Impact of Nursing Educational Program on Knowledge, Drug- Drug Interaction and Psychological Stress, of Heart Failure Patients in Sulaimani Cardiac Hospital

 Introduction

Heart failure (HF) is a major global health concern that affects both individuals and society. Measures such as hospital readmission rates, mortality rates, and healthcare costs can be used to quantify this burden. The key to preventing complications lies in having a proper understanding of the illness (Baeez & Younis, 2019).

The preservation of a patient's clinical stability is the primary objective of heart failure treatment. Educational programs created by multidisciplinary teams have shown success in achieving this goal. For patient education and continuity of care, nurses in HF clinics play an essential role (Östman et al., 2021). HF was listed as a cause of death on 379,800 death certificates (13.4%) in 2018. The estimated cost of healthcare expenditures for this condition, including lost workdays, prescription drugs, and medical services, totaled $30.7 billion (Benjamin et al., 2019). Researchers have speculated that patients with chronic heart failure (CHF) may have higher rates of depression, anxiety, and stress than those in high-income nations, based on research conducted in other low- and middle-income countries (Tsabedze et al., 2021). Iraq’s non-communicable disease burden has increased since the 2003 war, with rapidly rising trends in hypertension and diabetes mellitus, which in turn elevate the risk of ischemic heart disease and cerebrovascular accidents (Hussain & Lafta, 2019).

Reduced quality of life (QoL) in HF patients is linked to longer hospital stays, higher mortality rates, and greater expenses for patients, families, and healthcare systems. Therefore, regular QoL evaluation and self-care are essential to improving survival rates (Moradi et al., 2020). Even with advances in medical management, both physical and psychological distress significantly harm patients’ quality of life and elevate adverse risk levels (Alpert et al., 2017; Jarab et al., 2023). Patients with cardiovascular diseases are more prone to drug–drug interactions because aspirin may block renal prostaglandins and compete with furosemide, reducing the diuretic effect (Akbar et al., 2021). To maximize patient care and improve therapeutic efficacy, pharmacists must stay up to date on food–drug interactions to prevent treatment failure or adverse effects (Yadav et al., 2020). Participation in continuing education initiatives can significantly improve the quality of life for individuals with heart failure, rendering such interventions beneficial and non-pharmacological (Lakdizaji et al., 2013).

The physical and psychological effects of HF symptoms are reflected in patients’ QoL, making it a key component of HF management. Severe symptoms often hinder self-care (Heo et al., 2009). Symptoms of heart failure can impair quality of life by reducing exercise tolerance and increasing stress, anxiety, depression, and emotional disturbance (Lakdizaji et al., 2013). Approximately 75% of HF patients report poor QoL (Shojaei, 2008). As heart failure treatments and survival rates improve, enhancing QoL becomes increasingly important (Salehitali et al., 2009). According to a comprehensive review of 21 trials, HF contributes to social isolation, low QoL, and psychological distress. Improving self-care requires structured interventions such as in-person instruction, psychological support, and patient education. The greatest improvements in QoL are achieved when face-to-face instruction is combined with follow-up phone consultations (Cui et al., 2019).

Emotion-focused coping has been linked to harmful lifestyle choices such as medication misuse, smoking, alcohol consumption, and physical inactivity. These behaviors negatively affect health and increase mortality (Alsentali & Anshel, 2015). In contrast, problem-focused coping involves behavioral and cognitive strategies aimed at modifying or managing the stressor—such as joining social groups, adopting religious practices, or seeking help (Herman & Tetrick, 2009). Therefore, understanding the factors that influence survival among heart failure patients is essential for developing effective stress-reduction and coping strategies (Alsentali & Anshel, 2015).

Drug interactions are responsible for adverse effects in approximately 7.3% of hospitalized patients and up to 88% of elderly patients. For instance, due to their high potassium content, bananas have been shown to lower blood pressure. Patients with hypertension have demonstrated improvements following a seven-day Ambonese banana diet therapy. Additional research indicates that elderly adults with moderate hypertension can lower their blood pressure without medication by consuming two Ambonese bananas (140 g/fruit/day) daily for one week. Since ACE inhibitors increase potassium—which regulates blood pressure—combining them with bananas can lead to hyperkalemia (Olivia & Suryana, 2018).

