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Special Section on Nursing Challenges and Solutions

The Effect of Care Pathways on Coronary Care Nurses: A Preliminary Study

Daghash, Hanan MMedSc, BScN; Abdullah, Khatijah Lim DClinP, MSc, RN, RM; Ismail, Muhammad Dzafir MBBS, MMedSc(Internal Medicine)

Author Information
doi: 10.1097/QMH.0000000000000336


Hospitals are complex environments where multidisciplinary health care professionals work interdependently to deliver care. The publication of To Err Is Human: Building a Safer Health System by the US Institute of Medicine (IOM, now the National Academy of Medicine (NAM)) and subsequent studies emphasized that the delivery of care is not error free and that medical error is a significant cause of death.1–3 Consequently, health care organizations face numerous challenges and obstacles in delivering safe, high-quality care in a manner that promotes professional well-being and overall satisfaction with work.

Extensive research is being conducted by researchers and clinical professionals to develop new approaches to increase awareness and enhance the use of evidence-based practices to improve the quality of care, patient safety, and the well-being of health care providers.4 A popular method of supporting evidence-based practices and improving the quality of care is through care pathways. Care pathways are defined as complex interventions for cooperative decision-making, organization, and standardization of expected care for a well-defined group of patients over a well-defined period.5 Care pathways are determined using 4 operational criteria6:

  1. A structured, multidisciplinary care plan;
  2. Translation of evidence-based practice into local structures;
  3. Algorithm or protocol frame utilization; and
  4. Labeled steps for a well-defined group of patients during a well-defined period.

The widespread use and prevalence of care pathways have been reported in hospitals in developed countries.7 Originating in the United States, care pathways have been used in health care since the 1980s. Care pathways are used widely in US health care settings; however, many consider US care pathways an option for managing pharmaceutical use, particularly specialty drugs.8 In the early 1990s, the concept was applied in the United Kingdom to increase efficiency and expand the use of guidelines in daily practice for clinical governance.9,10 Care pathways are used worldwide in different types of health care settings.7 They have been established in more than 80% of hospitals in the United States.4 In 1998, the United Kingdom National Survey reported that approximately 250 National Health Service (NHS) organizations were developing or employing care pathways.11 In 2018, the European Pathways Association (EPA), the world's largest care pathway professional organization, reported members in more than 50 countries, covering national health systems and social health insurance.12 According to Alashwal and Supriyanto,13 care pathways were introduced in Malaysia in 1999. Since then, 11 reports have been published.

A major drawback of using care pathways in Malaysia, the United States, and worldwide is the lack of evidence concerning designing and implementing them.13,14 Implementation strategies are poorly reported in the literature; hence, the best strategy for implementing a care pathway remains unclear.14,15 Most studies reported that care pathway implementation was based on staff education.16–20 In addition, the leader or manager was mentioned as the key for implementing care pathways.17–21 Identifying leaders or mentors could help encourage care pathway implementation after formal education. Moreover, Mcleod et al22 stated that the implementation phase is conducted through regular conferences for nurses and doctors and webinars to teach health care providers. Furthermore, Jabbour et al14 recommended implementing care pathways through the train-trainer model, e-education modules, posters, and reminders.

The benefits of care pathways include reduced hospital stays, maximized patient outcomes, increased patient satisfaction, reduced risk, and appropriately used resources.23–25 According to Evans et al,26 the positive impact of care pathways correlates with the involvement of health care providers and managers. Care pathways can impact the care process and collaboration among health care providers.27

Several studies have reported that care pathways improve multidisciplinary communication and collaboration27 and significantly improve teamwork.28–32 A multicenter study conducted by Aeyels et al33 showed improved teamwork processes among multidisciplinary care teams (doctors, nurses, allied health professionals, and others) after implementing a care pathway. It also increased knowledge,34 understanding of the respective roles, confidence, and decision-making ability.28,29,31,35 In addition, several studies found that care pathways improved nurses' autonomy,28,31,36 potentially increasing understanding of the respective roles, confidence building, and decision making.29,37 Thus, care pathways contribute to organized care processes and reduce burnout.32 However, care pathways create new roles and responsibilities, which could impact professional identities and relationships.38 According to the current literature review, most studies reported that care pathways positively impact teamwork.30–32,34,37 Moreover, one published study explored the impact of care pathways on burnout32 and 2 evaluated autonomy using the qualitative method.28,31 The current study aimed to close the research gap through a reliable and validated questionnaire to explore the impact of care pathways on teamwork, autonomy, and burnout among coronary care nurses.

