UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Perceptions of the helpfulness of a home follow up program to post myocardial infarction patients Gleason, Patricia Gail 1996

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_1996-0221.pdf [ 3.29MB ]
Metadata
JSON: 831-1.0087220.json
JSON-LD: 831-1.0087220-ld.json
RDF/XML (Pretty): 831-1.0087220-rdf.xml
RDF/JSON: 831-1.0087220-rdf.json
Turtle: 831-1.0087220-turtle.txt
N-Triples: 831-1.0087220-rdf-ntriples.txt
Original Record: 831-1.0087220-source.json
Full Text
831-1.0087220-fulltext.txt
Citation
831-1.0087220.ris

Full Text

PERCEPTIONS OF THE HELPFULNESS OF A HOME FOLLOW UP PROGRAM TO POST MYOCARDIAL INFARCTION PATIENTS by PATRICIA GAIL GLEASON B.S.N., The University of B r i t i s h Columbia, 1985 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of Nursing) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1996 © P a t r i c i a G a i l Gleason, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of A/&/~S//&^ The University of British Columbia Vancouver, Canada Date^jS^- / / DE-6 (2/88) 1 1 Abstract The purpose of t h i s study was to describe the elements of a v. h o s p i t a l funded, community based cardiac home follow up program which post myocardial patients and families found h e l p f u l during the recovery period immediately a f t e r discharge from h o s p i t a l to s i x weeks post discharge. A retrospective d e s c r i p t i v e survey was conducted on a convenience sample of 9 6 program pa r t i c i p a n t s . Forty eight participants returned the Cardiac Home Follow Up Questionnaire. The responses and scores of the items on the questionnaire were analyzed with d e s c r i p t i v e s t a t i s t i c s . The patients i n t h i s sample found the elements of information about physical changes, i n d i v i d u a l i z e d recovery plan, and the supervised, graduated exercise components of the program to be he l p f u l to them i n t h e i r recovery during the f i r s t 6 weeks afte r discharge from h o s p i t a l . While patients and f a m i l i e s found that the weekly home v i s i t s from the nurse were supportive, they also i d e n t i f i e d a need for more assistance i n strategies to deal with emotional aspects of heart disease. The issue of family involvement i n the home follow up program also yielded some int e r e s t i n g data. While most of the participants agreed that the experience of a myocardial i n f a r c t i o n influenced family functioning and therefore, family involvement was a po s i t i v e intervention for t h e i r recovery, 27% of the sample opposed t h i s idea. Despite discrepancies i n the family involvement content area, a I l l majority of participants acknowledged that the home follow up program assisted them i n maintaining l i f e s t y l e changes made af t e r t h e i r myocardial i n f a r c t i o n . F i n a l l y , most p a r t i c i p a n t s and family members were very s a t i s f i e d with the program and many viewed the experience as part of the comprehensive cardiac care provided by t h e i r community h o s p i t a l . The findings are discussed i n r e l a t i o n to the l i t e r a t u r e on patient education and research on i n d i v i d u a l i z e d cardiac follow up programs. The implications for nursing p r a c t i c e , education, and research are outlined. i v Table of Contents Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES v i LIST OF FIGURE v i i ACKNOWLEDGEMENT v i i i CHAPTER ONE Background to the Problem 1 Introduction 1 Background of the Program 7 The Cardiac Home Follow Up Program 7 Significance of the Study 9 Problem Statement 12 Purpose Statement 12 De f i n i t i o n of Terms 12 Assumptions 13 Outline of the Thesis Content 13 CHAPTER TWO: REVIEW OF RELEVANT LITERATURE 15 Introduction 15 Patient Education 15 Research i n Cardiac Follow Up Programs 17 Summary 24 CHAPTER THREE: METHODS 25 Introduction 25 Research Design 25 Sample C r i t e r i a and Selection Procedure 27 Data C o l l e c t i o n Procedures 28 Instrument 29 V a l i d i t y and R e l i a b i l i t y 29 Data Analysis 3 0 E t h i c a l Considerations 31 Summary 32 CHAPTER FOUR: PRESENTATION AND DISCUSSION OF RESULTS...33 Introduction 33 Sample Response 3 3 Demographics 34 Responses to the Program 38 Quantitative Findings and Discussion 39 Qual i t a t i v e Data 57 Parts of the Program Found to be Helpful 57 Suggestions for Program Changes 60 V Additional Comments 62 Limitations of the Study .....64 Summary 65 CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND IMPLICATIONS... 67 Introduction 67 Summary of the Findings 67 Conclusions 68 Implications for Nursing Practice 68 Implications for Nursing Education 69 Implications for Nursing Research 70 Summary 71 REFERENCES 72 APPENDIX A Letter to Participants 78 APPENDIX B Study Instrument 79 APPENDIX C Letter to Participants' Family Doctors 83 v i LIST OF TABLES Page Table 1: Demographic Characteristics of Part i c i p a n t s i n the Cardiac Home Follow Up Program 35 Table 2: Frequencies and Percentages of Individual Items 41 Table 3: Mean Scores for Individual Questions 44 Table 4: Summary of Frequencies and Percentages for Individual Items: Strongly Disagree or Disagree verses the Agree or Strongly Agree Groups 46 LIST OF FIGURE Page Figure 1 : Bar Graph Summary of Individual Items Collapsed to Disagree and Disagree and Agree Groups 4 v i i i ACKNOWLEDGEMENT I would l i k e to express my sincere gratitude to some of the people who helped me achieve t h i s goal. I am thankful fo r the generosity of the patients and families who took time to t e l l me t h e i r s t o r i e s and answered the survey. My cardiovascular nursing colleagues, Holly, Linda S., and Linda W., kindly and c r i t i c a l l y reviewed the survey t o o l and improved both the content and format. I am g r a t e f u l for the i n s p i r a t i o n of my mentors Helen Niskala and Rose Murakami. As well, my outstanding thesis committee, Carol J i l l i n g s , Sonia Acorn, and Raymond Thompson, provided me with c l e a r d i r e c t i o n and endless encouragement. I could not have succeeded without the patience and f l e x i b i l i t y of my supervisor and colleagues at the Broadway South Mental Health Team. Furthermore, the G e r i a t r i c Team generously allowed me to juggle work and school commitments over the l a s t 3 years and therefore made t h i s accomplishment possible. As well, I recognize the s i g n i f i c a n t contributions of many true friends who provided me with unlimited p r a c t i c a l and moral support. Specially thanks to Chris and Murphy for helping me get to the f i n i s h l i n e . F i n a l l y , my h e a r t f e l t thanks to my wonderful family Barbara, Dan, Sharon, and my late father, who have unwaveringly supported me i n a l l e f f o r t s . And to my r o l e model, my mother, Mary Ileana, thank you for making a l l things possible and meaningful. 1 CHAPTER ONE Background to the Problem Despite the p r o l i f e r a t i o n of primary prevention strategies, m i l l i o n s of North Americans continue to be diagnosed with chronic cardiovascular disease, the leading cause of death and d i s a b i l i t y i n Canada (Heart & Stroke Foundation of Canada, 1993). The unexpected event of a myocardial i n f a r c t i o n (MI) often i n i t i a t e s i n d i v i d u a l s and fam i l i e s into the chronic i l l n e s s arena. The sudden and often l i f e threatening nature of an MI accentuates the gravity of the i l l n e s s and requires that i n d i v i d u a l s and fami l i e s look for knowledge to discern what to expect i n the future. As well, patients and families must develop s k i l l s and receive support to manage new, complex regimes i n order to proceed along the continuum of r e h a b i l i t a t i o n ( E l l e r s , 1993) . Hos p i t a l i z a t i o n for a MI i s the f i r s t phase of the cardiac r e h a b i l i t a t i o n process. As Cornett and Watson (1984, p.3) propose"... the goal of cardiac r e h a b i l i t a t i o n i s to provide the patient and family with educational opportunities, the a b i l i t y to take care of themselves at home, and the a b i l i t y to make po s i t i v e decisions about t h e i r health." During the r e h a b i l i t a t i o n process, learning new information and ways to control heart disease i s a major r e s p o n s i b i l i t y for both the patient and family. r 2 T r a d i t i o n a l l y the dissemination of t h i s information s t a r t s i n the hospital setting, the acute phase of cardiac r e h a b i l i t a t i o n , and continues i n the community, the convalecent phase of cardiac r e h a b i l i t a t i o n (Cornett & Watson, 1984; Zemke, 1991). The purpose of providing health r e l a t e d information and in s t r u c t i o n through patient education i s to a s s i s t patients and families to become knowledgable, active, empowered participants i n the r e h a b i l i t a t i o n process. Research on patient education with cardiovascular patients and families confirms the benefits received from education, exercise, and support programs (Fridlund, Hogstedt, L i d e l l , & Larsson, 1991; Garding, Kerr, & Bay, 1988; G i l l i s s , Gortner, Hauck, Shinn, Sparacino, & Tompkins, 1993; Mullen, Mains, & Velez, 1992; Wilson-Barnett & Osborne, 1983). As well, there i s an expansive body of knowledge which i d e n t i f i e s the areas of concern for post MI patients and f a m i l i e s (Fair & Berra, 1995; Hilgenberg, Liddy, Standerfer, & Schraeder, 1992; Newton & Sivarajan Froelicher, 1989). Information concerning cardiac diet, safe exercise parameters, medication use, and other i d e n t i f i e d content areas should be reviewed with post MI patients and f a m i l i e s i n order to s a t i s f y t h e i r learning needs i n the post discharge period. In addition to relevant content, M i l l s , Barnes, 3 Rodell,and Terry (1985) assert that e f f e c t i v e patient education includes equal attention to a p o s i t i v e manner i n which the information i s presented. The attention to a motivational teaching s t y l e i s one component which authors i d e n t i f y as enhancing the teaching and learning i n t e r a c t i o n (Keeler, 1991; Redman, 1993; Smith, 1989). Despite knowing what to teach, how to teach, and when to teach, the patient education experience does not reach a l l patients who have been diagnosed with a MI, or t h e i r f a m i l i e s . Patients and families may be given accurate information during h o s p i t a l i z a t i o n which they cannot process because of physical and psychological l i m i t a t i o n s which negatively a f f e c t s t h e i r readiness to learn. A l t e r n a t i v e l y , the information may not be available to patients and fami l i e s due to r e s t r i c t e d hospital resources. Shorter h o s p i t a l stays af t e r a myocardial i n f a r c t i o n make acute care wards a challenging setting for nurses and other health professionals to incorporate relevant patient education programs as part of a comprehensive discharge plan. As well, the r e a l i t i e s of patients' sleep disturbances, fatigue, anxiety, lack of privacy, v a r i a t i o n s i n s t a f f teaching expertise, and competition for nursing time for other tasks act as s i g n i f i c a n t b a r r i e r s to appropriate information being transmitted and integrated by patients while i n the hospital setting (Bopp & Lubkin, 1990) . 