highlight the predominance of quantitative methodologies, favouring instead the use of qualitative methods. Although congruent with the study aim of description and comparison, no justification for the choice of a predominantly quantitative approach is given. This is surprising in light of previous recommendations. The use of the theoretical framework (Mirka 1994), which has been previously proposed as an educational framework for in-patient cardiac rehabilitation (Egan 1999), is both novel and interesting, in terms of its approach to adult learning and client responsibility. However, I suspect that, like many other studies in this area (Gerard & Peterson 1984, Karlik & Yarcheski 1987, Chan 1990, Ashton 1997), a theoretical framework is merely proposed and does not, in reality, provide any substantial direction to the study in question. The authors provide little evidence that the Mirka (1994) framework was used in this study to provide guidance to the data collection tool or data interpretation. A substantive section of the paper is devoted to the extrapolation of Mirka's principles, but with no distinct purpose or outcome. This seems to represent a missed opportunity, as Mirka has called for international collaborative projects in the field to test her framework in the practicum (Mirka, pers. comm., Laurentian University, Sudbury). Smith and Liles also fail to provide a clear justification for their choice of data collection instrument, although this may be defensible, as the focus of their study was not instrument testing or development. However, recent and quite specific criticisms of the instrumentation used in the field might have been addressed within such a justification or perhaps used to modify or adapt the tool used. Specifically, the Cardiac Patients Learning Needs Inventory (CPLNI) (Gerard & Peterson 1984, Turton 1998), which was used in several studies in this area, was found to be non discriminatory, with the majority of subject responses falling within the important or very important category (Timmins & Kaliszer 2003). This lack of sensitivity of this type of tool is also reflected in the present study, where subject responses tend to be located in the higher levels of importance. In common with the many researchers that previously used the CPLNI (Gerard & Peterson 1984, Karlik & Yarcheski 1987, Chan 1990, Wingate 1990, Ashton 1997), Smith and Liles attribute their findings to overall agreement with importance of the items, and not necessarily to any function of the instrument itself. However, this failure to adequately discriminate between categories makes comparison within the data difficult. For example, the lowest reported mean in this study is 2.58, indicating that subjects considered all statements as important. Hence, the suggestion that ‘people 65 and over appeared more interested in receiving information than those aged 64 and under’ appears unfounded given that all patients viewed all categories as important. Although reliability and validity of the instrument have been previously established, it may have been useful to re-establish content and construct validity within the current study context. First developed and tested in 1990 (Bubela et al. 1990), the instrument may require further refinement and testing, given the preponderance of more recent work in the field. Turton (1998), who performed the first pilot study of the CPLNI, made significant improvements to the tool after years of use, despite its rigour having been previously established (Timmins & Kaliszer 2003). Smith and Liles fail to explain the sample size of 20 patients; their study represents one of the smallest studies published in the field. Nor is their choice of sample population clearly outlined. Increasingly, patients presenting with a range of clinical signs and symptoms, including those characteristic of myocardial infarction, are subsequently diagnosed with acute coronary syndrome. In many cases, this syndrome achieves resolution with increasing use of primary angioplasty. Accordingly, the authors’ rationale for limiting their sample to patients with a diagnosis of myocardial infarction needs to be justified. The severity of the subjects’ condition (Gerard & Peterson 1984) is not alluded to, other than as an exclusion criterion, and therefore its influence as a dependent variable is not accounted for. This would have particular relevance when attempting to draw inferences with regard to age. Although the authors refer to potential differences between nurse and patient views on priority information needs, recent evidence suggests that these are now more congruent than considered heretofore (Timmins & Kaliszer 2003). The small sample size reduces confidence in procuring statistically significant findings, particularly when the results were only marginally significant. Further, some tentative conclusions regarding further information needs (such as driving and sources of support) of the sample are based on the qualitative comments of five patients only. In their discussion, the authors note that, in previous studies, no association was found between age and information needs. However, one study (Timmins & Kaliszer 2003) reported differences according to age. In contrast to Smith and Liles, Timmins and Kaliszer reported that the importance attached to statements related to physical activity decreased with increasing age (Timmins & Kaliszer 2003). While it appears that the authors place a little too much confidence in their findings, they nevertheless highlight an important yet under explored area of information needs of the older person in the period immediately before discharge following treatment for a myocardial infarction. Similar to women presenting with a myocardial infarction (O'Donnell et al. 2005), the older person may not present with stereotypical gender-associated symptoms, and it is therefore likely that their needs are not always met. The authors recognise limitations within their study, and do suggest the need for further studies, which are warranted. However, the proposed need for a study to evaluate changes in patients’ needs over time may not necessarily be warranted, as there is quite a lot of extant evidence relating to this particular aspect of need. Along with suggesting further topics of research, this paper, when placed in context with other work on the topic, makes a valuable contribution to the growing body of knowledge in this area.

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