In the United States, 1 in 2.9 women die of cardiovascular disease (CVD).1 Studies indicate that 64% of the women who die suddenly of coronary heart disease have no previous symptoms and that when compared with men, women have a higher risk of dying from a cardiac event, particularly during their first cardiac episode.1–3 Among hospital discharges, CVD continues to rank first in all disease categories involving women.1
The literature suggests that CVD morbidity and mortality in women may be attributed to their delay in seeking treatment. Lefler4 suggests that this delay can be characterized within 1 of 2 categories: gender bias from within and gender bias within the healthcare system. Gender bias from within refers to women who generally do not perceive themselves as susceptible to heart disease, do not recognize subtle noncardiac symptoms (discomfort from jaw pain or indigestion) as serious or cardiac in nature, and fail to call 911 or seek prompt medical attention.4 This group of women may not be aware of CVD risk factors. A study indicated that most women readily identified smoking (44%) and family history (40%) as CVD risk factors, but a small percentage seem to lack the ability to identify other risk factor such as high blood pressure (5%), cholesterol (14%), obesity (15%), and diet (16%) as risk factors.5 Such behavior suggests lack of knowledge and/or motivation to act on information about heart disease risk and prevention. Gender bias from within the healthcare system refers to the role played by healthcare providers who do not perceive atypical symptoms in women with the same urgency when men present with the classic symptoms of coronary heart disease.6–8 Many primary care physicians are not taking the initiative to perform routine CVD health assessment, health promotion, or preventive counseling, and corresponding treatment is often inadequate and not based on recommended guidelines.3,6,9 Related factors include lack of time to teach, lack of reimbursement for prevention and counseling on lifestyle interventions, limited time for patient visits, and the lack of insurance coverage.6,9–13 Thus, many women leaving a physician’s office or discharged from the hospital may likely go home without adequate advice from their healthcare provider (physician) on CVD risk and prevention.14 This is unfortunate considering that educating about risk factors through lifestyle intervention is an effective tool in CVD risk prevention and that spending even 3 minutes in counseling a patient about lifestyle modifications can be very rewarding.11
Government agencies, national professional organizations, and private corporations have collaborated in launching educational initiatives and media messages educating both women and healthcare professionals about the imminent risk of CVD and their role in risk prevention.15 Despite these efforts, only about 54% of women surveyed are aware that heart disease is a major threat to their health.16
As the nation’s largest healthcare profession, nurses’ ubiquitous presence in the hospital setting puts them in an ideal position to provide female patients with the constant and consistent message on heart health and risk prevention. With about 56% working directly with patients,17 nurses can make a difference in increasing women’s awareness of the risk of heart disease. A study indicated that nurses’ constant proximity to patients resulted in more favorable outcomes from counseling interventions on smoking compared with other healthcare providers.18 Checking patients’ blood pressure, discussing laboratory reports, and giving out medications are just a few of such seemingly rote nurse-patient interactions that could trigger teachable moments to discuss CVD risk factors and promote guideline-based lifestyle modifications.
Another reason why nurses are ideally placed in CVD risk and prevention education is their educational background and training. Nursing curriculums emphasize health promotion, prevention, patient education, communication skills, and counseling behaviors more so than educational curricula of other healthcare providers.19
However, little is known about staff nurses’ attitudes, beliefs, and perceptions toward CVD risk and preventive education while caring for female patients. Investigating their attitudes, perceptions, and other factors associated with their behavioral intentions to teach and counsel female patients about CVD risk and prevention is the first step in developing meaningful strategic plans for nurses to play a pivotal role in heart disease risk education especially among female patients.
Icek Ajzen’s Theory of Planned Behavior Plan (TPB) is useful in predicting a wide range of behaviors and behavioral intentions in patients, healthy populations, and healthcare professionals, including nurses.20–24 The TPB asserts that behavioral intention is the primary determinant or precursor to performing a desired or target behavior with an assumption that individuals consider all information, including their personal beliefs, their environment, and any personal resources available, before performing a target behavior.20–22,24 Performance of a target behavior can be explained or predicted by 3 main factors, constructs, or behavioral determinants: attitudes, beliefs of subjective norms, and beliefs of perceived behavioral control.20–22,24 In this study, the target behavior is nurses’ educating female patients (during teachable moments) about heart disease risk and prevention. Attitudes refer to the nurse’s favorable and unfavorable cognitive and affective perceptions toward educating female patients in their care about heart disease risk and prevention.20–22,24 Subjective norms are nurses’ beliefs and perception of how significant others or influential others will value their performance of the target behavior.20–22,24 Perceived behavioral control refers to nurses’ perceptions of whether the target behavior (educating their female patients on CVD risk and prevention) is an easy or difficult task.20–22,24 The Figure is a schematic representation of the TPB.