The current study implements the ST-elevation myocardial infarction (STEMI) care pathway because STEMI was reported as having a higher incidence in Malaysia with predictable care routines.39 Furthermore, Hunter and Segrott38 suggested that care pathway development should focus on common conditions with predictable care routines based on patients' and nurses' outcomes. In addition, according to the Annual Report of the Acute Coronary Syndrome Registry (2014-2015), in Malaysia, the highest percentage of hospitalized patients admitted to the cardiac ward are STEMI patients at 46.1%, with the Malaysian proportional mortality rate of cardiovascular diseases at 36%.40 A systematic review reported that implementing an acute coronary syndrome care pathway helps organize care processes, decrease treatment delays, and improve patient outcomes without adverse consequences for patients or additional resources and costs. However, most studies focused on patients' clinical outcomes rather than health care provider outcomes.41 Furthermore, the care pathway success differs significantly between establishments depending on the support it receives from nurses and other health care providers.27 However, information regarding cardiac wards is lacking. Although evidence is growing concerning the impact of care pathways on professional identities and relationships, unintended consequences might occur,38 and little is known about how coronary care nurses respond to care pathways. Although most studies show improved health care provider performance in various settings,28,30–32,34,37 one study investigated the impact of a STEMI care pathway on teamwork processes.33 Therefore, evidence remains lacking regarding the conditions for which care pathways can be most effective for improving nurse and health care provider outcomes.

Among health care workers, nurses are the most likely to struggle with burnout symptoms.42 Recently, a meta-analysis on burnout involving 45 539 nurses in 49 countries across multiple specialties found that 11.23% of participating nurses experienced burnout.43 Nurses in Malaysia are vulnerable to a high burnout level.44 Furthermore, nurses in critical areas have consistently been at high risk of burnout because they perform specialized tasks for critically ill and highly dependent patients.45 Therefore, it is necessary to evaluate tools supporting clinical care that may reduce the burnout risk. This study elaborates on an important question: What is the effect of a care pathway on the autonomy, teamwork, and burnout levels among coronary care nurses in a tertiary hospital?



A preliminary study using a quasi-experimental, pre/posttest one-group design was conducted. Questionnaire surveys were conducted with a convenience sample of 37 registered nurses in the cardiac ward. The pretest survey was conducted at baseline before the intervention, and the posttest survey was conducted 4 months after dissemination of the care pathway.

Participants and study setting

This study was conducted in a 39-bed cardiac ward in a large tertiary hospital in Malaysia between September 2017 and February 2018. The sample size for the current study was estimated on the basis of a paired t test derived from Power and Sample Size Calculation (PS) software version 3.0, an interactive program for performing power and sample size calculations.46 The sample size was obtained on the basis of a calculated effect size from previous studies for which α = .05 and power (1 − β) = 0.80.47–49 To achieve an 80% power, α was set at .05 and the effect size at 0.30. The final sample size was estimated on the basis of the maximum estimated sample size for autonomy, teamwork, and burnout (n = 49). A convenience sample approach was used. Nurses to whom the following criteria applied were included in the study: all nurses who had worked in the cardiac ward for at least 6 months and were willing to participate. The exclusion criteria were: nurses on long-term sick leave or maternity leave, or those who had worked for less than 6 months in the cardiac ward. Although a total of 37 coronary care nurses participated in this study, which is less than the calculated sample size of 49, this number is acceptable for a preliminary or feasibility study, where hypothesis testing is inappropriate.50,51

Research instrument

The current study used a self-administered questionnaire with 2 sections. Section I included 7 questions for collecting demographic data such as age, gender, ethnicity, education level, and years of working in the cardiac ward.

Section II included 69 items, which measured autonomy, teamwork, and burnout levels. The researchers incorporated the Dempster Practice Behavior Scale (DPBS) for measuring autonomy levels. The DPBS is a 30-item instrument with a 5-point Likert scale ranging from 1 (not at all true) to 5 (extremely true).52 For general scoring, the higher the score, the greater the extent of autonomy. The scoring range is 30 to 150. The Brief Teamwork Perceptions Questionnaire (T-TPQ) measures the level of teamwork. The T-TPQ is a 20-item instrument with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Teamwork was deemed good and acceptable for participants who scored 3 or higher, while those scoring less than 3 experienced teamwork that was poor and required improvement.48 This can be calculated from the mean of each factor or overall mean. Mean subscale scores of 3 or above (corresponding with strongly agree, agree, or neutral) were considered good teamwork, while a mean subscale score below 3 (corresponding with disagree and strongly disagree) was considered poor teamwork, requiring improvement. The Copenhagen Burnout Inventory (CBI) was used to measure burnout levels. The CBI is a 19-item instrument with a 5-point Likert scale: 100 (always), 75 (often), 50 (sometimes), 25 (seldom), 0 (never/almost never).53 Scores of less than 50 are considered “low/no burnout,” 50 to 74 “moderate or risk of burnout,” and a score exceeding 75 “high burnout.” Although all the instruments had established sound psychometric properties in the original English language versions, it was essential to reestablish the validity and reliability for the translated versions (see Supplemental Digital Content, Annex 1, available at:

The questionnaire was developed in English and translated to Bahasa Malaysia (Malaysia's national language) according to the standard forward-backward procedure proposed by Guillemin and colleagues54; this was performed separately with the help of 2 professional bilingual translators. The questionnaire was then translated back into English by 2 additional professional bilingual translators. The final version was administered in both languages. Three nursing experts checked the questionnaire's content validity. Its reliability was tested through a pilot study of 28 registered nurses sharing the same characteristics as the target participants. The results yielded Cronbach α coefficients for the DPBS, T-TPQ, and CBI of 0.970, 0.963, and 0.940, respectively. The questionnaires were deemed reliable in terms of internal consistency because all the obtained α coefficients exceeded 0.70.

Care pathway development and implementation

The care pathway was developed using an extensive literature review, a local guideline, and an expert panel comprising 2 cardiologists, 1 matron-in-charge, 2 clinical nurses, and 1 nurse tutor (see Supplemental Digital Content, Annex 2, available at: Numerous discussion meetings were held with the expert panel before the care pathway's acceptance in this study.

The implementation comprised a 1.5-hour educational session, supervised hands-on practice using the care pathway, and multiple site visits. These components were designed to enhance the nurses' knowledge and skills in using the STEMI care pathway and managing patients with STEMI. Each educational session included 5 to 6 nurses to ensure sufficient opportunities for discussion. Because of the nurses' work patterns and other personal commitments, the educational session was repeated 9 times. The content for the educational sessions was developed using an extensive literature review. This included an overview of the basic terms, concepts, components, and objectives of the care pathway and an outline of the benefits. Case studies were presented to the group, and participants were encouraged to present and discuss the cases.

Following the educational sessions, a researcher individually coached and supervised the nurses daily in 15- to 20-minute one-to-one sessions from Monday to Friday for 2 weeks. Each session focused on applying the care pathway using case scenarios and existing ward patients. The care pathway was then introduced and disseminated into a clinical setting, with copies provided to the unit by a researcher. A total of 26 site visits were conducted over 4 months. The visits were held 3 times per week during the first month and then decreased to 2 visits per week for the second month, 1 visit per week for the third month, and 1 visit per week for the last month. During these site visits, a researcher monitored the nurses' practice and compliance with the care pathway by reviewing the nursing notes (see Supplemental Digital Content, Annex 3, available at: The current study involves 2 types of care pathways: STEMI post-Percutaneous Coronary Intervention (PCI) and STEMI post-Thrombolytic. During the implementation phase, the charge nurses were responsible for ensuring the appropriate care pathway was included in the patient chart when they were admitted to the unit. At the end of this phase, the pathway was implemented into daily practice. The pathway document was used to guide the team in managing the care process for a patient with myocardial infarction.

Data collection

During the pre- and post-intervention phases, the questionnaire and a cover letter explaining both the study and the voluntary nature of participation were supplied to the study participants. Data were collected in the cardiac ward at 2 different points in time—immediately before the education session and 4 months after the care pathway implementation. The questionnaire was administered on paper.

Ethical considerations

Ethical approval was obtained from the hospital's ethics committee (reference no. 2017531-5294). A copy of the questionnaire and an information leaflet outlining the study's aim and purpose, voluntary participation, and confidentiality of responses were given to all the eligible participants. A sealed box was placed at the cardiac ward entrance for the return of the completed questionnaires, indicating the participants' consent to engage in the study. Anonymity was maintained by using codes rather than the participants' names. Completed questionnaires were kept in a locked cabinet and password-protected computer files to protect confidentiality. Only the principal researcher accessed all the data.

Data analysis

The data were analyzed using the Statistical Package for Social Sciences (SPSS), version 22.0. Descriptive and inferential data were measured, and a preliminary test for the assumption of normality was conducted. The demographic data were expressed as frequency, proportion, median, and interquartile range (IQR). A paired t test was used to examine the differences between the baseline and post-intervention for autonomy, teamwork, and burnout. Furthermore, a one-way analysis of variance was used to assess whether burnout levels differ on the basis of nurses' demographic characteristics.