The current study aims to assess the impact of a nursing educational program on the psychological stress of heart failure patients in the Cardiac Hospital in Sulaimani City and to evaluate their knowledge regarding HF disease, its pathophysiology, and drug–drug and food–drug interactions.

Methodology

 Design of the Study

Quantitative design a (quasi-experimental study) was used to assess impact of nursing educational program on psychological stress from heart failure patients in Cardiac Hospital in Sulaimani city. The study was carried out during the periods of 3rd August 2021 to 10th February 2024.

Administrative Approval

The protocol of the study approved by college of Nursing-University of Sulaimani, an official agreement letter from the College of Nursing - University of Sulaimani was sent to the Directorate of Health, Cardiac Hospital in Sulaimani city to grant facilitation and cooperation during carrying out of Nursing educational program.

The Study's Setting

This study conducted at Cardiac Hospital in Sulaimani city, which is the main hospitals for cardiac diseases. Cardiac Hospital in Sulaimani City- Iraqi Kurdistan region, serves as the primary institution for managing cardiovascular disease patients.

The Study Sample

Non-probability purposive sample was used as a method for selecting samples in this study. Patients who were admitted to the Cardiac hospital were diagnosed with HF by the cardiologists and they were invited to participate in the study. 200 patients participated in the study. The participants were divided into two groups 100 recruited for the interventional and 100 for the control group.

Criteria for Inclusion and Exclusion

  The study included adults from 18 and above who diagnosed with HF with reduced ejection fraction (HFrEF), approved by a cardiologist teams. They retained the right to refuse or withdraw from the study. Exclusion criteria encompassed severe mental health problem.

Instruments of the Study

The study tool was composed of three parts, part one dealt with demographic data of patients with HF such as: age, gender, marital status, level of education, residential area, financial situation, part two is dealt with knowledge of HF and part three dealt with drug-drug and food-drug interactions before and after the nursing educational program.

Validity of the study

The data collection validity was established through a review process involving five experts. They evaluated and provided feedback on the study tool, leading to revisions that enhanced the instrument's final validity by making it more pertinent and comprehensible.

 Pilot Study

 It was conducted with 20 patients with HF from the initial study sample during the period of January 15th 2022.

Reliability of the study sample

The reliability was determined by the Cronbach Alpha Correlation Coefficient and Stability (test- retest) approach, producing a strong association (r = 0.85). 

Approaches of data collection

All patients diagnosed with HF and admitted to the Cardiac hospital in Sulaimani City were included in this study sample. Data were collected through face-to-face interviews with the patients for their information. The data collection period spanned from March 26th, 2022. Completing the questionnaire about HF took approximately 10 minutes. More than 50 Patients did not match the inclusion criteria, 23 patients did not agree for participation in the study sample, finally 200 patients remained with HF for both intervention and control groups.

Statistical Analysis of the study sample

Version 26 of the statistical package of social science (SPSS) was used to code and organize the data into computer files. The inferential data analysis, and frequency and percentage computation and qui square, independent t test were used to process the data.

Results

Table 1: Participants’ socio-demographic and clinical characteristics (the own numbers are percentages)

* Performed by Chi- square test                            ** performed by independent t test 

    Table (1) demonstrated that the total number of HF patients were 200, their mean age (±SD) was 68.3 ± 11.2 years and the age range were between 38 – 100 years. No significant differences were detected in the mean age of the two study groups (p = 0.23 and 0.11 respectively). (72%, 69%) of both groups were males respectively. (52%, 50%) of both groups were widower respectively, and they live alone or with their children. While others were married and live with their wives or their husbands. The proportion of illiterate patients was higher in the control group than the intervention group (65% and 59%), respectively. In both groups non- governmental employee was a higher proportion of the study sample than governmental employee. Almost all of the patients of the intervention group (95%) were living in urban areas compared to (87%) of patients of the control group. (63%,68%) of both intervention and control groups were in low economic state, while, only (8%,4%) of them had sufficient economic state.