The TPB literature is lacking on nurses’ intentions to practice CVD risk and prevention education, particularly in female patients. However, a few studies with similar theoretical underpinnings provided insight and direction on the theory’s applicability to this research study.
Nash et al26 confirmed the effect of attitudes, subjective norms and perceived behavioral control beliefs on nurses’ intentions to assess patients’ pain. In describing pediatric nurses’ intentions in fever management (use of antipyretics), Walsh et al27 suggested that nurses’ SN seemed to be a more influencing factor. A study by Kortteisto et al28 on a target population of physicians, nurses, and other healthcare professionals showed that the strongest factor affecting physicians’ use of clinical guidelines in practice was perceived behavioral control beliefs, whereas beliefs of subjective norms were the strongest factor among the nurses. The study of Limbert and Lamb23 indicated subjective norms as the strongest predictor of physician use of asthma treatment guidelines. Similarly, the studies of Pessoa-Silva et al29 and O’Boyle30 also suggested the importance of the opinions of superiors (SN) among healthcare workers to perform personal hand hygiene (target behavior).
Other variables may be helpful in understanding the TPB theoretical constructs in relation to behavioral intention24; therefore, specific nurses’ professional attributes (extraneous variables) were selected and included in survey. A nurse’s background can affect patient care outcomes.31,32 Years of professional experience is another attribute that can affect nurses’ attitudes, beliefs, and perceptions, as suggested by Benner33 on role experiential learning as essential in the growth process and knowledge acquisition. Membership in professional organizations may also add to nurses’ educational and knowledge base affecting practice behavior intentions. Professional nursing associations such as the American Nurses’ Association often communicate to the membership values that are central to societal health.34 In addition, professional associations have educational journals and offer workshops that provide nurses with information about evidence-based guidelines of care. Other factors with potential effects on nurses’ attitudes, subjective norms and perceived behavioral control beliefs include time constraints and staffing issues (nursing shortage),35,36 which may diminish nurses’ abilities perceived behavioral control to provide timely CVD risk and patient education to female patients.
The primary aim of this study was to explore and describe attitudes, beliefs and perceptions associated with staff nurses’ practice intentions to educate female patients about heart disease risk and prevention, using the TPB as the study framework. The secondary aim was to determine if selected professional nurses’ attributes were also associated with their practice intentions to educate women on heart disease risk and prevention. The research questions posited for the study were as follows:
- Are nurses’ attitudes, subjective norms and perceived behavioral control beliefs each significantly associated with their practice intentions to provide heart disease risk and prevention education?
- Which of the 3 factors have the most significant association with nurses’ practice intentions to provide heart disease risk and prevention education?
- Does a relationship exist between selected nurses’ professional attributes (basic educational nursing education, highest educational nursing education, years of nursing practice experience, professional organization membership, knowledge of heart disease risk in women, and knowledge of the American Heart Association [AHA] evidence based-guidelines on CVD prevention among women) and their practice intentions (as high intenders vs low intenders) to provide heart disease risk and prevention education?
Design, Sample, and Setting
This study is cross-sectional, exploratory, descriptive, and correlational in design. Study participants completed a self-report survey questionnaire. The target population consisted of 337 registered nurses (RNs) in telemetry and medical surgical units of a community hospital in southern New Jersey, providing direct patient care (full-time, part-time, or per diem). Nurses at least 18 years of age and in practice as a nurse for at least 6 months were eligible to participate in the study. Nurses were excluded from the study if they were (a) involved or have been involved in any research study with female patients, (b) in managerial positions (ie, head nurse, unit manager, unit director) in the clinical setting, and (c) diagnosed with heart disease by their healthcare providers. These exclusion criteria controlled any possible bias and effect on attitudes, subjective norms, perceived behavioral control beliefs, and intentions.