4 In t h i s author's c l i n i c a l experience, a patient who i s discharged from hospital a f t e r a myocardial i n f a r c t i o n may have informal education, general written material, and b r i e f contact with s u r v i v a l instructions to manage cardiac emergencies, but l i t t l e else to help i n i n d i v i d u a l i z e d day-to-day management of chronic cardiovascular i l l n e s s issues. In addition family roles and expectations have also undergone changes as a r e s u l t of the MI experience (Dracup, Meleis, Baker, & Edlefsen, 1984; Hilgenberg, et a l . , 1992; Rankin, 1992). In the exhilaration of preparing for discharge from h o s p i t a l , a patient may not f u l l y appreciate the impact of the impending t r a n s i t i o n and subsequently lack the to o l s necessary to manage the change i n support structures. In the post discharge period the patient moves from a supportive h o s p i t a l environment where information and care are provided without prompting, to the home setting where uncertainty i s present (Christman, McConnell, P f e i f f e r , Webster, Schmitt, & Reis, 1988). The discharge to the home setting represents the confirmation of the convalescent phase of cardiac r e h a b i l i t a t i o n where the patient reaches "... p h y s i o l o g i c a l s t a b i l i t y " ( C o r n e t t & Watson, 1984, p.3). However, psychological s t a b i l i t y may not have been achieved, and patients and families may be unclear about appropriate a c t i v i t y l e v e l s , confused about instructions, and fear the 5 return of an MI or other exaggerated health concerns, and experience depression, denial, and anxiety symptoms (Cornett & Watson ). Approximately 4 to 6 weeks a f t e r discharge from h o s p i t a l , based on t h e i r medical s t a b i l i t y , MI patients may be e l i g i b l e to attend the t h i r d phase of formal cardiac r e h a b i l i t a t i o n programs which are community based and may or may not provide medical supervision (Brannon, Geyer, Foley & Wolf, 1988; Pashkow & Pashkow, 1993). These programs incorporate exercise, education, and strategies to f a c i l i t a t e r i s k factor modification and achieve changes i n behaviour. During t h i s post discharge period the patient and family resources are limited, and d i f f e r depending on the a v a i l a b i l i t y of community or hospital programs. Often patients problem solve as situations a r i s e and u t i l i z e the v i s i t s to doctors or emergency departments to request information. Many patients and families seek information from friends with s i m i l a r problems or investigate the s e l f help route to f i n d information. However, c l i n i c a l practice reveals a large number of patients and families who do nothing when a feature such as prolonged fatigue or persistent shortness of breath occur because they believe these symptoms to be normal i n t h e i r recovery. Many patients do not want to bother the physician and do not report c h a r a c t e r i s t i c s of t h e i r i l l n e s s u n t i l scheduled appointments when they may reveal t h e i r descriptions or choose to minimize the events. 6 One patient expressed to t h i s author the abandonment he f e l t a f t e r discharge from hospital i n t h i s analogy. When a person i s i n the hospital with an MI you are treated l i k e someone buying a new car; doctors, nurses, n u t r i t i o n i s t s , can't do enough for you. But when you go home there i s no one to ask or c a l l . No one to help you drive t h i s machine now that the emergency i s over. Clearly, a gap exists i n the a b i l i t y of patients and fam i l i e s to access relevant information consistently and develop problem solving s k i l l s i n the community s e t t i n g immediately post discharge and during the f i r s t 4 to s i x weeks at home. In some communities several non p r o f i t groups or hospitals o f f e r education and support classes f o r post MI patients and families. T r a d i t i o n a l l y such classes have been d i d a c t i c i n nature and the content focuses on cardiac anatomy and physiology, medication compliance issues, sexuality, and r i s k factor modification recommendations, but lack the p r a c t i c a l problem solving approach necessary to help patients learn new strategies to manage t h e i r i l l n e s s regimes. As well, these programs are r e s t r i c t e d to people who can meet on scheduled days, have access to reasonable transportation, and can afford the fee. Also, i f the programs are scheduled i n the evening, e l d e r l y people are less l i k e l y to be included i n the patient education forum. Therefore when a community based program of education, exercise, and support for patients discharged a f t e r a 7 myocardial i n f a r c t i o n i s available, i t i s important to look at the nature of the program and the impact on the c l i e n t s i n order to s a t i s f y e t h i c a l and evaluative requirements. The Cardiac Home Follow Up Program, being evaluated i n t h i s research, i s an example of such an i n i t i a t i v e . Background of the program The o r i g i n a l Early Discharge Cardiac Program was established i n 1982 with support from a grant from the B r i t i s h Columbia Health Research Foundation. The program goal was to provide specialized community nursing care to myocardial i n f a r c t i o n patients i n the convalescent phase of t h e i r r e h a b i l i t a t i o n and therefore reduce h o s p i t a l stay for patients who did not experience major complications (Litherland & Costanzo, 1984). The Cardiac Home Follow Up Program The e x i s t i n g Home Follow Up Cardiac Program i s an extension of the cardiac r e h a b i l i t a t i o n education and support program that i s i n i t i a t e d i n the ho s p i t a l s e t t i n g , and coordinated by the Nursing Unit Manager. Approximately one hundred and twenty two patients experience the program each year. The program employs one cardiac nurse expert 4 days a week and vacation replacement i s supplied by the cardiac ward at the hospital thus allowing for uninterrupted service to the community. The medical and nursing s t a f f of Step Down and the Coronary Care Units i d e n t i f y potential program candidates 8 who have experienced a myocardial i n f a r c t i o n , and a r e f e r r a l i s processed to the cardiac nurse expert. The cardiac nurse expert reviews the patient's course of recovery i n h o s p i t a l , and v i s i t s the patient and family while the patient i s s t i l l h o s p i t a l i z e d , to arrange the f i r s t home v i s i t . The program runs 4 day a week from eight t h i r t y to four t h i r t y during the day. Each patient and family u n i t stay i n the program 4 to 6 weeks, and the cardiac nurse expert averages one home v i s i t per week. In the i n i t i a l home v i s i t the patient, family member(s), and nurse set out an in d i v i d u a l i z e d plan for convalescence. Risk factors are reviewed, and an exercise regime i s outlined. The cardiac nurse expert accompanies the patient on the i n i t i a l walking program. The patient's blood pressure, pulse rate, and respir a t o r y rate are evaluated before and a f t e r exercise, and the exercise regime i s adjusted according to i n d i v i d u a l responses. A portable cardiac rhythm telemetry monitor i s also used by the cardiac nurse expert to i d e n t i f y rhythm changes before or afte r a c t i v i t y sessions. During subsequent home v i s i t s , the patients and fam i l i e s review and c l a r i f y information about symptom management, medications, n u t r i t i o n concerns, a l t e r n a t i v e therapies, and various personal worries that they experience since leaving the hosp i t a l . The families receive written i n s t r u c t i o n s and pamphlets about exercise, d i e t , and other appropriate health information to reinforce the nurse 9 expert's teaching v i s i t s . The patient's progress i s charted, and the cardiac nurse expert communicates changes or patient concerns to the car d i o l o g i s t s and family physicians. The patients and families also have telephone access to the program nurse, and they can c a l l the cardiac ward at the hos p i t a l for additional support. Patients and families are discharged from the program a f t e r 4 to 6 weeks and maintain contact with t h e i r family physicians and ca r d i o l o g i s t s . Some patients are discharged because of further medical c r i s e s , such as open heart surgery, which requires further hospital care. Occasionally, patients w i l l refuse to be enroled i n the program or discharge themselves from the program because they are not ready to attempt l i f e s t y l e changes aft e r t h e i r MI. The cardiac nurse expert provides the written materials to these patients and i n v i t e s them to c a l l the program o f f i c e i f they decide to enrol i n the future. However, patients may be enroled i n the program more than one time i f t h e i r condition requires home follow up. Significance of the Study C l i n i c a l involvement by the researcher with program pa r t i c i p a n t s yielded q u a l i t a t i v e data which suggest that patients and families found the early discharge program experience an in t e g r a l part of t h e i r r e h a b i l i t a t i o n and a po s i t i v e , confidence building exercise. Evaluation c r i t e r i a for conventional cardiac r e h a b i l i t a t i o n education and 10 exercise programs include return to work, h o s p i t a l readmission rates, absolute changes i n behaviours, r i s k factors, mortality, and morbidity rates. However, the a b i l i t y of the patient to manage the cardiac i l l n e s s i n the long term i s not t y p i c a l l y described or considered. Therefore, studies of the facets of programs which equip patients with relevant knowledge and s k i l l s w i l l add to the body of knowledge i n the s h i f t i n g paradigm of patient education and learning. Research indicates that i n d i v i d u a l s are able to learn from d i d a c t i c teaching s t y l e s (Mayou, MacMahon, Sleight, & Florencio, 1981; Milazzo, 1980; Rahe, S c a l z i , & Shine, 1975). Furthermore, patients benefit from relevant, noncoercive, in d i v i d u a l i z e d community care, which prepares them to take part i n decisions around t h e i r r e h a b i l i t a t i o n (Pashkow & Pashkow, 1993; Wenger, 1993). The process which allows patients to make the t r a n s i t i o n from an i l l n e s s free person to a person with an i d e n t i f i e d chronic cardiovascular disease who has survived a c r i t i c a l MI i s an area which requires further d e s c r i p t i o n . As well, c l i n i c i a n s need relevant, research based information which i d e n t i f i e s interventions which f a c i l i t a t e or hinder the t r a n s i t i o n i n order to structure accountable programs which meet the information and support needs of the p a r t i c i p a n t s (Ruzicki, 1987). Addi t i o n a l l y , the responses w i l l provide patient and family feed back and evaluative data to the program d i r e c t o r 11 on the relevance of the program and o f f e r information for continuous program improvement or refinement. As a r e s u l t of t h e i r feedback, the study w i l l provide the consumer of care a voice i n the program construction. In order to examine the nature of such a program, t h i s researcher considered several concepts and frameworks to design a survey for the program par t i c i p a n t s . Self e f f i c a c y , empowerment, mastery, qua l i t y of l i f e , and t r a n s i t i o n were considered. While the theory of s e l f e f f i c a c y helps researchers to predict which populations are l i k e l y to be successful i n modification of behaviours which reduce r i s k factors (Holden, 1991), the conceptualization does not a s s i s t i n the description of program components. As well, empowerment (Fahlberg, Poulin, Girdano, & Dusek, 1991) and mastery (Younger, 1991) are concepts which patients who succes s f u l l y learn to manage chronic cardiovascular regime seem to possess. Similarly, quality of l i f e i s also an element which researchers are attempting to quantify as measurement of outcomes afte r a MI (Wenger, 1986; Wenger, 1993) . Schumacher and Meleis (1994) outline a t r a n s i t i o n model and describe education and support programs as interventions which a s s i s t patients a f t e r acute i l l n e s s experiences. Since t h i s study w i l l describe the program elements which MI patients and families found h e l p f u l i n the 6 week period post discharge from hospi t a l , a t h e o r e t i c a l framework was not required. 