Table 2 Comparisons Between Intervention and Control Groups Regarding Knowledge of Heart Failure and Drug–Drug and Food–Drug Interactions Before and After the Nursing Educational Program

ᵃ Performed by Chi-square test.
Note. Post-intervention results revealed significant improvement in participants’ knowledge of heart failure, symptoms, and drug–drug interactions in the intervention group compared with the control group (p ≤ .001).

Table 3 Comparisons Between Both Groups Regarding the Use of Analgesic Drugs Before and After the Nursing Educational Program

ᵃ Performed by Chi-square test.
Note. A statistically significant reduction in the use of high-risk NSAIDs was observed among intervention participants after the educational program (p < .001).

Table 4 Comparisons Between Intervention and Control Groups Regarding Psychological Distress (Perceived Stress Scale) Before and After the Nursing Educational Program

ᵃ Performed by Chi-square test.
Note. The educational program significantly reduced perceived stress levels among intervention patients compared with the control group (p < .001).

Discussion

This study included 200 patients with heart failure (HF). Of these, 100 patients who received a nursing educational program comprised the intervention group, whereas 100 patients admitted to the cardiac hospital and receiving routine care served as the control group. After implementation of the nursing educational program, the numbers decreased to 94 and 90, respectively, due to patient mortality. The mean age of participants was 68.3 ± 11.2 years (range = 38–100 years). This finding aligns with the results of Lakdizaji et al. (2013) in Iran, who reported a mean age of 61.7 ± 9.4 years among their participants. In both the intervention and control groups of the present study, the majority of participants were male—consistent with studies conducted in Greece (Stavrianopoulos, 2016) and Iran (Lakdizaji et al., 2013), which also reported a higher proportion of men.

Nearly half of participants in both the intervention and control groups were married, in agreement with Stavrianopoulos (2016), who observed that slightly more than half of his sample were married. More than half of the widowed participants in both groups lived alone, and fewer than one-quarter lived with their children. More than half of both groups were illiterate, which contrasts with findings from Stavrianopoulos (2016), Akbari et al. (2019), and Lakdizaji et al. (2013), where most participants had at least a primary or secondary education. Furthermore, more than half of participants in both groups in the present study reported a low economic status (income lower than expenditures), which is consistent with the results of Akbari et al. (2019) in Tehran and Lakdizaji et al. (2013) in Iran. Regarding living arrangements, the current findings also mirror those of Lakdizaji et al. (2013), as nearly half of participants in both studies lived with their spouses.

Before the nursing educational program, nearly all patients in both the intervention and control groups lacked knowledge about HF and its pathophysiology, including symptoms. Moreover, none of the participants had information regarding food–drug or drug–drug interactions. After the intervention, the experimental group demonstrated marked improvements in their understanding of HF, its pathophysiology, symptoms, and interactions, with more than half showing gains in each domain, while no change was observed in the control group. Although there was no significant difference between the two groups before the intervention, a statistically significant improvement in knowledge was observed in the intervention group compared with the control group after the program (p = .001). These findings contradict those of Gosadi et al. (2021), who reported greater awareness among patients with chronic noncommunicable diseases in the Jazan region of Saudi Arabia. The difference may be attributed to low literacy rates among HF patients in the current study and insufficient nursing education or support for HF management. Nevertheless, the present findings are consistent with Baeez and Younis (2019), who demonstrated significant improvements in patients’ understanding of HF in Erbil following the implementation of a health education program, along with enhanced overall health status.

Before the intervention, nearly half of the intervention group and more than half of the control group reported high perceived stress, while the remainder demonstrated moderate stress, and only 2% of participants in each group showed low stress. After the program, high stress levels declined to less than one-quarter in the intervention group but remained above half in the control group. The difference between the two groups was statistically significant (p = .001). These results differ from those of Bhagyalakshmi et al. (2012) in India, who found no HF patients with high stress levels; rather, more than half of their participants exhibited low stress, and nearly half had moderate stress. The higher stress levels in the present study may be explained by older age, long-standing illness, comorbidities, and social isolation—particularly among widowed patients who lacked emotional support and faced financial hardship. The researcher also observed that limited attention from family members, due to occupational commitments, and the absence of multidisciplinary collaboration (among cardiologists, psychiatrists, and pharmacists) contributed to the psychological burden. The lack of effective nursing management further exacerbated these outcomes. Conversely, the results differ from Endrighi et al. (2016) in the United States, who also reported a high level of stress among HF patients. Similarly, Năstasă and Fărcaş (2015) observed that HF patients experience significant psychological distress that impairs coping mechanisms, leading to anxiety and depression, which in turn hinders recovery. Chronic stress additionally produces physiological strain through neuroendocrine and metabolic disruptions.