Measurement of Attributes, Attitudes, Perceptions, and Practice Intentions
The Nurses Educating Women About Cardiovascular Disease (NEWCVD) Questionnaire was developed by the research investigator to gather data on nurses’ attitudes, beliefs of subjective norms and perceived behavioral control, and intention to provide heart disease risk and prevention education while caring for female patients. According to Ajzen, each behavioral intention is unique; therefore, a survey instrument using the TPB as its framework should be developed specifically for the target behavior of the study.37 The instrument collected data on demographic information as well as selected professional attributes.
Development of the survey questionnaire items was based on the following: literature about the TPB, the theorist’s guidelines on developing questions,37 sample questions of studies using the TPB, the literature on factors affecting nurses as patient educators,38 an instruction manual on questionnaire development using the TPB,39 and the investigator’s background working with staff nurses in her role as an inpatient cardiac rehabilitation educator.
The instrument is a 63-item self-administered survey questionnaire composed of 4 subscales on attitudes, subjective norms, perceived behavioral control, and intention. Most of the questions use a 7-point Likert scale from strongly agree (7) to strongly disagree (1). Studies in the related literature used similar rating scales, with the 7-option response as most often recommended in TPB literature.3,28,39
Instrument Validation and Reliability Testing
A panel of content experts (7) was chosen to help establish the face validity and content validity of the instrument; all nurse educators had a doctoral degree with clinical backgrounds in at least 2 or more of the following: women’s health, adult health, cardiovascular health, health promotion, school health, and adult critical care. For instrument validation, 5 to 10 experts are recommended, with a range up to 10.40,41
The panel was asked to evaluate each question based on the representativeness of the item within the theoretical construct’s definition and the clarity of the item. Each item was rated on a scale of 1 to 4 for representativeness and clarity, with 1 indicating the item is not clear or not representative of the theoretical construct and 4 indicating clarity and representativeness.41 The Content Validity Index (CVI) was calculated based on the relevance or the representativeness of the measure.41
The CVI for each item was calculated by counting the number of experts who rated the question item as 3 or 4 and dividing that by the total number of experts.
This is the proportion of content experts who rated the item as content valid.42
To estimate the CVI for each measure, the average CVI was calculated across the items for each measure. A CVI of 0.80 is recommended for new measures.43 The measure is considered adequate if calculated CVI is greater than 79% agreement; it is considered questionable if the CVI is 70% to 79% agreement, and it is unacceptable if the CVI is calculated at a less than 69% agreement.42
The resulting content validity scores for the subscales were as follows: attitudes, 0.95 (95% agreement); subjective norms, 0.88 (88% agreement); perceived behavioral control, 0.98 (98% agreement); and intention, 0.85 (85% agreement). The total average CVI for the instrument is 0.915 (92% agreement). Feedback and comments from the expert panel were used to further refine the survey items. The TPB constructs in the NEWCVD Questionnaire were also evaluated for internal consistency reliability using Cronbach coefficient α. This measure is often used in Likert-type items that are summed for a composite score.44 A value of .70 to .80 has been noted as an acceptable value for Cronbach α,45 although according to Kline, psychological constructs (such as the TPB constructs) can often be observed to be below .70 owing to the inherent diversity of such type of constructs.46 The researcher must then exercise caution regarding decisions based on the reliability guidelines.47 To assess reliability, Cronbach α was computed on the items in each of the summated scales of the NEWCVD Questionnaire. For attitudes, Cronbach α was .81, indicating good reliability; for subjective norms, Cronbach α was .70, suggesting reasonable internal consistency; for perceived behavioral control, Cronbach α was .61, indicating minimally adequate reliability. Based on Kline’s assertions,46 none of the items in the PBC scale was eliminated.
After approvals from the institutional review boards were obtained, access to the study participants was also granted by the directors of nursing education and research of the participating institution. The hospital’s research liaison nurse was the research investigator’s main contact for the study. Research packets were given to and distributed by the research liaison nurse. Each packet contained a research participation request letter (the recruitment letter) stating the purpose of the research study and indicating that participation is voluntary and that confidentiality and participant anonymity will be maintained throughout the study. Participant eligibility was determined by the completion of 5 questions in the research participation letter. Eligible participants were requested to complete the survey questionnaire. Inside the research packet was the solicitation letter attached to the NEWCVD Questionnaire. The solicitation letter reiterated the content of the research participation request letter and also indicated that the return of the completed questionnaire implied the nurses’ consent to participate in the study. A Go Red for Women heart pin was included in the packet. A 9 × 12 envelope marked “Survey” was included in the packet with instructions on a 2 × 4 white label on the return of the completed questionnaires in designated drop boxes. The research investigator maintained no contact with the study participants throughout the data collection period. Communication and follow-up were limited to the research liaison nurse of the healthcare institution.