12 Problem Statement What are the perceptions of MI patients and t h e i r f a m i l i e s about the content and helpfulness of a home follow up program ? i s the problem statement for the study. Purpose Statement The purpose of the study i s to investigate the effectiveness of a home follow up program which aims to provides information, exercise, and support to post-MI patients and t h e i r families i n the zero to six week time period immediately post discharge. Also, the research w i l l attempt to outline the facets of the program that were h e l p f u l to participants i n t h e i r recovery. The question w i l l provide data on the partic i p a n t s ' evaluation of the contribution of the program i n maintaining l i f e s t y l e changes within the same time period. D e f i n i t i o n of Terms Myocardial Infarction (MI)- permanent damage to heart muscle as a r e s u l t of interruption i n the c i r c u l a t i o n of the heart muscle Patient- A person who experiences a MI Family- the patient's i d e n t i f i e d s i g n i f i c a n t other(s) Cardiac r e h a b i l i t a t i o n - a d i r e c t i o n a l process which involves physiological, psychological, and s p i r i t u a l healing a f t e r a MI Patient education-the process which a s s i s t s patients to learn and integrate health-related practices into t h e i r 13 d a i l y l i v e s (Smith, 1989). Assumptions The study i s based on the following assumptions: 1. Participants i n the early discharge program possess i n d i v i d u a l differences and previous experiences which influence the conditions of t h e i r unique r e h a b i l i t a t i o n a f t e r an MI. 2. The program i s assumed to provide a forum f o r par t i c i p a n t s to have contact with a cardiac nurse expert and the contribution of the nurse expert's communication and c l i n i c a l excellence are an i n t e g r a l part of the program Outline of Thesis Content There are f i v e chapters i n t h i s t h e s i s . The background to the problem, problem statement, purpose, d e f i n i t i o n of terms, and assumptions of the study are outlined i n Chapter One. As well, the Cardiac Home Follow Up program i s described. In Chapter Two, relevant l i t e r a t u r e i s reviewed. The categories of Patient Education and Research i n Cardiac Follow Up Programs comprises the l i t e r a t u r e review. In Chapter Three the methodology i s presented. The research design, purpose, sample selection and c r i t e r i a , data c o l l e c t i o n procedure and instrument, data analysis, and e t h i c a l considerations are explained. Furthermore, i n Chapter Four the sample i s described and the findings are presented and discussed. In conclusion, Chapter Five 14 includes a summary of the study and conclusions with implications for nursing practice, education, and research. 15 CHAPTER TWO Review of Relevant Literature In t h i s chapter the exis t i n g l i t e r a t u r e on c h a r a c t e r i s t i c s of cardiovascular post h o s p i t a l i z a t i o n patient education programs which focus on helping patients and f a m i l i e s a f t e r a myocardial i n f a r c t i o n w i l l be examined. Also, several studies of cardiac s u r g i c a l patients and fami l i e s w i l l be included as the issues they encounter are s i m i l a r i n nature. Patient Education E l l e r s (1993) asserts that the aim of patient education i s " . . . t o promote an understanding of i l l n e s s , treatment, and health, and the patient's active p a r t i c i p a t i o n must be part of t h i s learning process(p.96)." The process of patient education and current models of cardiac r e h a b i l i t a t i o n advocate strategies which support and help patients change behaviours rather than d i d a c t i c a l l y providing information to f a c i l i t a t e medical regime compliance (Smith, 1989; Wenger, 1993). Furthermore, successful patient education i s r e a l i z e d when the patient takes health related content, becomes an active p a r t i c i p a n t i n the i l l n e s s management routines, and incorporates changes i n behavior into d a i l y practices (Smith, 1989) . The s o c i a l context of i l l n e s s management practices, immediate p r i o r i t i e s of the patients including q u a l i t y of l i f e issues, and perceptions of patient learning needs also 16 deserve consideration when planning e f f e c t i v e patient education experiences (Smith, 1989). As well, providing patients and families with accurate information and i l l n e s s management s k i l l s f a c i l i t a t e s confidence building, and increases consumer strength to negotiate productive r e l a t i o n s h i p s within the complex health care (Thorne, 1993). Wilson-Barnett and Osborne (1983) took a comprehensive view of patient education when they evaluated twenty nine studies of patient teaching. Twenty three of the studies i d e n t i f i e d a d i s t i n c t benefit for patients from a sustained r e l a t i o n s h i p between teachers and patients that allowed for repeated opportunities for questions to promote understanding. As well, t h e i r review directed nurses to focus on i d e n t i f y i n g patients p r i o r i t i e s for learning. Mullen, Maines, and Velez (1992) performed a meta analysis of 28 controlled t r i a l s of education for cardiac patients and summarized the attributes of d i d a c t i c and behavioral programs which a s s i s t cardiac patients i n achieving a healthy t r a n s i t i o n . The authors i d e n t i f i e d that patient educators need to employ key elements for successful programs. These elements include reinforcement and feedback opportunities, programs indi v i d u a l i z e d to the learners need with relevant content and the tempo set by the p a r t i c i p a n t s . As well, successful educative experiences f a c i l i t a t e p o s i t i v e behaviour development by p r a c t i c a l attention to reducing resource barriers and enhancing necessary s k i l l s to 17 encourage success. Both Wilson-Barnett and Osborne (1983) and Mullen, Maines, and Velez (1992) provide v a l i d a t i o n for the r a t i o n a l e of spending resources on patient education, which c l e a r l y provides consumers with benefits. At the same time, they charge educators to design meaningful learning programs which meet patient needs and p r i o r i t i e s , rather than the needs and p r i o r i t i e s of the educators. Jenny (1993) predicts that the Canadian patient education movement w i l l be i n greater demand as governments, who are changing and r e a l l o c a t i n g health services, look for ways to meet the consumers' needs. Therefore, attention to these recommendations from the meta-analyses w i l l provide relevant patient education programs and p o s i t i v e learning experiences for the consumers of care. The l i t e r a t u r e describing i n d i v i d u a l i z e d programs of education, exercise and support for chronic cardiovascular patients and families varies i n methodologies and i n timing of intervention strategies. The following section w i l l describe several studies which u t i l i z e telephone follow up, alone or i n conjunction with an enhanced patient education program, as well as face to face patient support provided i n the community. Research i n Cardiac Home Follow Up Programs In a p i l o t study, Keeling and Dennison (1995) used a d e s c r i p t i v e design and q u a l i t a t i v e methods to explore how 18 receptive MI patients and t h e i r spouses would be to post discharge telephone follow up. While a l l subjects were ho s p i t a l i z e d for a myocardial i n f a r c t i o n , nine also underwent percutaneous transluminal coronary angioplasty (PTCA), two required coronary artery bypass g r a f t surgery (CABG), and one surgical subject was implanted with an automatic cardioverter d e f i b r i l l a t o r . This population represents a broad perspective of the post MI cardiovascular i l l n e s s experience i n the post hospital phase. Two cardiac nurse c l i n i c i a n s contacted twenty one male subjects and t h e i r wives i n hospital and subsequently c o l l e c t e d data about patient and/or spouse concerns by 3 telephone follow up contacts at f i v e , fourteen, and twenty one days a f t e r discharge. The two hundred and s i x t y response phrases were sorted, analyzed for content, and f i v e themes were described. The themes included 11 d i f f i c u l t y i n accepting changed health status; attempts at cardiac r i s k factor reduction; concern for f i n a n c i a l d i f f i c u l t i e s ; dealing with uncertainty during early convalescence; appreciation for the nurse caring to telephone them and appreciation for the information and advise given i n the telephone contact"(Keeling & Dennison, 1995, p.47). The themes led the researchers to i d e n t i f y informational needs, emotional needs, and r e f e r r a l needs, as important aspects of follow up care that could be met through telephone contact by a cardiac nurse c l i n i c i a n . 19 Several authors ( Beckie, 1989; Garding, Kerr & Bay, 1988; G i l l i s s , Gortner, Hauck, Shinn, Sparacino, & Tompkins, 1993; G i l l i s s , Neuhaus, & Hauck, 1990; N i c k l i n , 1989; Pozen, Stechmiller, Harris, Smith, Fried,& Voigt, 1977; Tack & G i l l i s s , 1990;) describe experimental studies which employed telephone contact by nurse experts as part of or the e n t i r e therapeutic intervention used to provide support and information to patients and families during the post discharge phase of t h e i r cardiac i l l n e s s experience. Pozen and colleagues studied 102 MI patients who were randomized into high and low r i s k groups with matched controls, then exposed to an aggressive program of psychosocial support and education implemented by an nurse. The authors examined factors such as return to work time i n t e r v a l s , increase i n knowledge of disease and medical regime, and reduction of anxiety as indices of t h e i r patients' healthy t r a n s i t i o n a f t e r a myocardial i n f a r c t i o n . The i n d i v i d u a l i z e d , intensive, intervention started i n h o s p i t a l and continued i n the community through weekly telephone or personal contact by the cardiac nurse expert. Families were included i n three sessions pre-discharge. Through v a l i d and r e l i a b l e questionnaires, the authors concluded that the experimental post-MI group returned to work an average of 2 months sooner than the control group. Knowledge leve l s i n i t i a l l y improved at the pre discharge administration but equalized among a l l groups at one month and six months. No s i g n i f i c a n t 20 difference was found on reducing patient anxiety, but the experimental group reported decreased smoking behaviours at 6 months. The authors note that the t r i a l had a 15 percent a t t r i t i o n rate and therefore the r e s u l t s may be more representative of compliant patients. While the outcomes of timing of return to work, knowledge, and compliance to medical regimes are evolving towards control and containment of chronic cardiovascular i l l n e s s , t h i s research acknowledges the p o s i t i v e e f f e c t of an i n d i v i d u a l i z e d , therapeutic nursing intervention for post discharge cardiac patients. N i c k l i n (1986) reported research findings which outlined categories of concern for which discharged medical and s u r g i c a l cardiac patients and families and other interested parties sought telephone advice from a h o s p i t a l based cardiac nurse. The reference phone number was given to patients as part of t h e i r discharge planning education booklet and advice was available 24 hours a day, 7 days a week. F i f t y f i v e percent of the non randomized 217 c a l l s were placed within two weeks after discharge and f o r t y percent of that number occurred i n the f i r s t week a f t e r the patients l e f t the ho s p i t a l . The c a l l e r s sought advice for treatment of persistent chest pain and arrhythmias, medication concerns, leg pain/swelling, g a s t r