Nurse-Led Self-Management Support After Coronary Artery Bypass Surgery

Background and Rationale:

Coronary artery bypass graft (CABG) surgery is the most common major open-heart operation worldwide. Despite surgical advances, patients continue to face clinical, psychological, and self-management challenges during recovery. Anxiety is common during the preoperative waiting period, and depression and anxiety persist for many patients after surgery, which is associated with poorer adherence and recovery. The early period after discharge is a high-risk window in which patients must manage medications, wound care, symptom monitoring, and lifestyle changes at home, and inadequate preparation contributes to avoidable readmissions and emergency department visits.

Existing perioperative education studies are largely fragmented, delivering education either before surgery or at discharge only, without continuous nurse-led support across the full recovery pathway. Current care in this setting is mainly physician-directed and episodic, with limited proactive nursing follow-up after discharge. Telehealth follow-up offers a low-cost way to extend nursing support beyond the hospital stay, and WhatsApp is widely used across age groups in Jordan, making it a feasible delivery channel. No previous trial has combined preoperative, discharge, and post-discharge telehealth nurse-led support, including continuous nurse availability for patient-initiated questions, into a single continuous model for CABG patients.

Theoretical Framework:

BRIDGE-SM (Bridging Recovery through Integrated Digital Guidance and Education for Self-Management) is grounded in Orem's Self-Care Deficit Theory, operationalized as a supportive-educative nursing system, and the Transitional Care Model, which guides continuity across care transitions through a single consistent nurse. The Re-Engineered Discharge (RED) protocol from the Agency for Healthcare Research and Quality is used as the implementation framework for the discharge phase.

Intervention Development:

Before trial start, all BRIDGE-SM materials will undergo content validation by an 8-member expert panel: two consultant cardiologists, two advanced practice critical care nurse specialists with cardiac surgery experience, two patients who previously underwent CABG, and two academic nursing faculty with cardiac nursing and research expertise. All materials are in Arabic at a health literacy-appropriate level and reviewed for cultural appropriateness.

Intervention Delivery:

The intervention is delivered by a clinical nurse specialist with at least a Bachelor of Science in Nursing and at least three years of cardiac surgery perioperative experience, who completes a two-day structured orientation to the protocol before the trial begins.

Phase 1 (Preoperative Assessment Clinic): A face-to-face individualized session covering the surgical procedure and expected inpatient course; medication management; risk factor modification (diet, activity, smoking cessation, weight); wound care and sternal precautions; warning signs and an emergency action plan; psychological support including coping strategies and breathing exercises; and collaborative self-care goal setting with the patient and family caregiver. An Arabic educational video and electronic leaflets are sent via WhatsApp.

Phase 2 (Discharge Day): A face-to-face session in the patient's room incorporating all 11 RED components, documented with a fidelity checklist. Content includes medication review and reconciliation, activity restrictions and sternal precautions, wound care and surgical site infection warning signs, post-CABG dietary guidance, an individualized After Hospital Care Plan, teach-back confirmation, and orientation to the telehealth follow-up schedule. Participants receive a printed Arabic discharge self-management booklet in addition to the standard institutional leaflets.

Phase 3 (Post-Discharge Telehealth, 30 days): Four scheduled telephone calls on Days 3, 14, 21, and 30 after discharge following a standardized assessment guide (symptom review, wound assessment, medication adherence, diet and activity, psychological well-being, and reinforcement of self-care goals). Throughout the 30-day post-discharge period, the nurse is available for participant-initiated WhatsApp messages or calls, with responses within four hours. The intervention ends at Day 30. All contacts are recorded in a Telehealth Contact Log. A predefined escalation protocol (new or worsening chest pain, acute shortness of breath, fever above 38.5 C, wound dehiscence or sternal instability, uncontrolled palpitations) triggers immediate referral to cardiac emergency services.

Standard Care (both groups): Routine preoperative assessment per the institutional clinical practice guideline, identical inpatient perioperative nursing care from admission to the day before discharge, standard verbal discharge instructions and written leaflets, and routine outpatient clinic appointments at 1 to 2 weeks after discharge without proactive nurse follow-up. Inpatient care is kept identical between groups to isolate the effect of the pre-admission, discharge, and post-discharge components.

Outcome Assessment Timing:

All outcomes are assessed in both groups at Day 45 after discharge, two weeks after completion of the 30-day post-discharge intervention.

Randomization and Blinding:

Participants are allocated 1:1 by computer-generated block randomization prepared before recruitment. Allocation is held by an independent person not involved in recruitment, intervention delivery, or outcome assessment, and is revealed only after consent and baseline assessment. Weekly operative lists serve only as a recruitment frame. Participants and the intervention nurse cannot be blinded; an independent record reviewer verifies readmission and emergency department events against medical records, and outcome assessors are blinded to allocation where feasible.

Sample Size:

Assuming a 15% composite event rate in the control group and a 40% relative reduction (9%) with BRIDGE-SM, two-sided alpha 0.05, and 80% power, 163 participants per group are required. Allowing for 10 to 15% attrition, 384 participants (192 per group) will be enrolled.

Statistical Analysis:

Analyses follow the intention-to-treat principle using IBM SPSS version 29. The primary outcome will be compared using the chi-square or Fisher's exact test, reported as relative risk, absolute risk reduction, and number needed to treat with 95% confidence intervals. Participants lost to follow-up will be classified as "no event" in the primary analysis, with a worst-case sensitivity analysis classifying them as "event." Continuous secondary outcomes will be compared using independent-samples t-tests or Mann-Whitney U tests. A per-protocol sensitivity analysis will include intervention participants who completed at least 3 of 4 scheduled calls. Intervention fidelity is monitored through session checklists, contact logs, and review of a 10% random sample of session notes; delivery of at least 80% of protocol elements defines adequate fidelity.

Ethics and Monitoring:

The study is approved by the Royal Medical Services Ethics Committee and the University of Jordan ethics committee. Given the single-centre design, short follow-up, and low-risk nursing intervention, trial conduct is monitored by the principal investigator and supervisor without a formal Data Monitoring Committee. Control group participants are offered a nurse consultation and After Hospital Care Plan review after their follow-up ends.