Power and Sample Size Determination
Based on Cohen’s48(p93) definition of a moderate effect as r = 0.30, the study (2-tailed test with an α of .05) would need 84 study participants to obtain a power of 0.80. According to Cohen, 0.80 is the desired power value if no previous data are available: the “desired power convention is offered with the hope that it will be ignored whenever an investigator can find a basis in his substantive concerns in his specific research investigations to choose a value ad hoc.”46(p56)
Descriptive statistics were used to summarize demographic characteristics, personal attributes, professional data, and the scaled items obtained from the NEWCVD Questionnaire. Percentages and frequency distributions were used for nominal data (categorical/dichotomous). Likert scale responses were examined using measures of central tendency and skewness. In this study, Likert scale responses were treated as approximating continuous/interval data. Items assessing indirect measurements of the TPB constructs were not analyzed in this study. Data distributions were examined using histograms. Spearman’s ρ correlation was used to examine the association between direct measures of attitudes and intention, direct measures of SN and intention, and PBC and intention.
Chi-square tests were performed to test the null hypotheses of no association between each of the selected nurses’ professional attributes and practice intentions. All the data analyses were conducted using Statistical Package for Social Sciences version 17 (SPSS, Inc, Chicago, Illinois).
A total of 337 research packets were distributed and 226 were returned. Most of the returned questionnaires were not completed (127, 56.19%); 5 respondents (2.21%) had history of heart disease, and 3 respondents (1.32%) were nurse managers. Both are study exclusion criteria. Ninety-one of the returned packets were deemed eligible for inclusion in the data analyses (return rate of 40.26%).
Tables 1 and 2 describe the personal and professional attributes of the study participants. The participants’ ages ranged from 22 to 59 years. Gender distribution of the sample was 92.3% women and 7.7% men. Racial and ethnic distribution of the research study participants was composed of 2 major groups: white, non-Hispanic (56%) and Asian or Pacific islanders (35.2%).
Results in Table 2 indicate that the initial nursing degree preparation for most nurse respondents was an associate degree in nursing (49.5%) compared with those with bachelor’s degrees (40.7%). However, the highest degree obtained among the participants is a bachelor’s degree (47.3%). For other professional attributes, a significant number of participants (65.9%) did not belong to any professional organization, and most worked full-time. More than half (60.4%) were aware of the risk of heart disease among women based on scoring correctly on all 4 questions about the topic, and a little more than half of the respondents (52.7%) responded that they were aware of the AHA guidelines of care for CVD prevention among women.
To address research questions 1 and 2, the mean scores for each of the direct measures (attitudes, subjective norms and perceived behavioral control beliefs) were calculated. The descriptive data summary on the subscale items (assumed to be scale/normal data in this study) for attitudes, subjective norms and intention did not meet the criteria for normality, revealing skewed distributions (>−1 or +1): attitudes = −1.456, subjective norms = −1.045, and intention = −1.112; perceived behavioral control had a normal distribution and a skew value of −0.114. (Mean/mode scores were as follows: attitudes = 30/32, subjective norms = 17/18, perceived behavioral control = 16/16, and intention = 18.5/19.)
Spearman ρ correlation was used to test the association between each of the direct measures and intention: the value for attitudes and intention was 0.315 (P < .01); subjective norms and intention, 0.823 (P < .01); and perceived behavioral control and intention, 0.500 (P < .01). The findings (Table 3) indicate that a strong association exists between staff nurses’ practice intentions and their attitudes, subjective norms and perceived behavioral control beliefs toward educating women about heart disease risk and prevention, with subjective norms having the strongest association.
To address research question 3, cross-tabulations (χ2 statistic) were used for each professional attribute and the intention score, which was dichotomized as “high intender” and “low intender.” Low intenders were study participants who responded 0% to 50% to the following survey question: “In the next month, approximately what percentage of your women patients do you expect to educate about heart disease risk and prevention? Circle one number: 0%, 25%, 50%, 75%, 100%.” Participants who circled 75% to 100% were grouped as high intenders. Table 4 summarizes the findings on the effect of each professional attribute on practice intention. Using the χ2 statistic, the study findings revealed a significant association between nurse’s knowledge of evidence-based guidelines on prevention of CVD among women and their intention to educate female patients about heart disease risk and prevention. No association was observed with the other selected attributes.