o i n t e s t i n a l problems, psychologic issues, and miscellaneous questions. The study v e r i f i e s the need for the opportunity f o r 21 patients and families to ta l k with a cardiac expert within the immediate post discharge period. In for t y three percent of the telephone c a l l s , the nature of the problem required that the patient seek emergency department assessment. In t h i s study, the patients and families were a c t i v e l y seeking further information or confirmation of t h e i r concerns to ensure a movement towards successful t r a n s i t i o n a f t e r a cardiac i l l n e s s event. In a related study of patients 6 to 8 weeks post discharge, Garding, Kerr, and Bay (1988) concluded that the 9 patients i n the telephone support group received s i g n i f i c a n t assistance i n areas of pathophysiological information, exercise topics, and selected aspects of i l l n e s s regime management which promotes a healthy t r a n s i t i o n post MI. Beckie (1989) confirmed i n a study of 74 post coronary artery bypass patients that within the 6 week period post discharge, patients who received education and support from a nurse expert through telephone contact scored higher i n the realm of disease related knowledge and regime management and convalescence rest requirements. As well, the experimental group demonstrated lower l e v e l s of state anxiety at the 6 week period compared to the control group, and there was an inverse relationship established between patient knowledge and anxiety l e v e l s . Both studies suggest that the intervention f a c i l i t a t e d patient movement towards recovery by contributing to bridge gaps i n patient knowledge and subsequent s k i l l l evels i n regime management. As well, the p o s i t i v e e f f e c t of the support programs on anxiety helps a s s i s t patients i n t h e i r r e h a b i l i t a t i o n goal. With a s i m i l a r population, Tack and G i l l i s s (1990) studied the e f f e c t of a telephone support and education program on recovery for 75 cardiac s u r g i c a l patient-family p a i r s where the participants were c a l l e d weekly by nurses for the f i r s t month at home, then contacted by telephone at week 6 and 8 post discharge. The nurses recorded patient and family concerns and progress after each phone c a l l . The content analysis of the notes revealed common p a r t i c i p a n t concerns as nursing diagnosis, which were c l a s s i f i e d i n North American Nursing Diagnosis Association (NANDA) taxonomy, and included altered comfort, pain; i n e f f e c t i v e coping, i n d i v i d u a l ; a c t i v i t y intolerance; sleep pattern disturbance; and altered n u t r i t i o n . As well, the authors describe elements of the telephone program u t i l i z e d by the nurses to help participants i n t h e i r recovery. The elements of assessment, r e f e r r a l s to other services, supportive counselling, and teaching program nurses were i n t e g r a l parts of the program. However, the effectiveness of the program to the p a r t i c i p a n t s was not included within the scope of the study. The study also outlines the type of t r a n s i t i o n a l a c t i v i t i e s accomplished by the participants such as managing or preventing health problems, health promoting work, taking 23 part i n normalizing events, or p a r t i c i p a t i n g i n a c t i v i t i e s which eith e r help, or hinder recovery. The d e s c r i p t i v e nature of the study expands on the r e s u l t s of N i c k l i n (198 6) and discusses the psychosocial as well as the p h y s i c a l problems that patients and families t r y to solve a f t e r a major cardiac event. The valuable p a r t i c i p a n t data acknowledges the e f f o r t that i s required to make the t r a n s i t i o n to recovery after cardiac surgery and provides d i r e c t i o n for future program development i n the area of patient education and chronic i l l n e s s regime management. Since i l l n e s s events are experienced by the i n d i v i d u a l and t h e i r families, research on the impact of interventions on the family unit support system i s h e l p f u l to the cardiac population. G i l l i s s , Neuhaus, and Hauck (1990) studied 67 p a i r s of coronary artery bypass patients and t h e i r spouses who received nursing interventions aimed at improving family functioning post discharge. As well as supplemental pre-discharge support, the participants were contacted by telephone weekly for the f i r s t 4 weeks post discharge and again at 6 and 8 weeks. The pencil and paper reporting descriptors f a i l e d to demonstrate s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s i n the experimental group at 3 or 6 months. The authors proposed small sample size, protracted timing of written data c o l l e c t i o n , lack of i n c l u s i o n of q u a l i t a t i v e data from telephone c a l l s , and possible weak q u a l i t y of the telephone intervention as explanations of the lack of 24 e f f e c t . However, the Locke-Wallace Marital Adjustment Scale data suggests that while a l l patient scores increased, the spousal scores decreased over time i n d i c a t i n g increased s t r a i n on the partner of the patient as the patient s t a b i l i z e s during t r a n s i t i o n . Therefore the research continues to expose areas where he l p f u l support can be directed to cardiovascular patients and f a m i l i e s . G i l l i s s , et a l . (1993) studied 156 cardiac s u r g i c a l patients where 75 received enhanced i n d i v i d u a l i z e d pre-discharge session as well as weekly telephone support to 4 weeks post discharge and further follow up at weeks 6 and 8 post h o s p i t a l i z a t i o n . The e f f e c t of the program was s t a t i s t i c a l l y s i g n i f i c a n t i n changing patient s e l f e f f i c a c y towards walking behaviours, which was sustained throughout the research. The hypotheses that the program would p o s i t i v e l y a f f e c t s e l f e f f i c a c y for l i f t i n g , climbing, general and working a c t i v i t i e s , better mood states ,and improved q u a l i t y of l i f e were not supported. However, the intervention encouraged participants to walk more than the controls, which i s a s i g n i f i c a n t contribution i n improving functional status i n t h i s population and a l t e r n a t i v e l y promotes favourable r e h a b i l i t a t i v e focus. Summary The review of the l i t e r a t u r e has demonstrated r e l a t i v e p o s i t i v e e f f e c t s of individualized programs aimed at the period immediately post h o s p i t a l i z a t i o n a f t e r a cardiac event. However, there i s l i t t l e research which attempts to assess patient and family perceptions of the relevance of the content of such programs to a s s i s t i n ongoing program evaluation and improvement. In t h i s chapter the findings from the l i t e r a t u r e on patient education have been discussed and s e l e c t i n d i v i d u a l i z e d nursing interventions programs for cardiovascular patients and families have been described. The next chapter w i l l outline the d e t a i l s of the proposed study. 2 6 CHAPTER THREE Methods The methods of the study which describe p a r t i c i p a n t s ' views of the effectiveness of the cardiac home follow up program are outlined i n t h i s chapter. The research design, sample se l e c t i o n procedure, study instrument, and data analysis are also described. Research Design A descriptive study was selected to examine the perceptions of MI patients and families about the content and helpfulness of a home follow up program of support, exercise, and education. As P o l i t and Hungler (1991) state," d e s c r i p t i v e research outlines a phenomenon of i n t e r e s t to the nursing profession" (p.19). The phenomenon of i n t e r e s t i n t h i s study i s the community based post-MI home follow up program of information, exercise, and support. Examination of the program c h a r a c t e r i s t i c s w i l l add to the body of knowledge on patient education. A descriptive design w i l l allow the inclus i o n of q u a l i t a t i v e data of t h i s understudied population to augment the quantitative information and present a thorough p o r t r a i t of the program (Brink & Wood, 1989) . The design i s retrospective i n nature to capture a viewpoint of the patients' assessments of the program which can be c o l l e c t e d i n a reasonable time period. P o l i t and Hungler report that although ex post facto investigations are weaker than experimental studies, they are valuable i n 27 studying phenomena such as recovery, s a t i s f a c t i o n , and w e l l -being, when linked to nursing interventions. Sample C r i t e r i a and Selection Procedure Since the research was concerned with the perceptions of patients and families of the home follow-up program, a non p r o b a b i l i t y convenience sample of 122 p a r t i c i p a n t s who started i n the program over the previous 12 months were approached by mail and invited to p a r t i c i p a t e i n the study. Prospective respondents had been h o s p i t a l i z e d at a community hospital for a MI and they were enroled i n , but need not have completed, the cardiac home follow up program. The nurse expert who runs the program provided 122 p a r t i c i p a n t names, addresses, and family physician, to the researcher, from the hospital data base which included the previous one year period from August 1994 to August 1995. The community Hospital Research Committee also requested that each pote n t i a l participants' family physician receive a l e t t e r describing the purpose of the study and v e r i f y that the p o t e n t i a l participant had not expired. The researcher mailed l e t t e r s to the 64 family doctors or c a r d i o l o g i s t , i d e n t i f i e d by the data base l i s t . Six physicians c a l l e d to request exclusions for 7 patients and 1 patient moved out of the country with no forwarding address. As a r e s u l t of the contact from family doctors, 114 cardiac home follow up program participants were included i n the convenience sample. 28 Data C o l l e c t i o n Procedures Each person i n the sample received a package i n the mail which included a copy of the questionnaire with ins t r u c t i o n s for completing the questionnaire. The package also included a cover l e t t e r explaining the purpose of the research, the way the response data w i l l be u t i l i z e d , and an i n v i t a t i o n for participants to receive r e s u l t s when the study i s completed (Appendix A). As well, the material consisted of i n d i v i d u a l l y addressed and postage paid return envelopes and a telephone number and address where pa r t i c i p a n t s could contact the researcher, or research supervisor, for c l a r i f i c a t i o n of instructions. Two people telephoned the researcher because they did not take the program but wanted to know i f they should t r y and f i l l out the questionnaire. They were thanked for t h e i r c a l l and advised to disregard the request and therefore they were also excluded. The investigator planned to send a follow up reminder postcard to a l l participants at 1 and 3 week a f t e r the questionnaire package mail delivery i n an attempt to r e p l i c a t e the success of the Total Design Method, which average a seventy seven percent response for questionnaires handled i n t h i s manner (Dillman, 1983). The postcards, i n v i t i n g participants to send i n t h e i r completed questionnaires, went out i n a single mailing on January 7,1996, a f t e r the Christmas and New Year season. 