Nurse-Led Empowerment Program Transforms Pacemaker Patients’ Self-Care Skills

For the roughly one million people worldwide who receive a permanent pacemaker each year, the small device implanted under the skin of the chest is only the beginning of a lifelong relationship with cardiac technology. What happens after the implantation procedure, however, often determines whether that relationship succeeds. Patients who leave hospital without understanding how their device works, how to monitor the implantation site, or when to seek medical help face a heightened risk of avoidable complications, from wound infections to lead dislodgement and missed signs of device malfunction. A new quasi-experimental study from Egypt, published in BMC Nursing, suggests that a carefully structured, nurse-led empowerment protocol can close this gap dramatically, more than doubling patients’ knowledge scores and producing some of the largest effect sizes reported in this field of nursing research.

The research team, led by Walaa Nady Sayed Kamel of Beni-Suef University together with colleagues from Tanta University and Kafrelsheikh University, recruited seventy adults with newly implanted permanent pacemakers at Tanta University Hospitals between December 2025 and April 2026. The study was grounded in two well-established theoretical frameworks: Bandura’s self-efficacy theory, which holds that people are more likely to perform health behaviours when they believe they are capable of doing so, and a patient-empowerment model that positions patients as active partners in their own care rather than passive recipients of instructions. This theoretical grounding mattered in practice, because the intervention was designed not simply to deliver information but to build confidence through repeated, hands-on mastery experiences, the mechanism that Bandura identified as the most powerful driver of self-efficacy.

The design was a non-equivalent control-group, pretest-posttest quasi-experiment, reported in accordance with the TREND statement for non-randomised evaluations. Thirty-five participants received routine hospital care alone, while a further thirty-five received that same routine care plus the structured empowerment protocol. Because the two arms were recruited in consecutive calendar periods rather than randomised concurrently, a strategy the authors used to prevent educational contamination between groups, group membership was confounded with time period, a limitation the researchers acknowledge explicitly. The protocol itself consisted of four individual sessions lasting thirty to forty-five minutes each, delivered by nurses using illustrated Arabic booklets, live demonstrations, and return demonstrations in which patients performed each skill themselves until competence was achieved. After the sessions, participants received weekly telephone reinforcement calls during the first month, a component designed to consolidate learning and address emerging questions before they hardened into unsafe habits.

The researchers measured three co-primary outcomes at baseline, immediately after the intervention, and at one-month follow-up. Knowledge was assessed with the Pacemaker-Related Knowledge Questionnaire, scored from zero to twenty. Practical competence was evaluated with an Observational Checklist scored from zero to fifty, in which trained assessors watched patients perform device-related self-care tasks. Self-care behaviour was measured with the Self-Care Behaviours Scale, scored from zero to twenty. Because three primary comparisons were tested, the team applied a family-wise significance threshold of 0.017, obtained by dividing the conventional 0.05 level by three, a conservative Bonferroni-style correction that reduces the risk of false-positive findings when multiple hypotheses are examined simultaneously.

The results were striking across all three domains. Mean knowledge scores in the intervention group rose from 6.51 at baseline to 15.31 immediately after the protocol, while the control group improved only from 5.57 to 7.46. The group-by-time interaction, tested with repeated-measures analysis of variance and the Greenhouse-Geisser correction for deviations from sphericity, yielded an F statistic of 148.09 with a p value below 0.001 and a partial eta squared of 0.685, meaning that roughly two-thirds of the variance in knowledge change over time was attributable to the intervention. The between-group difference after the intervention was 7.85 points, with a 95 percent confidence interval of 5.67 to 10.03 and a Cohen’s d of 1.69, an effect size conventionally classified as very large.