Most study participants were women, 30 to 49 years old (median age, 42 years). The National Sample Survey of Registered Nurses (NSSRN; 2008) shows a median age of 46 years, with women as the main gender distribution and the latter reflecting the historical dominance of women in the nursing profession.49 Most of the racial and ethnic distribution consisted of white, non-Hispanic (56%). This is consistent with national data. However, the study demographics revealed an overrepresentation of Asian or Pacific islanders (35.2%) within the second group, contrary to national data, which describe a racial/ethnic distribution of the other group of nurses to consist of smaller almost equal subgroups composed of black/African American, non-Hispanic, 4.6%; Asian or Pacific islander non-Hispanic, 3.3%; Hispanic, 1.8%; American Indian/Alaskan Native, 0.4%; and 2 or more racial backgrounds, 1.5%.50 This inconsistency could perhaps be attributed to the suburban location of the hospital setting, which attracts both the white non-Hispanics and the Asian or Pacific islanders.
The highest degree obtained among the participants is consistent with the NSSRN report that “a larger percentage of RNs whose highest education is a bachelor’s degree are employed in hospitals” as compared with RNs with an associate degree in nursing. Also confirmed was the national trend that in most employment settings, nurses had either an associate or a baccalaureate degree as their highest nursing or nursing-related educational preparation.49
Although most TPB studies suggest the predominant association between PBC and the target behavior,23 the primary finding of this study indicated a strong association between the influence of subjective norms on nurses’ practice intentions to educate female patients about heart disease risk and prevention. Similar findings were observed on TPB studies on healthcare professionals’ practice behaviors, presented in the literature review.23,27,29,30 On closer scrutiny, the significant effect of subjective norms in this study and previous studies suggests that healthcare professionals with favorable perceptions of a specific practice behavior that is associated with an “influential other” (a person, organization, policy, guideline, standard of care, or evidence-based practice) will likely have strong intentions to perform the target behavior. Worth noting is that educating women about heart disease risk and prevention is linked with the AHA evidence-based guidelines.
The predominant effect of subjective norms suggests 4 essential components: (1) select external and social forces (influential others) within the study participants’ environment, set up standards and norms of practice expectations; (2) nurses value the opinion of these external and social forces; (3) these external and social forces value or expect performance of the target behavior, and (4) study nurse participants indicate high intentions to do the behavior because of the value and expectations from those influential others.
Among the item questions in the survey instrument (NEWCVD Questionnaire), the following were included as “significant or influential others” in the subjective norms subscale questions: physicians, cardiologists, nurse managers, nursing administration, coworkers, patients, and patients’ families and significant others, and 2 questions note the AHA and the Joint Commission.
Examples of questions for the subjective norms subscale (influential or significant others) are the following:
- A cardiologist, whose opinions I value, expects me to educate my patients on heart disease risk and prevention.
- Hospital administration expects me to educate my patients on heart disease risk and prevention.
- The Joint Commission expects me to educate my patients on heart disease risk and prevention
Examples of questions for the perceived behavioral control subscale are the following:
- I am confident of my abilities to educate my patients about heart disease risk and prevention.
- I am more likely to educate patients who ask about heart disease risk and prevention education.
The strong influence of nurses’ subjective norms on practice intention may also be due to a particular attribute or attributes within the organization that helped shape their beliefs, perceptions, and motivations (intentions) for the target behavior. One such attribute could be the institution’s history of Magnet status recognition, the highest and most prestigious distinction that healthcare institutions can receive for nursing excellence and high-quality patient care.51 To achieve this recognition, hospitals must demonstrate organizational strategies that promote excellence in professional nursing practice behaviors.52 The Joint Commission has similar expectations during hospital reaccreditation. It is therefore possible that both attributes, along with organizational approaches to its mission and vision,50 contributed to the findings. Organizational theory supports this influence of work environment and culture on behaviors of employees.53
The lesser association of attitudes and perceived behavioral control beliefs with intention could be explained by Ajzen’s assertions that “the relative importance of attitude, subjective norm, and perceived behavioral control in the prediction of intention is expected to vary across behaviors and situations.”20(p188) In situations where subjective norms influences are stronger (as in this study), a dampened effect on the target behavior by the remaining 2 variables may be evident in the results.22
The summary results on the attributes have implications for the participating healthcare institution. It appears that a large proportion of nurses are not aware of the guidelines on CVD prevention in women. Workshops on evidence-based guidelines for CVD prevention in women should be available to staff nurses on a regular basis. These sessions can serve as a constant reminder of the heightened need to apply evidence-based knowledge in the practice environment and can groom nurses to be champions of the AHA guidelines, particularly CVD prevention in women. Workshops on motivational interviewing can be a worthwhile initiative and can enhance positive perceptions of control (“I can find time to teach”) for the target behavior.