29 Instrument A questionnaire was developed by the researcher to describe the c h a r a c t e r i s t i c s of the post MI program which patients and families found helpful i n t h e i r recovery (Appendix B). The instrument i s divided into three parts. Part 1 contains 16 statements about the content and format of the home follow up program. The respondents were requested to indicate on a four point scale, t h e i r opinions about program components. The scale contains the options 1= strongly disagree, 2=disagree, 3=agree, and 4=strongly agree. The higher the score, the more h e l p f u l the item i s viewed by the respondent. Part 2 contains four open ended questions asking the par t i c i p a n t s to i l l u s t r a t e parts of the program found h e l p f u l and to delineate suggestions for program improvement or change. Most of the people i n the survey group f i l l e d i n t h i s section and several r e p l i e d with suggestions to improve the effectiveness of the program. Part 3 of the questionnaire contains items on demographics, such as age and gender, and also asks about family involvement i n the program, and l i f e s t y l e changes made and maintained since the heart attack. V a l i d i t y and R e l i a b i l i t y V a l i d i t y r e f l e c t s "...the degree to which an instrument measures what i t i s intended to measure"(Polit & Hungler, 1991, p.657). Since the cardiac home follow up program had not previously been evaluated, 30 the researcher devised a questionnaire to measure the he l p f u l c h a r a c t e r i s t i c s of the program. The items were developed based on the l i t e r a t u r e and the researcher's interviews i n a p i l o t program which explored the experience of 7 former participants with the cardiac home follow up program. Face v a l i d i t y and content v a l i d i t y of the instrument were established by a panel of 3 cardiac nurse experts who have research backgrounds. These experts reviewed the study instrument for appropriateness of content and provided suggestions for changes i n the questionnaire. Plans were made to p i l o t the questionnaire by 3 former patients who have experienced an MI. However, the pre-Christmas timing of the review and the u n a v a i l a b i l i t y of the researcher for a 3 week period, made t h i s step unattainable and none of the 3 questionnaires were returned by former patients. R e l i a b i l i t y r e f e r s 1 1 . . . to the consistency, s t a b i l i t y , and r e p e a t a b i l i t y of a data c o l l e c t i o n instrument"(Brink & Wood, 1988, p.172). The researcher's instrument i s being used for the f i r s t time and therefore the r e l i a b i l i t y has not been established. Data Analysis The data from Parts 1 and 3 of the study instrument were analyzed by a s t a t i s t i c a l consultant, who u t i l i z e d the S t a t i s t i c a l Package for the Social Sciences (SPSSx), version 4.0. Each question from 1 to 16 i n Part 1 was reviewed and 31 r e s u l t s displayed i n frequency tables, which also describes v a l i d percents, i n which missing data are suppressed. Furthermore, the mean score and standard deviation of for each question i s reported. The summary of frequencies for the t o t a l "disagree" and "agree groups" for i n d i v i d u a l questions i s also presented i n chart and bar graph forms. Data on the demographic variables from Part 3 are displayed i n frequency tables and v a l i d percents. In addition to the quantitative evaluation, analysis was conducted on the data from the open ended questions i n Part 2 of the instrument. The responses were categorized and described i n themes. E t h i c a l Considerations Participant c o n f i d e n t i a l i t y was ensured by numerical i d e n t i f i c a t i o n of the respondents' questionnaires. P a r t i c i p a t i o n i n the study was voluntary and no coercion was applied by the researcher or the cardiac nurse expert. The covering l e t t e r indicated that the consent i s assumed i f the p a r t i c i p a n t s return the completed questionnaire to the researcher. The questionnaires, return envelopes, and postage were provided to the respondents and therefore they did not incur monetary expenses or r i s k . The returned data were retained i n a safety deposit box u n t i l analysis was completed. 32 Summary In the preceding chapter, the methods selected to describe the study re s u l t s has been outlined. As well, the p a r t i c i p a n t selection c r i t e r i a and sampling procedures were delineated. The measurement to o l designed for the research, was described and the e t h i c a l considerations were reported. F i n a l l y , the data c o l l e c t i o n and analysis procedures were outlined. 33 CHAPTER FOUR Presentation and Discussion of Results The c h a r a c t e r i s t i c s of the sample of respondents who pa r t i c i p a t e d i n the cardiac home follow up program are described i n the f i r s t part of t h i s chapter. In the second section of the chapter, quantitative and q u a l i t a t i v e findings from the survey are presented. Sample Response Of the 114 surveys mailed, 6 were returned undelivered. Twelve people who received the questionnaire contacted the researcher by telephone or mail to explain that they did not take the program and therefore they were not q u a l i f i e d to complete the survey. A l l of these patients who contacted the researcher reported that they received one or two v i s i t s from the cardiac nurse at home after aneurysm surgery, open heart surgery, or a mild heart attack. However, they did not perceive that they had participated i n a program and as a r e s u l t excluded themselves from the study. A l l of the people who excluded themselves i n t h i s manner wished me well i n my research despite t h e i r i n a b i l i t y to p a r t i c i p a t e i n evaluating the cardiac program. Therefore, 18 i n d i v i d u a l s were removed from the o r i g i n a l sample of 114, r e s u l t i n g i n 96 p o t e n t i a l participants. In t o t a l , 48 (50%) usable questionnaires were returned. Several participants did not complete portions of the demographic section but provided information on the 34 remainder of the survey. As well, one respondent pa r t i c i p a t e d i n the program 18 months previously. Data from t h i s questionnaire were included and the time frame documented. Demographics The sample i s described i n terms of age, gender, experience with the program, and status of completion of the program. The l e v e l of family involvement, status of l i f e s t y l e changes, maintenance of l i f e s t y l e changes, and recommendation of the program to others who have heart disease are also outlined. The largest group of respondents was between 65 to 74 years of age (46.7%), male (82.2%), and had experienced the cardiac home follow up program for the f i r s t time (88.9%)(Table I ) . Most participants completed the program (93.0%) and the length of time since the program was taken varied from 2 month to 18 months. The majority of subjects (86%) reported that family members were involved i n the program, l i f e s t y l e changes were made (88.9%), that the cardiac home follow up program helped them maintain l i f e s t y l e changes (86.4%). F i n a l l y , most of the respondents (97.7%) would recommend the program to other patients who have heart disease. The information from the demographic section of the survey questionnaire r e f l e c t s the age c h a r a c t e r i s t i c of the sample of program participants i n a circumscribed geographic area i n B r i t i s h Columbia. As anticipated, the majority of Table I: Demographic Characteristics of Part i c i p a n t s i n the cardiac Home Follow Up Program (n=48) Ch a r a c t e r i s t i c Frequency •Va l i d Percent Age (years) 75 and over 8 65-74 21 55-64 8 45-54 6 35-44 2 25-34 0 Missing data 3 Gender Female 8 Male 37 Did not answer 3 Program Experience F i r s t time 40 Second time 4 Third time 1 Did not answer 3 Completed the Program Yes 40 No 3 Did not reply 5 Time frame (months) since p a r t i c i p a t i o n i n Program 2-4 6 5-9 18 10-14 13 15-19 3 No reply 8 Family Involved Yes 37 No 6 Did not indicate 5 Made L i f e s t y l e Changes Yes 40 No 5 Did not answer 3 Maintained L i f e s t y l e Changes Yes 38 No 6 Did not indicate 4 Recommends the Program Yes 43 No 1 Did not respond 4 17.8 46.7 17.8 13 . 3 4 . 4 0.0 missing 17.8 82 . 2 missing 88.9 8 . 9 2.2 missing 93.0 7.0 missing 22 .5 45.0 32.5 7.5 missing 86.0 14.0 missing 88.9 11.1 missing 86.4 13 .6 missing 97.7 2.3 missing * Missing data suppressed 36 the p a r t i c i p a n t s (64.5%) are 65 years or older, while the age range of 35 to 64 i s represented by a smaller percentage (35.5%). This i s explained by the older resident population of the community, which i s a favoured retirement l o c a t i o n . While the age range i s higher than other regions i n the province, the trend i n demographics which proposes that our population w i l l consist of a larger group of c i t i z e n s over the age of 65 years by the year 2 001, may make t h i s sample a picture of future age proportioned programs of community care. Studies show that as the population ages, the r i s k f or mortality from cardiovascular causes r i s e s , most dramatically, regardless of gender, i n the over 65 year group (Heart and Stroke, 1993). The 82.2% male and 17.8% female d i v i s i o n of respondents i s also consistent with Canadian s t a t i s t i c s which report the incidence of cardiovascular disease i n men i s almost double that of women u n t i l women reach menopausal age, when t h e i r r i s k advances towards the r i s k to men (Heart and Stroke Foundation of Canada, 1993). In addition to age and gender, experience with the program was examined. Most of the subjects described a f i r s t experience with the cardiac home follow up program, and a majority completed the 6 week program i n the previous 2 to 18 months. Many of the subjects were introduced to the d i e t and exercise regimes of r i s k factor modification and l i f e s t y l e changes after the heart attack experience. 37 These practices also impact on family l i f e , therefore, the items concerning l i f e s t y l e changes and family involvement proved to be important c h a r a c t e r i s t i c s . The sample findings indicate that most subjects reported that l i f e s t y l e changes were made and maintained a f t e r t h e i r MI. Many authors profess that a c t i v i t i e s aimed at increasing exercise, c o n t r o l l i n g hypertension, modifying dietary f a t s , and cessation of smoking are some of the factors which impede coronary disease, and reduce r e i n f a r c t i o n r i s k (American Heart Association Writing Group, 1994) . Also, recent epidemiological reviews suggest that maintenance of an aerobic exercise program i s associated with reduction i n many of the previously mentioned coronary r i s k factors (Young, Haskell, J a t u l i s , & Fortmann, 1993) . Therefore, cardiac r e h a b i l i t a t i o n programs, such as the cardiac home follow up program, promote the p o s i t i v e changes recommended by the current knowledge i n cardiac r e h a b i l i t a t i o n . While making l i f e s t y l e changes are important, maintaining the changes can be a challenge to any program. Towards t h i s end, Pashkow and Pashkow (1993), i n s t r u c t program designers and c l i n i c i a n s to devise interventions which are achievable, thus encouraging patients to make long term r i s k factor modification goals attainable. The data from t h i s study r e l y on s e l f report and do not i d e n t i f y 38 s p e c i f i c r i s k factors, but the high percentages of l i f e s t y l e change and maintenance suggests that the program i s e f f e c t i v e i n these essential areas. The involvement of family was also acknowledged by a majority of the participants i n the study. F i n a l l y , an overwhelming number of the participants (97.7%) indicated t h e i r s a t i s f a c t i o n with the cardiac home follow up program, by s t a t i n g they would recommend the program to other people who have heart disease. Findings from Part 1 of the questionnaire, the individual items about the program, w i l l be discussed i n the following section. Responses to the Program In Part 1 of the survey, respondents were asked to rate t h e i r l e v e l of disagreement or agreement with statements about t h e i