Before implementation of the nursing educational program, nearly three-quarters of the intervention group and more than half of the control group reported frequent analgesic use. After the program, analgesic use decreased markedly to 42.6% in the intervention group but increased to over half in the control group (p = .001). Prior to the intervention, almost half of the participants in the intervention group and over one-quarter of those in the control group were unaware of the names of the analgesics they were taking. Less than one-quarter in each group reported using ibuprofen, naproxen, paracetamol, Mobic, or diclofenac. After the educational program, unawareness of medication names persisted due to high illiteracy levels, yet the use of ibuprofen, naproxen, and other NSAIDs declined in the intervention group. Most participants in the intervention group began to use paracetamol, while ibuprofen and naproxen remained common in the control group. Although no significant difference in analgesic use was observed prior to the intervention, a significant distinction emerged after the program (p = .001), indicating that nursing education effectively modified patients’ medication behaviors toward safer options.

Pharmacologic therapy for HF typically includes diuretics, vasodilators, anticoagulants, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), digoxin, angiotensin receptor–neprilysin inhibitors (ARNIs), and nitrates (Heidenreich et al., 2022). Simultaneous use of diuretics (thiazide or loop) with ACE inhibitors or ARBs and digoxin can increase the risk of hospitalization due to digoxin intoxication, cardiac arrhythmias, and electrolyte imbalances (Wang et al., 2018; Wola et al., 2022). Combining ACE inhibitors or ARBs with nonsteroidal anti-inflammatory drugs (NSAIDs) may also precipitate acute kidney injury (Ishiguro et al., 2008). Medication plays a vital role in improving public health, preventing disease, and extending life expectancy. However, pharmacotherapy-related complications—affecting between 42% and 81% of hospitalized patients—underscore the importance of vigilant medication management to optimize healthcare outcomes (Costa et al., 2017).

A meta-analysis by Zheng et al. (2018) found that 33% of patients in general wards and 67% of those in intensive care experienced at least one potential drug–drug interaction during hospitalization. Although some interactions may be clinically insignificant, it remains crucial to distinguish between theoretical and harmful interactions. A systematic review of 10 studies reported prevalence rates ranging from 1.2% to 64% among intensive care patients (Gonzaga de Andrade Santos et al., 2020). Poor adherence to treatment can lead to decompensation episodes, resulting in hospital readmissions ranging from 15% to 64%. Effective HF management therefore requires a comprehensive therapeutic plan encompassing medication, lifestyle modification, and individualized education. Multidisciplinary collaboration—among nurses, physicians, pharmacists, and dietitians—is essential to enhance understanding and compliance (Rabelo et al., 2007). The nursing profession, rooted in social justice and community health advocacy (Pittman, 2019; Tyson et al., 2018), positions nurses as key educators who dedicate more time to patient care than physicians. They encourage adherence, facilitate self-management, and reinforce appropriate medication practices. The current findings suggest that deficiencies in nurses’ skills, motivation, and self-confidence may impair the quality of education provided to patients, consequently increasing stress levels among those living with HF.

Conclusion

Before the implementation of the nursing educational program, nearly all participants lacked knowledge about heart failure, its pathophysiology, and drug–drug interactions. Following the program, the intervention group exhibited significant improvements in knowledge compared with the control group. Nearly half of the intervention group and more than half of the control group experienced high levels of stress prior to the program; however, after the intervention, stress levels declined to less than one-quarter in the intervention group while remaining elevated in the control group. The nursing educational program produced statistically significant differences between the two groups (p ≤ .05), confirming its effectiveness in improving knowledge, promoting safe medication practices, and reducing psychological stress among patients with heart failure.