Most nurses in this study did not belong to professional organizations. Organizational initiatives could include (1) encouraging nurses to belong to professional organizations by reimbursing or subsidizing costly membership fees or underwriting attendance at professional conferences; (2) using information technology resources to show nurses what professional organizations ( ie, AHA, National Heart, Lung, and Blood Institute, and the Preventive Cardiovascular Nurses’ Association) have to offer to members, patients (education tools), and the community; and (3) ensuring training and availability of resources and tools for teaching about heart disease risk factors. The latter initiative may boost nurses’ perceptions of control over the target behavior.
Understanding staff nurses’ attitudes, perceptions, and intentions to educate female patients about heart disease risk and prevention can impact nursing education. Curricular threads for entry-level nursing practice must include developing leadership roles in disease management models of care led by nurses. Including these in the practicum experiences of students may be beneficial. In addition, practicum leadership roles that integrate collaborative experiences with different healthcare professionals should be encouraged. With the current and growing emphasis on CVD risk preventive healthcare, it is likely that more healthcare professionals, no matter the specialty, will share in the responsibility in primary and secondary prevention or delaying or modifying a cardiac event or outcome.54
Although most of the study participants reflected major characteristics from the 2008 national survey (NSSRN),49 generalizability of the study is limited because participants were limited to 1 type of hospital setting and the racial distribution was not consistent with national data. This study should be repeated in other types of clinical settings, such as hospitals that have not yet achieved Magnet recognition or in other settings with ethnic distributions consistent with NSSRN data. Measurement error associated with response set bias is another limitation. Given the results indicating subjective norm beliefs to have the strongest association, nurses who chose to participate may already have stronger motivations to complete the questionnaire; they may be more responsive to the effect of influential others in the hospital environment compared with the nonresponders. Similarly, self-report responses may be biased based on what the study participant thinks should be the desirable or expected response. The NEWCVD Questionnaire is another limitation. This instrument was developed by the principal investigator with content validity by 7 experts. Additional tests of validity and reliability are warranted to further the instrument’s applicability to other nurse populations. Redeveloping the instrument to be shorter and incorporating case scenarios or clinical vignettes may be considered in future studies. Comparing studies of intention with actual observation or documentation of the performance of the target behavior will add to the validity and reliability of the instrument.
Research literature is replete with data on heart disease as the leading cause of death in women. The effects of prevention (whether primary or secondary) and following recommended lifestyle changes on cardiac events are also well known. However, knowledge of heart disease risk and prevention is still lacking among most women in the United States. All healthcare professionals must take conscious and conscientious efforts to educate women in their care about heart disease risk and prevention measures. Nurses, particularly those in the clinical setting, play a pivotal role in heart disease risk prevention education. A better understanding of factors associated with their practice intentions to educate women about heart disease risk and prevention is one essential step toward this challenge.
The study findings indicate that factors such as attitudes, subjective norms and perceived behavioral control beliefs are associated with nurses’ practice intentions to educate female patients about heart disease risk and prevention. Subjective norms or perceptions of significant others’ expectations regarding a target behavior appear to have the most influence on nurses’ intentions to educate female patients about heart disease risk and prevention. Perceived behavioral control was the second variable with the strongest association.
Healthcare organizations and nursing curriculums must develop creative strategies to heighten nurses’ attitudes, subjective norms and perceived behavioral control beliefs to educate female patients about heart disease. Clearly, as the largest group of healthcare professionals in the healthcare setting, nurses’ role in this target behavior could contribute to an incremental increase in US women’s awareness of heart disease risk factors and prevention strategies.