Practical competence showed an even more dramatic transformation. Intervention participants improved from a mean of 16.29 on the fifty-point observational checklist to 41.17, whereas control participants moved only from 14.91 to 18.54. The interaction effect was again highly significant, with F of 120.34, p below 0.001, and partial eta squared of 0.639. The post-intervention between-group difference of 22.63 points, with a confidence interval of 17.40 to 27.86 and a Cohen’s d of 2.03, represents an exceptionally large effect, one that exceeds the thresholds typically associated with clinically meaningful change by a wide margin. Self-care behaviour scores, measured on the twenty-point scale, climbed from 13.63 to 19.00 in the intervention group against a rise from 12.86 to 15.00 in controls, producing a difference of 4.00 points, a confidence interval of 2.52 to 5.48, and a Cohen’s d of 1.26. All three interactions remained significant at the corrected family-wise threshold, and importantly, the groups did not differ significantly on any recorded baseline characteristic, strengthening the argument that the observed differences stemmed from the intervention rather than pre-existing disparities.

The gains were partially sustained at the one-month follow-up, a detail with real clinical significance. Educational interventions in cardiac care frequently produce immediate improvements that evaporate once active teaching stops, a phenomenon known as the decay effect. The persistence of benefit here, even if incomplete, suggests that the weekly telephone reinforcement during the first month may have served as an effective maintenance mechanism, giving patients opportunities to rehearse knowledge and skills in their home environment while support was still available. This finding aligns with a broader trend in health-services research toward designing interventions with built-in booster components rather than relying on single episodes of education delivered at discharge, a moment when patients are often anxious, fatigued, and cognitively overloaded by the experience of recent surgery.

The authors are careful about what their design can and cannot prove. Because allocation was non-random and confounded with calendar period, and because outcome assessment was unblinded, the findings are best interpreted as an association observed under a quasi-experimental framework rather than causal evidence equivalent to that of a randomised controlled trial. Unblinded assessment, in particular, raises the possibility of measurement bias, since assessors aware of group assignment could unconsciously score the intervention group more generously. Secular changes between recruitment periods, such as shifts in staffing or seasonal differences in patient mix, represent an additional although less likely threat, given that the two periods spanned only a few months and baseline characteristics were well matched. The study was retrospectively registered on ClinicalTrials.gov under identifier NCT07743346, and the researchers received no external funding for the work.

Even with these caveats, the study carries substantial practical weight, particularly for low- and middle-income countries where robust evidence on structured post-implantation education has been scarce. The intervention required no expensive technology, no new devices, and no specialist physicians; it relied on nurses, printed booklets in patients’ own language, demonstrations, and phone calls, making it highly scalable in resource-constrained health systems. The effect sizes observed, with Cohen’s d values ranging from 1.26 to 2.03, are far larger than those typically reported for educational interventions in chronic disease management, where values above 0.8 are already considered large. If replicated under randomised, attention-controlled conditions with blinded assessment and longer follow-up, a protocol of this kind could reshape standard post-implantation nursing care, turning the weeks after pacemaker implantation from a period of anxious uncertainty into one of genuine patient empowerment. For now, the message from Tanta is clear and compelling: when nurses are given the structure and time to teach properly, patients learn, and what they learn may protect the device that keeps their hearts beating on schedule.

Subject of Research: Effect of a nurse-led empowerment protocol on knowledge, skills, and self-care in permanent pacemaker patients

Article Title: Effect of a structured nurse-led empowerment protocol on knowledge, practical skills, and self-care behaviours among patients with permanent pacemakers: a quasi-experimental study

Article References: Kamel, W. N. S., Assaf, A. R. A., Shehata, A. M., & Afify, N. M. M. (2026). Effect of a structured nurse-led empowerment protocol on knowledge, practical skills, and self-care behaviours among patients with permanent pacemakers: a quasi-experimental study. BMC Nursing, 25(1), Article 917. https://doi.org/10.1186/s12912-026-05368-3

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05368-3

Keywords: permanent pacemaker, nurse-led intervention, patient empowerment, self-efficacy, self-care behaviours, quasi-experimental study, nursing education, cardiac care, patient knowledge, Egypt, BMC Nursing, post-implantation care