r experience with the cardiac home follow up program. The r e p l i e s were scored i n the following manner: strongly disagree = 1; disagree = 2; agree =3; strongly agree = 4; No Answer = missing data. The mean and standard deviations were calculated and the re s u l t s reviewed i n the following section i n quantitative terms. The data from the 48 usable questionnaires were assessed for the frequency and v a l i d percent of the strongly disagree and disagree group i n addition to the agree and strongly agree group and mean scores i n each of the 16 questions ( Tables 2 and 3 ). The researcher 39 constructed the questions so that the choice of the strongly agree group indicates that the participant found that item most h e l p f u l . In the following section, i n d i v i d u a l questions w i l l be reviewed and sample score r e s u l t s w i l l be discussed. Q u a l i t a t i v e Findings and Discussion Question 1 asked about the information provided i n the program about physical changes the par t i c i p a n t may experience post MI. A majority of respondents agreed (63.8%) or strongly agreed (31.9%) that the program s a t i s f i e d t h i s requirement for t h e i r information (Table 2). The item mean score was 3.3 (sd=.54) (Table 3), with a maximum possible score of 4.0. Clearly, most of the subjects' informational needs concerning potential physical changes post MI were s a t i s f i e d by the program. Experts accept that information about these changes i s a c r i t i c a l component to cardiac r e h a b i l i t a t i o n programs and as s i s t s patients i n responding appropriately to warning signs and other p o t e n t i a l l y dangerous presentations of cardiac disease (Keeling & Dennison, 1995; Newton & Sivarajan Froelicher, 1989; Pashkow & Pashkow, 1993). A recent review of problems encountered by cardiac patients i n the f i r s t 6 months post MI and coronary artery bypass gr a f t (CABG) surgery, affirms that physical changes continue to be problematic to patients a f t e r they leave the hospital (Jaarsma, Kastermans, Dassen, & Philipsen, 1995). 40 Table 2: Frequencies and Percentages of Individual Items n=48 frequency * v a l i d percent Q 1. The program provided information about physical changes I might experience af t e r a heart attack. Disagree 2 4.3 Agree 30 63.8 Strongly Agree 15 31.9 Missing 1 missing Q 2. The program offered information about emotional changes I might experience af t e r a heart attack. Strongly disagree 1 2.1 Disagree 5 10.6 Agree 3 0 63.8 Strongly Agree 11 22.9 Missing 1 missing Q 3. During the program I had a chance to t a l k about what i t was l i k e for me to have a heart attack. Disagree 4 8.7 Agree 34 73.9 Strongly Agree 8 17.4 Missing 2 missing Q 4. My family were included i n the program sessions and r e h a b i l i t a t i o n plan. Disagree 5 10.6 Agree 28 59.6 Strongly Agree 14 29.8 Missing 1 missing Q 5 . The program examined my in d i v i d u a l heart disease r i s k f a c t o r s . Disagree 7 14.9 Agree 28 59.6 Strongly Agree 12 25.5 Missing 1 missing 41 Table 2 : Frequencies and Percentages of Individual Items n=48 frequency * v a l i d percent Q 6. The program showed me ways to problem solve medical complications of my heart disease. Disagree 4 8.5 Agree 34 7 2.3 Strongly Agree 9 19.1 Missing 1 missing Q 7. The program showed me ways to deal with emotional aspects of my heart disease. Strongly disagree 1 2 . 2 Disagree 10 21.7 Agree 3 0 65.2 Strongly Agree 5 10.9 Missing 2 missing Q 8. The program helped me to talk to my doctor about my heart disease. Disagree 9 2 0.0 Agree 30 66.7 Strongly Agree 6 13.3 Missing 3 missing Q 9. I am more confident about managing my heart disease than I was before taking the program. Disagree 3 6.4 Agree 26 55.3 Strongly Agree 18 38.3 Missing 1 missing Q 10. The frequent contact with the cardiac nurse reduced some of the stress about recovering at home. Disagree 2 4.2 Agree 22 45.8 Strongly Agree 24 50.0 Q 11. The program was a source of support for me while I was recovering at home. Strongly Disagree 1 2.1 Disagree 1 2.1 Agree 22 45.8 Strongly Agree 24 50.0 42 Table 2 : Frequencies and Percentages of Individual Items n=48 frequency * v a l i d percent Q 12. The exercise part of the program helped me to resume a c t i v i t i e s during my recovery. Disagree 2 4.3 Agree 21 44.7 Strongly Agree 2 4 51.1 Missing 1 missing Q 13. The program information and problem solving ideas were presented c l e a r l y and e a s i l y understood. Disagree 2 4.4 Agree 23 51.1 Strongly Agree 20 44.4 Missing 3 missing Q 14. An in d i v i d u a l i z e d plan for recovery i s e s s e n t i a l a f t e r a heart attack. Disagree 2 4.3 Agree 16 3 4.8 Strongly Agree 28 60.9 Missing 2 missing Q 15. My heart attack affected the workings of my whole family Strongly Disagree 1 2.1 Disagree 12 25.0 Agree 2 0 41.7 Strongly Agree 15 31.3 16. The program helped us understand the changes within the family a f t e r my heart attack. Disagree 10 21.3 Agree 28 59.6 Strongly Agree 9 19.1 Missing 1 missing Table 3: Mean Scores for Individual Questions Item Mean score SD QI 3 . 3 .54 Q2* 3 . 0 . 62 Q3 3 .1 . 51 Q4 3 .1 . 61 Q5 3.1 . 63 Q6 3 .1 .52 Q7* 2.8 .63 Q8* 2.9 .58 Q9 3 . 3 .59 Q10 3 . 5 . 58 QU 3.4 . 65 Q12 3.5 .58 Q13 3.4 .58 Q14 3.6 . 58 Q15* 3 . 0 .81 Q16* 3 . 0 . 64 * lower scores 44 Table 4: Summary of Frequencies and Percentages f o r Individual Items:Strongly Disagree or Disagree verses Agree or Strongly Agree Item Frequency *Valid percent Frequency V a l i d percent DISAGREE AGREE Qi 2 4.3 45 95.7 Q2 6 12.8 41 87.2 Q3 4 8.7 42 91.3 Q4 5 10. 6 42 89.4 Q5 7 14.9 40 85.1 Q6 4 8.5 43 91.5 Q7 11 23.9 35 76.1 08 9 20.0 36 80. 0 Q9 3 6.4 44 93.6 Q10 2 4.2 46 95.8 Q U 2 4.2 46 95.8 Q12 2 4.3 45 95.7 Q13 2 4.4 43 95.6 Q14 2 4.3 44 95.7 Q15 13 27.1 35 72 .9 Q16 10 21.3 37 78.7 * v a l i d percent missing data suppressed 45 Figure 1: Bar Graph Summary of Individual Items Collapsed to Disagree and Agree Groups C A R D I A C H O M E F O L L O W UP P R O G R A M Questionnaire Responses Item 0 20 40 60 . 8 0 100 Percent % H B Disagree g l i i Agree n = 48 46 Therefore, the confirmation from the sample that information on physical changes i s h e l p f u l indicates that t h i s content needs to be retained i n the program. The provision of information about emotional changes following a MI was the topic of question 2. A large percentage of respondents agreed (63.8%) or strongly agreed (22.9%), while a few disagreed (10.6%) or strongly disagreed (2.1%)(Table 2). The item achieved a mean score of 3.0 (sd=.62)(Table 3). While the score i s not as high as that assigned to the information on physical changes, the l i t e r a t u r e confirms the need to provide patients and t h e i r f a m i l i e s with tools to a s s i s t them i n dealing with the i n e v i t a b l e psychological changes following a c r i t i c a l cardiac event (Cornett & Watson, 1984; Rankin, 1992; S c a l z i & Burke, 1982; Wishnie, Hackett, & Cassem, 1977). In a recent publication, Dracup (1995), estimates that emotional d i s a b i l i t y i s experienced by almost one quarter of the post MI population. Although individuals d i f f e r i n t h e i r coping s t y l e s and a b i l i t i e s , the provision of an opportunity to ant i c i p a t e emotional changes i s also an important a facet of t h i s community based r e h a b i l i t a t i o n program. A review of problems encountered by cardiac patients i n the f i r s t 6 months post MI and coronary artery bypass g r a f t surgery also highlighted psychological changes continue as a s i g n i f i c a n t area, i n which they required more information and assistance (Jaarsma, et a l . , 1995). Because the sample assigned a lower 47 score for t h i s item, the program needs to include more content on information about potential emotional changes a f t e r a heart attack. Question 3 i d e n t i f i e d that many par t i c i p a n t s were able to t a l k about the personal relevance of the heart attack experience. Most of the subjects agreed (73.7%) or strongly agreed (17.4%) with t h i s statement (Table 2). The item generated a t o t a l mean score of 3.1 (sd=.51)(Table 3). The c l i n i c a l experience of the researcher with cardiovascular patients reveals that patients want c l i n i c i a n s to understand what the heart attack experience was l i k e for them. Most encounters with cardiovascular patients begins with a recounting of the heart attack experience from beginning to end. Hawthorne (1991) believes that when cardiac disease i s described, the MI event remains prominent i n the minds of most people. Hawthorne also advocates viewing chronic cardiac i l l n e s s through a trajectory framework and therefore, the sudden event of a MI becomes part of the person's understanding the course of t h e i r i l l n e s s . Perhaps the opportunity to reveal these data acts as a therapeutic intervention which f a c i l i t a t e the r e h a b i l i t a t i o n process. This valuable piece of information may as well set the context from which a t r u l y i n d i v i d u a l i z e d care plan can be constructed. Family involvement i n the program was the focus of question 4. Most subjects agreed (59.6%) or strongly agreed 48 (29.8%) that t h e i r family was included i n the program (Table 2). The mean score was 3.2 (sd=.61)(Table 3). The findings confirm what authors profess as a valuable part of cardiac r e h a b i l i t a t i o n : inclusion of spouse or other family members i n the programs ( Newton & Sivarajan Froelicher, 1989; Schott & Badura, 1988). This inclusion concept i s also supported i n the l i t e r a t u r e by the recognition of the importance of an individual's s o c i a l context i n successful patient education (Smith, 1989). Furthermore, researchers have expanded t h e i r programs of education and support to include both patients and spouses i n recognition of the value of t h i s s i g n i f i c a n t s o c i a l network ( G i l l i s s , et a l . , 1990; Keeling & Dennison, 1995; N i c k l i n , 1986; Pozen et a l . , 1977; Tack & G i l l i s s , 1990). Question 5 examined the a b i l i t y of the program to target the par t i c i p a n t s ' individual r i s k factors during recovery at home. The majority of respondents agreed (59.9%) or strongly agreed (25.5%) that t h i s item was s a t i s f i e d by the program. The mean score was 3.1 (sd=.63)(Table 3). Since t h i s point can be considered a d e f i n i t i v e example of an in d i v i d u a l i z e d plan of care, t h i s discussion w i l l be incorporated with question 14, which focuses on the in d i v i d u a l i z e d plan for recovery. Problem solving strategies to deal with medical complications of heart disease was the focus of question 6. The p o s i t i v e trend continued as the majority of respondents 49 agreed (72.3%) or strongly agreed (19.1%) that t h i s was accomplished i n the sessions (Table 2). The mean score was 3.1 (sd=.52)(Table 3). The importance of including problem solving techniques i n cardiac programs continues to be validated by many authors (Beckie, 1989; Garding et a l . , 1988; Newton & Sivarajan Froelicher, 1989; N i c k l i n , 1986). Recently, Dracup (1995) observed that patients who have had a MI demonstrate the same median delay rate of 4 hours, also reported by the general population, before seeking h o s p i t a l treatment of serious cardiac complications. Consequently, favourable responses from these scores may be l i f e s a v i n g i n nature and reveal that the program parti c i p a n t s understand the warning signs that herald complications, and therefore can act appropriately. In question 7, the topic of strategies to deal with emotional aspects of heart disease was explored. Most of the par t i c i p a n t s agreed (65.2%) or strongly agreed (10.9%) with the statement (Table 2). However, the mean score was 2.8 (SD=.63)(Table 4), and constituted the lowest mean score of a l l 16 items. This low score affirms that the emotional content area i s not as well supported with p r a c t i c a l problem solving interventions i n t h i s cardiac follow up program. Since cardiac patients continue to require such problem solving s k i l l s i n the f i r s t 6 months afte r discharge from h o s p i t a l (Jaarsma, et a l . , 1995), the low score for t h i s item d i r e c t s the exis t i n g program to improve i n s t r u c t i o n for 50 p a r t i c i p a n t s to develop and practice strategies to deal with the emotional aspects of heart disease. The help provided to participants to t a l k to t h e i r doctors about t h e i r heart disease concerns was assessed i n question 8. The res u l t s showed that the majority of subjects agreed (66.7%) or strongly agreed (13.3%) with the item (Table 2). The mean score of 2.9 (sd.