What’s New and Important
Summary of findings
- Staff nurses’ subjective norms or their perceptions of the expectations of influential others are highly associated with their practice intentions to educate female patients about heart disease risk and prevention.
- An association was found between staff nurses’ knowledge of the evidence-based guidelines for CVD prevention among women and their intention to educate female patients about heart disease risk and prevention.
Implications for practice
- Healthcare institutions should incorporate more structured strategies that use staff nurses’ ubiquitous presence and opportunities for teachable moments, to educate female patients about heart disease risk and prevention.
- Strategies must not only be based on the effect of subjective norms but also enhance the effect on staff nurses’ attitudes and perceived behavioral control toward educating women about heart disease risk and prevention.
- Continuing staff education for nurses about evidence-based guidelines on CVD disease risk and prevention in women is recommended.
1. Roger VL, Go AS, Lloyd-Jones DM, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease
and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011; 123: e18–e209.
2. Lerner DJ, Kannel WB. Patterns of coronary heart disease
morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J. 1986; 111 (2): 383–390.
3. King KB, Mosca L. Prevention of heart disease
in women: recommendations for management of risk
factors. Prog Cardiovasc Nurs. 2000; 15 (2): 36–42.
4. Lefler L. The advanced practice nurse’s role regarding women’s delay in seeking treatment with myocardial infarction. J Am Acad Nurse Pract. 2000; 14 (10): 449–456.
5. Fernandez RS, Salamonson Y, Griffiths R, Juergens C, Davidson P. Awareness of risk
factors for coronary heart disease
following interventional cardiology: a key concern for nursing practice. Int J Nurs Pract. 2008; 14 (6): 435–442.
6. Heidrich J, Behrens T, Raspe F, Keil U. Knowledge and perception of guidelines and secondary prevention of coronary heart disease
among general practitioners and internists. Results from a physician survey in Germany. Eur J Cardiovasc Prev Rehabil. 2005; 12 (6): 521–529.
7. Karthik S, Tahir N, Thakur B, Nair U. Risk
factor awareness and secondary prevention of coronary artery disease: are we doing enough? Interact Cardiovasc Thorac Surg. 2006; 5 (3): 268–271.
8. Naidoo VV, Fox KM. Fashioning a new approach to coronary care in women. Heart. 2006; 92 (3 suppl):1.
9. Burke LE, Fair J. Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions. J Cardiovasc Nurs. 2003; 18 (4): 256–266.
10. Wenger NK, Manson J, Shlipak M. Heart disease
in older women. Contemp Ob Gyn. 2002; 8: 69–82.
11. Eckel RH. Presidential address. Preventive cardiology by lifestyle intervention: opportunity and/or challenge? Circulation. 2006; 113 (22): 2657–2661.
12. Mosca L. Overcoming barriers to better lipid management in women. Adv Stud Med. 2002; 2 (11): 416–421.
13. Mosca L, Merz NB, Blumenthal RS, et al. Opportunity for intervention to achieve American Heart Association guidelines for optimal levels in high risk
women in managed care setting. Circulation. 2005; 111 (4): 488–493.
14. Bello N, Mosca L. Epidemiology of coronary heart disease
in women. Prog Cardiovasc Diseases. 2004; 46 (4): 287–295.
15. Pregler J, Freund KM, Kelinman M, et al. The heart truth professional education campaign on women and heart disease
: needs assessment and evaluation results. J Womens Health. 2009; 18 (10): 1541–1547.
16. Mosca L, Mochari-Greenberger H, Dolor RJ, Newby LK, Robb KJ. Twelve- year follow-up of American women’s awareness of cardiovascular disease risk
and barriers to heart health. Circ Cardiovasc Qual Outcomes. 2010; 3 (2): 120–127.
18. Andrews JO, Tingen MS, Waller JL, Harper RJ. Provider feedback improves adherence with AHCRP smoking cessation guidelines. Prev Med. 2001; 33 (5): 415–421.
19. Zapka JG, Pbert L, Stoddard AM, Ockene JK, Goins KV, Bonollo D. Smoking cessation and smoking counseling with pregnant and post-partum women: a survey of community health center providers. Am J Public Health. 2000; 90 (1): 78–84.
20. Ajzen I. The Theory of Planned Behavior
. Organ Behav Hum Dec Process. 1991; 50: 179–211.