Demographic characteristics of the study sample

A total of 37 coronary care nurses participated in this study. Of 49 coronary care nurses, 12 were ineligible to enroll in this study: 4 were on maternity leave; 2 were transferred to another hospital; 3 took study leave; 1 was transferred to another unit; and 2 were unavailable to care for patients during the study period. Newly recruited staff nurses were excluded, as they did not complete the pretest survey or attend the education session. Most of the respondents were female (94.6%; n = 35), the median age of the respondents was 26.5 years (IQR = 23-31), and the median length of clinical experience was 4 years (IQR = 2-8) (Table 1).

Table 1. - Demographic Characteristics (N = 37)
Variable Frequency (%) Median (IQR)
Female 35 (94.6)
Male 2 (5.4)
Malay 34 (91.9)
Non-Malay 3 (8.1)
Age, y 26.5 (23-31)
≤23 10 (27)
24-28 9 (24.3)
29-33 11 (29.7)
≥34 5 (13.5)
Education Level
Diploma 36 (97.3)
Bachelor's degree 1 (2.7)
Duration of working experience in cardiac ward, y 4 (2-8)
≤1 8 (21.6)
2-4 15 (40.5)
5-9 10 (27.0)
10≥ 4 (10.8)
Abbreviation: IQR, interquartile range.

Autonomy, teamwork, and burnout levels after implementing the care pathway

The Shapiro-Wilk test examining the normality of the variables (autonomy, teamwork, and burnout) revealed that a parametric analysis was appropriate. The paired t test to examine the differences between the autonomy, teamwork, and burnout scores before and after implementing the care pathway revealed that the decrease in the burnout level among the coronary nurses was statistically significant post-intervention with a medium effect size. No statistically significant change in teamwork and autonomy levels was observed among the coronary nurses post-intervention (Table 2).

Table 2. - Paired-Samples t Test Comparing Pretest and Posttest Surveys (N = 37)
Pre-intervention Post-intervention
Mean SD Mean SD t P Effect Size
Autonomy 98.00 18.55 102.29 14.66 −1.53 .135
Teamwork 3.86 0.44 3.87 0.52 −0.029 .977
Burnout 58.12 16.87 52.69 13.94 2.23 .032 a 0.37
aSignificant at the .05 level (2-tailed).

Further analysis, using a one-way analysis of variance, examined the differences in the burnout levels between the pre-intervention and post-intervention phases according to the nurses' demographic characteristics. The results revealed no statistically significant differences in burnout levels according to these demographic characteristics (Table 3).

Table 3. - Difference Between Burnout Level by Nurses' Demographic Characteristics (N = 37)
Pre-intervention Post-intervention Difference Between Pre-intervention and Post-intervention
Demographic Characteristics Mean SD F P Mean SD F P Mean SD F P
Age, ya


0.47 .70

0.64 .59

0.06 .98
Duration of working experience in cardiac ward, ya


0.15 .92

1.71 .18


1.20 .32
aAnalysis of variance was used.


The current study aimed to evaluate the association of the care pathway with the autonomy, teamwork, and burnout levels among coronary care nurses. To the best of the researchers' knowledge, no prior study had been conducted to evaluate the impact of care pathways among nurses working in hospitals in Malaysia. In the present study, nurses scored lower for burnout items post-intervention, indicating that the care pathway was associated with reduced burnout among coronary care nurses. This is similar to the findings from a previous study outside Malaysia.32 The reduced burnout in the current study may be attributed to a better work environment, as care pathways can help reduce unnecessary variations through standardization of care delivery. The care pathway can lead to organized care processes and role clarification, which support nurses in delivering optimal care.27 No statistically significant variation in burnout level was found on the basis of the nurses' demographic characteristics.

The current study results showed a slight improvement in autonomy level among coronary care nurses after the care pathway was implemented, although it was not statistically significant. Enkin et al55 claimed that using care pathways to standardize care led to reduced professional autonomy. However, several studies, mostly using qualitative methods, suggested that care pathways increased autonomy in expressing and using nursing skills.28,31,36 In the current study, a possible explanation may relate to the Asian culture, in which physicians are viewed as the decision makers and nurses are expected to follow their orders concerning patient care.56 Practice change will be achievable and sustained if reinforced by a change in behavior and culture at both the unit and organizational levels, and supported by local managers.57 In addition, the small sample size may have hindered our ability to detect a statistically significant improvement.