=.58)(Table 3). This t o p i c i s part of the specialized s k i l l required to i n t e r a c t with providers of cardiac information and care. In order to promote understanding of the cardiac i l l n e s s , treatments and choices ( E l l e r s , 1993) sharing a clear, common language could help to b u i l d therapeutic relationships between the consumers and providers of care (Thorne, 1993). As the second lowest mean score of the 16 items, the r e s u l t advises the present cardiac program to increase the focus on development of t h i s communication s k i l l . In question 9, the respondents were asked to comment on whether they were more confident about managing t h e i r heart disease since completing the home follow up program. A majority of subjects agreed (55.3%) or strongly agreed (38.3%) that they had achieved t h i s stance (Table 2). The item received a mean score of 3.3 (SD=.59)(Table 3). The discussion from question 6 on problem solving as part of the regime of r e h a b i l i t a t i o n applies equally to t h i s statement. However, the introduction of the element of confidence suggests that the participants have integrated-the knowledge 51 about physiological and emotional changes and are active p a r t i c i p a n t s i n t h e i r cardiac care, a hallmark of e f f e c t i v e patient education and relevant r e h a b i l i t a t i o n (Smith, 1989; Wenger, 1993). As Thorne (1993) observes, confidence i n management of chronic i l l n e s s regimes i s acquired over time, and depends heavily on' experiential knowledge. Therefore, the repeated p o s i t i v e interactions with the program may a s s i s t the participants gain confidence i n t h e i r a b i l i t y to succes s f u l l y manage cardiac regimes. The following two questions, question 10 and question 11, w i l l be discussed together as they r e l a t e to the support provided to the participants. The focus of question 10 was the e f f e c t of the repeated contact with the cardiac nurse on reducing the stress of home recovery. The respondents were almost unanimous i n t h e i r agree (45.8%) or strongly agree (50%) choices and the item obtained a mean score of 3.5 (sd=.58)(Tables 2 and 3). Similarly, the responses to question 11 uncovered the opinion that the program was a source of support to the participants. Of the sample, 45.8% agreed and 50% strongly agreed with the statement and the mean score was 3.4(sd=.65)(Tables 2 and 3). The subjects' reports of stress reduction during recovery because of repeated contact and the ove r a l l supportive nature of the program r e f l e c t the benefits of developing a sustained r e l a t i o n s h i p between instructor and parti c i p a n t s with frequent opportunities for c l a r i f i c a t i o n of information 52 (Wilson-Barnett & Osborne, 1983). These therapeutic v i s i t s by a nurse also provide a chance for p a r t i c i p a n t s to receive e s s e n t i a l reinforcement and feedback (Mullen, et a l . , 1992). The concept that the participants f e l t cared f o r and appreciated the opportunity to get support i n the form of information or counselling i s confirmed by at lea s t one study on post discharge follow up programs (Keeling & Dennison, 1995). In addition to the value of the supportive nature of the program, subjects described the conviction that the exercise component of the program helped them to resume a c t i v i t i e s during recovery. From the data i n question 12, most of the participants agreed (44.7%) or strongly agreed (51.1%) that the exercise part of the program was h e l p f u l (Table 2). The item mean score was 3.5 (sd=.58)(Table 3) and represents the second highest score a f t e r i n d i v i d u a l i z e d care plan item i n question 14. Since exercise i s a c r u c i a l component i n cardiac recovery regimes (American Heart Association Writing Group, 1994; G i l l i s s , et a l . , 1993; Newton & Sivarajan Froelicher, 1989), the opinion of the par t i c i p a n t s that the a c t i v i t y part of the program was h e l p f u l may promote the maintenance of the behaviour. As well, the subjects' views indicate that success i n the supervised exercise portion of the program s u f f i c i e n t l y supported and encouraged them to resume unspecified pre i n f a r c t i o n a c t i v i t i e s . As r e f l e c t e d i n the high mean scores, 53 the p a r t i c i p a n t s value the supervised exercise component of the program and therefore t h i s element should be retained and perhaps enhanced. As an adjunct to questions 1, 2, and 5, which r e l a t e to information and r i s k factors, question 13 looked at the c l a r i t y of the information presented by the Cardiac Home Follow Up Program. The majority of the respondents agreed (51.1%) or strongly agreed (44.4%) with the statement (Table 2). The item mean score was 3.4 (sd=.58)(Table 3). Since one of the goals of the patient education process i s to promote integration of an individualized plan, and u t i l i z a t i o n of knowledge and s k i l l for management of the recovery regime (Smith, 1989), confirmation from the par t i c i p a n t s scores that the information i s well presented and understandable i s reassuring. The quality of the communication between providers and consumers must be clear and f l u i d to provide opportunities for feedback and reassurance (Mullen et a l . , 1992) . The information i n question 14 reveals that the majority of participants agreed (34.8%) or strongly agreed (60.9%) that a f t e r a heart attack, the plan for recovery should be ind i v i d u a l i z e d (Table 2). The item mean score was 3.6 (sd=.58)( Table 3) and represents the highest mean score of the 16 items. The l i t e r a t u r e supports i n d i v i d u a l i z e d plans as a fo c a l point for successful patient education programs and r e h a b i l i t a t i o n program ( E l l e r s , 1993; Mullen 54 et a l . , 1992; Wenger, 1993). As well, personalized pr e s c r i p t i o n s for recovery emphasise the p r i o r i t i e s of the par t i c i p a n t s , rather than the providers of care, and therefore, the content has more relevance (Mullen et a l . , 1992; Smith,1989). Since the participants of the Cardiac Home Follow Up Program confirm the importance of the in d i v i d u a l i z e d plan for recover by a t t r i b u t i n g the item the highest mean score, the program i s sanctioned to continue to provide personalized recovery needs assessments and recovery plans. Because of the similar root, questions 15 and 16, w i l l be discussed together. The b e l i e f that a heart attack a f f e c t s family functioning was explored i n question 15. A large percentage of subjects agreed (41.7%) or strongly agreed (31.3%) with the statement and the topi c received a mean score of 3.0 (sd=.81)(Tables 2 and 3). Interestingly, a s i g n i f i c a n t number of participants either strongly disagreed (2.1%) or disagreed (25%) with t h i s statement, which explains the larger variance i n t h i s mean score. The f a c t that some MI patients dispute any impact of the event i n t h e i r f a milies may be explain by the l i t e r a t u r e which c i t e s d i f f e r i n g concerns between patients and spouses, as a source of stress during cardiac recovery (Newton & Sivarajan Froelicher, 1989). While many participants acknowledged the changes i n family functioning post MI, a smaller group perhaps equated a short hospital stay, and re s o l u t i o n of 55 symptoms as signals that the MI would not r e a l l y change t h e i r l i v e s (Wenger, 1993). This group probably would not view themselves as being chronically i l l . On the same s o c i a l contextual theme, the f i n a l question r e l a t e s to the part the program played i n helping p a r t i c i p a n t s understand changes within the family, post MI. Many par t i c i p a n t s agreed (59.6%) or strongly agreed (19.1%) with the statement and as a re s u l t , the item mean score was 3.0 (sd=.64)(Tables 2 and 3). Surprisingly, the mean scores for questions 2, 15, and 16, are low at 3.0 for a l l three items. These questions are linked by the emotional changes experienced by the participant and t h e i r perception of the e f f e c t of t h e i r MI on the family. The lower scores may r e f l e c t expressive d i f f i c u l t i e s p articipants encounter when dealing with a serious i l l n e s s . The basis for these responses cannot be uncovered i n t h i s study, but the discrepancy between views on ef f e c t of MI on family functioning i s a valuable element to consider when providing and planning care. G i l l i s s et a l . (1990) noted a decrease i n family functioning at 3 months post MI regardless of intervention or control group. However, on a Ma r i t a l Assessment t o o l at 6 months after the c r i s i s of cardiac surgery, the patients showed improvement but spouses d i d not. Therefore, the potential paradoxical r e l a t i o n s h i p s between patients and family i n the recovery period post MI, continues to pose challenges for therapeutic in c l u s i o n s , to 56 providers of r e h a b i l i t a t i o n programs. Clearly, the lower scores for these items d i r e c t the present program to increase attention to the emotional aspects and include family functioning content for patients who are recovering from a MI. In Table 4 and Figure 1 the collapsed data of the two groups, program participants who agree or strongly agree, and program participants who disagree or strongly disagree are summarized. Undoubtedly, the majority of p a r t i c i p a n t s j o i n the former group and confirmed that the program was h e l p f u l to them during t h e i r recovery a f t e r a MI. The most he l p f u l components of the program achieved v a l i d percents above 9 0% from the "agree " group. These components included the exercise portion (95.7%), support from the nurse's weekly home v i s i t s (95.8%), i n d i v i d u a l i z e d recovery plan (95.7%), information about possible physical changes post MI (95.7%), c l a r i t y of information and problem solving ideas (95.6%), and strategies to deal with medical complications of heart disease (91.5%). D i s s i m i l a r i t y , the participants described disagreement with the items from the questionnaire which focused on the impact the heart attack had on t h e i r family (27.1%), help received from the program to understand changes i n family functioning post MI (21.3%), a c q u i s i t i o n of s k i l l s to deal with emotional aspects of 57 heart disease (23.9%), and s k i l l s to t a l k with t h e i r physicians about participant concerns related to t h e i r heart disease(20%)(Table 4 and Figure 1). The preceding section summarizes the quantitative data provided from Part 1 and Part 3 of the Cardiac Home Follow Up program Questionnaire. The responses from p a r t i c i p a n t s to the open ended questions i n Part 2 of the questionnaire w i l l be described i n the following section. Q u a l i t a t i v e Data Open ended questions i n v i t e d respondents to comment on aspects of the program that helped them f e e l p h y s i c a l l y and emotionally better. Similarly, participants were asked to recommend areas for program changes i n order to improve the service. F i n a l l y , subjects had an opportunity to report a d d i t i o n a l comments about t h e i r experience with the