22. Armitage C, Conner M. Efficacy of the Theory of Planned Behavior
: a meta- analytic review. Br J Soc Psychol. 2001; 40 (4): 471–499.
23. Limbert C, Lamb R. Doctors’ use of clinical guidelines: two applications of the Theory of Planned Behavior
. Psychol Health Med. 2002; 7 (3): 301–310.
24. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall Inc; 1980.
26. Nash R, Edwards H, Nebauer M. Effect of attitudes, subjective norms and perceived control on nurses’ intentions to assess patients’ pain. J Adv Nurs. 1993; 18: 941–947.
27. Walsh AM, Edwards HE, Courtney MD, Wilson JE, Monaghan SJ. Fever management: paediatric nurses’ knowledge, attitudes, and influencing factors. J Adv Nurs. 2005; 49 (5): 453–464.
28. Kortteisto T, Kaila M, Komulainen J, Mantyranta T, Rissanen P. Healthcare professionals’ intentions to use clinical guidelines: a survey using the Theory of Planned Behavior
. Implement Sci. 2010; 5: 51. doi: 10.1186/1748-5908-5-51.
29. Pessoa-Silva CL, Posfay-Barbe K, Pfister R, et al. Attitudes and perceptions toward hand hygiene among health care workers caring for critically ill neonates. Infect Control Hosp Epidemiol. 2005; 26 (3): 305–311.
32. Aiken L, Clarke SP, Cheung R. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003; 290 (12): 1618–1623.
33. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing; 1984.
34. American Nurses’ Association. Code of Ethics for Nurses With Interpretative Statements. Silver Springs, MD: American Nurses’ Association; 2001.
35. Estabrooks C, Floyd JA, Scott-Findlay S, O’Leary K, Gushta M. Individual determinants of research utilization: a systematic review. J Adv Nurs. 2003; 43 (5): 506–520.
36. Pravikoff D, Tanner A, Pierce S. Readiness of U.S. nurses for evidence based practice. Am J Nurs. 2005; 105 (9): 40–51.
38. Marcum J, Ridenour M, Shaff G, Hammons M, Taylor M. A study of professional nurses’ perceptions of patient education. J Contin Educ Nurs. 2002; 33 (3): 112–118.
39. Francis JJ, Eccles MP, Johnston M, et al. Constructing Questionnaires Based on the Theory of Planned Behavior
. New Castle, UK: Center for Health Services Research; 2004.
40. Lynn M. Determination and quantification of content validity. Nurs Res. 1986; 35 (6): 382–385.
41. Rubio DM, Berg-Weger M, Tebb S, Lee E, Rauch S. Objectifying content validity: conducting a content validity study in social work research. Soc Work Res. 2003; 27 (2): 94–104.
42. Hyrkas K, Appleqvist-Schmidlechmer K, Oksa L. Validating an instrument for clinical supervision using an expert panel. Int J Nurs Stud. 2003; 40: 619–625.
43. Davis L. Instrument review: getting the most from your panel experts. Appl Nurs Res. 1992; 5: 194–197.
44. Witte RS, Witte J. Statistics. Hoboken, NJ: John Wiley & Sons, Inc; 2004.
45. Field A. Discovering Statistics Using SPSS. 3rd ed. Thousand Oaks, CA: Sage Publications Inc; 2009.
46. Kline P. The Handbook of Psychological Testing. 2nd ed. London, England: Routledge; 1999.
47. Cortina JM. What is coefficient alpha? An examination of theory and applications. J Appl Psychol. 1993; 78 (1): 98–104.
48. Cohen J. Statistical Power Analysis for the Behavioral Sciences. New York, NY: Taylor & Francis; 1988.
50. Curry L, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med. 2011; 154 (6): 384–390.
51. Drenkard K. Going for the gold: the value of attaining Magnet recognition. Am Nurse. 2010; 5 (3): 50–52.
52. Manojlovich M. Predictors of professional nursing practice behaviors in hospital settings. Nurs Res. 2005; 54 (1): 41–47.
53. Klingle R, Burgoon M, Afifi W, Callister M. Rethinking how to measure organizational culture in the hospital setting: the hospital culture scale. Eval Health Prof. 1995; 18 (2): 166–186.
54. Merz NB. Training for primary prevention of CVD fits broader spectrum. Cardiology. 2009; 38 (10): 4–5.
Keywords:© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
heart disease; prevention education; risk; theory of planned behavior