In terms of teamwork, the current study result is consistent with the previous study by Gibbon et al,58 which reported no change in teamwork after implementing a care pathway. This contradicted previous studies, which suggested that care pathways improve teamwork and decrease conflict on the multidisciplinary teams.28,30–34 For example, a posttest-only randomized controlled trial concluded that the mean score of interprofessional teamwork for the intervention group (3.8) was higher than for the control (3.5).32 Based on the scoring system of the teamwork questionnaire, a possible explanation for the failure to report a significant improvement in teamwork in the current study could be the already high level of teamwork among most coronary care nurses (mean = 3.86) at baseline before implementing the care pathway.48 Teamwork was deemed good and acceptable for participants who scored 3 or higher, while those scoring less than 3 experienced teamwork that was poor and required improvement.48 Thus, the level of teamwork among most coronary care nurses (mean = 3.86) at baseline before implementing the care pathway indicated a good/acceptable level of teamwork, according to Castner et al.48 A possible explanation for the higher level of teamwork could relate to the sample in this study, as most nurses trained in the same school of nursing under the same hospital, leading to familiarity with each other since training. It is also important to mention that the current study contained solely nurses who received the intervention. Future studies should also consider including other health care providers if seeking to improve multidisciplinary teamwork.

The current study provided useful information concerning the association of the care pathway with autonomy, teamwork, and burnout levels among coronary care nurses. Some limitations are worthy of attention. First, this is a preliminary study using a pre/posttest-only one-group research design; this is the weakest quasi-experimental design because it lacks a comparison group. However, it is not practical or ethical to randomly select nurses in the same unit. Another limitation is using a self-reported questionnaire to collect the data because their accuracy cannot be ensured. Participants may give socially desirable responses, leading to response bias. Hence, collecting nurses' data using a self-reported questionnaire might be unreliable; other data collection methods should be considered, such as using a reliable and valid structured observation checklist to ensure the nurses practice the pathway correctly. The results may not be generalizable to other settings due to the small sample size and study setting. Further research should be considered using larger samples in multicentered randomized controlled trials.

The main strength of the current study was that the care pathway was designed systematically based on the literature review and expert panel. Consensus meetings were held by the expert panel in which their comments were integrated into the care pathway. In addition, data collection was conducted in Malaysia's largest teaching hospital that serves more than 3 million patients. The study also used well-developed and validated instruments to measure autonomy, teamwork, and burnout among coronary care nurses.

Implications for nursing and health policy

Because of the nature of their work of providing care for ill patients, nurses in the high-intensity environment of the cardiac ward will continue to face burnout, as health care organizations face severe challenges in improving these work environments. However, care pathways are used worldwide in different settings to manage and improve the care process,4 as they provide a systematic method for managing care and reducing redundant tasks.

In the United States, the current use of care pathways and their impact on costs, patient outcomes, nurse outcomes, and quality of care in health care settings have not been characterized fully.8 All elements of pathway development, implementation, and evaluation should be systematically adopted and endorsed. Furthermore, nurses play an important role in care pathway development and implementation. In the future, care pathways are expected to increasingly influence quality of care, health care provider outcomes, and patient outcomes.

In the current study, the findings presented a statistically significant reduction in burnout among coronary care nurses associated with the STEMI care pathway. This finding is important for health care managers. When nurses experience less burnout and fatigue, they become more emotionally engaged and their well-being improves.59 In addition, they may become more alert to potential safety hazards and care more for patients' needs.

Managers should consider actively supporting nursing decisions and autonomy. Furthermore, implementing care pathways may enhance nurse autonomy and resist traditions that diminish this. To accomplish this, nurse managers must support their staff in their decision making.

Care pathways are complex interventions. What works for one organization could fail in another because the readiness and capacity for change vary.27 It is important to note that merely changing interventions may not change behavior. Further studies should involve health care managers to increase their professionals' support in their decision making and enhance teamwork. Mixed-methods designs would be required to improve mutual understanding and overcome the potential barriers to implementing care pathways.


The care pathway was associated with reduced nurse burnout. The results showed a slight improvement in autonomy level among coronary care nurses after the care pathway was implemented. Although this is a preliminary study, from a practical viewpoint, it can help policy makers and managers to reduce burnout. This study highlights the importance of using care pathways as a tool to reorganize the care process and improve the working environment. Managers must support nursing decisions and provide continuous education to enhance nurses' autonomy.


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burnout; cardiovascular nursing; care pathways; professional autonomy; ST-elevation myocardial infarction; teamwork

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