program. Parts of the program found to be h e l p f u l Three themes emerged from the data regarding the parts of the program which helped subjects f e e l p h y sically and emotionally better. F i r s t l y , the respondents i d e n t i f i e d that i n d i v i d u a l discussions with a caring, encouraging cardiac nurse, i n t h e i r homes, i n s t i l l e d confidence i n t h e i r a b i l i t i e s to survive r e h a b i l i t a t i o n . The benefits of personalized recovery plans has been confirmed i n the quantitative section with the discussion of questions 5 and 14. Secondly, the incremental exercise component, supervised by a c l i n i c a l l y s k i l l e d professional, also 58 provided additional security while recovering at home. As an in t e g r a l part of the r e h a b i l i t a t i o n regime ,this theme was also validated with i n the dialogue for questions 12. Thirdly, the provision of information about physical a c t i v i t i e s , d i e t , and the heart attack was e s s e n t i a l to t h e i r physical and emotional well being i n the period post MI. S i m i l a r l y , the discussion from questions 1, 2, and 13 of f e r l i t e r a t u r e support for these themes. A l l p articipants i d e n t i f i e d p o s i t i v e therapeutic interactions for both education and support i n the program post MI, because the nurse repeatedly v i s i t e d them i n t h e i r homes. Authors endorse repeated opportunities f o r reinforcement, c l a r i f i c a t i o n , and occasions for feedback, to f a c i l i t a t e e f f e c t i v e patient education (Mullen, et a l . , 1992; Wilson-Barnett & Osborne, 1983). A d d i t i o n a l l y , respondents stated that the nurse communicated a sense of caring, which they found equally b e n e f i c i a l . The following excerpts from the partic i p a n t s ' comments w i l l describe t h e i r perceptions of he l p f u l parts of the program. "Most he l p f u l was the v i s i t to my home by the heart nurse taking me for i n i t i a l walks and instructions at exercise classes." " A l l the information given to me and the nurse v i s i t s e s p e c i a l l y t a l k i n g to me that I would f e e l better on certain diets and proper food to help me to get well again and return to normal l i v i n g etc." "Assurance from the nurse that I was better." "Knowing that there was someone to c a l l i f necessary." 59 "The weekly home v i s i t s and walking and check up on blood pressure and pulse etc." "The one on one attention." "Discussing the emotional reactions of the body post heart attack." "Being able to tal k to my nurse about my problems; t a l k i n g about my heart attack was of great emotional benefit." "The understanding and care of the nurse giving the program." "Attitude of attending nurse at my home while I was recovering. She gave me much confidence." "The home nurse got me off my duff and out walking." "Knowing others have experienced s i m i l a r problems and survived." "The assurance of both nurses and doctors to carry on a way of normal l i f e . " Some respondents placed emphasis on the nurse's c l i n i c a l expertise and a b i l i t y to monitor physical parameters as an important factor i n the program which provided a d d i t i o n a l security to proceed i n the r e h a b i l i t a t i o n process. "Through walking with a q u a l i f i e d nurse,you become confident to s t a r t a c t i v i t i e s on your own with spouse and family." "Staged a c t i v i t y program over 4 - 6 weeks.Well thought out and monitored-more for my wife's well being than mine." "Being monitored and encouraged i n l i f e s t y l e changes." "Assessment of the amount of exercise to perform on i n d i v i d u a l conditions." Many respondents focused on the information on d i e t and 60 exercise as s i g n i f i c a n t aspects of the program that helped them f e e l both p h y s i c a l l y and emotionally better. " A l l information given to me and nurse v i s i t s e s p e c i a l l y t a l k i n g . " "Understanding what happened and being aware of signs." "A greater understanding of a heart attack." "Information and problem solving ideas helped." "Information enabled me to properly begin and continue my exercise regime." "Knowing exactly what was going on i n my body and support having the home nurse to t a l k to." From the preceding responses, the subjects valued the continuity of and caring nature of an expert cardiac nurse who provided information and support to them during the immediate post h o s p i t a l i z a t i o n period. The supervised exercise program and the monitoring c a p a b i l i t y of the nurse also encouraged and i n s t i l l e d confidence i n the p a r t i c i p a n t s ' a b i l i t i e s to proceed along t h e i r personal recovery course. Suggestions for program changes While a large number of subjects did not indicate a need to modify the program, several participants answered question 19 with recommendations for program improvement. These recommendations included supplemental follow up contact, and better communication linkages. "Follow up to reinforce changes and reading of books on change reversing heart disease." 61 "More d i r e c t access to heart doctor and nurse when problems arose at home." "Extended nurse contact with periodic follow up." "Follow up v i s i t or phone c a l l once or twice i n 6 months." "Contact number to a nurse to discuss symptoms." "Keep the program going and keep i n contact with patients." As well, several respondents indicated a need for a more intense experience and a greater amount of family i n c l u s i o n i n the exis t i n g post MI program, i n order to improve the program . "Increased frequency and number of v i s i t s . More attention to spouse, especially i f older." "More spouse counselling." "Include other family members. More information about psychological e f f e c t s . " A d d i t i o n a l l y , two subjects c l e a r l y sought more information to manage t h e i r heart disease. "Patients could receive more information on the medical data,ie.cholesterol count,.blood counts etc. which would aid patient i n tracking t h e i r physical progress. More s p e c i f i c information would be h e l p f u l . " "More emphasis on f a t reduced di e t at home." The concept of peer support was mentioned by two pa r t i c i p a n t s , as a factor that could enhance the program and help people recovering at home after a heart attack. This suggestion f i t s into the framework which accepts that c h r o n i c a l l y i l l patients value experiential learning above medical information (Thorne, 1993). "A Buddy system to tal k to someone who has been through procedures would reduce the fear f a c t o r . " "Volunteers who have success s t o r i e s to accompany the q u a l i f i e d nurse." Additional comments The l a s t open ended question asked for a dditional comments on the par t i c i p a n t s ' experience with the home follow up program. More than half of the respondents used t h i s space to provide t h e i r evaluation of the program. Subjects c l e a r l y f e l t the sense of connectedness and partnership with t h e i r community hospital and they expressed gratitude and s a t i s f a c t i o n with t h e i r involvement with the home follow up program. These data are sim i l a r to the findings of Keeling and Dennison (1995), who evaluated a telephone follow up program to post MI patients. "Exercise program i n hospital and at home were most h e l p f u l . " "Whole experience was po s i t i v e ; i n hos p i t a l the Intensive Care Unit care was extraordinary and l i v i n g alone the follow up program was a great asset." "Program i s O.K. The hospital part was magical." "Impressed with information received i n h o s p i t a l and more impressed with the cardiac nurse home v i s i t s ; wonderful worthwhile program." While some participants succinctly stated that they were s a t i s f i e d with the program, others reported on the s p e c i f i c benefits received as a r e s u l t of the program. "Excellent program . Keep i t up." 63 "Great as i t i s . " " F i r s t rate." "The program r e a l l y helped i n a l l aspects." "A very p o s i t i v e program." "Made me f e e l more knowledgeable and secure." "The program and especially the v i s i t i n g nurse were a tremendous help to us." "Wonderful. Really u p l i f t e d my morale." "I am most greatful for the services of a knowledgeable and empathetic person." "I f e l t being i n good hands and well cared for and advised about taking care of myself i n the future." "I learned alot about myself; how to handle emotional stress and take i t easy-not to get angry but walk away from the trouble. I learned to relax and be calm i n bad situations." "The program prevented my family and friends from turning me into a cardiac c r i p p l e . " "I was t o t a l l y s a t i s f i e d with the follow up by the nurse who came to the home. Kept my exercise on track and was of great help to my wife." The s k i l l development of managing stress indicates that the p a r t i c i p a n t worked on devising a strategy based on an i n d i v i d u a l plan of care. The l i t e r a t u r e espousing the benefits of personal prescriptions has been previously described and t h i s example i l l u s t r a t e s how the i d e a l can be actualized. The s o c i a l context of the participant's p o s i t i o n i n the family i s also declared i n these q u a l i t a t i v e data, where one participant asserts that the program prevented 64 d i s a b i l i t y from unnecessary protection from family and friends. The r e p e t i t i o n of v a r i a t i o n of family involvements continues to be revealed i n the q u a l i t a t i v e data f o r the p a r t i c i p a n t s i n the program. Limitations of the Study The study r e s u l t s are representative of a s e l e c t group of patients i n a s p e c i f i c geographic location who have experienced an MI, therefore, the findings are generalizable only to t h i s group. As well, the strong therapeutic r e l a t i o n s h i p developed with the program nurse may influence the study data as participants would l i k e to provide favourable r e s u l t s for the program evaluation. The study r e s u l t s should be considered within the context of the methods used. The small sample s i z e , with a return rate of 50%, captures the opinions of the compliant group who chose to respond. The researcher did not make any provisions to contact non responders to explore reasons why they did not return the survey. Rich data could be generated from dialogue with people who participated i n the program but did not want to put t h e i r opinions on paper. As well, the subjects were required to be l i t e r a t e to p a r t i c i p a t e i n the survey, therefore a marginalized group may also have been excluded from providing valuable information about the Cardiac Home Follow Up Program. While the questionnaire items were constructed based on the researcher's interviews with a s i m i l a r population from 65 the same geographical area, the subjects were asked t h e i r opinion about the items without finding out how important the item was to t h e i r cardiac recovery. An assessment of the rank l e v e l of importance of each item to the p a r t i c i p a n t s would make the evaluation of scores more meaningful. Moreover, the small sample size did not lend i t s e l f to v a l i d i t y checks, such as factor analysis. Summary The preceding chapter outlines the mean scores from the ind i v i d u a l items of the questionnaire, describes and discusses the demographic findings, and presents the q u a l i t a t i v e data from the respondents who p a r t i c i p a t e d i n the Cardiac Home follow up Program. The response to the Cardiac Home Follow Up Program was generally p o s i t i v e . The highest mean scores on the in d i v i d u a l items were question 14, which asked about the importance of individualized plan of recovery post MI, and item 12, which asked about the helpfulness of the exercise part of the program. As well, the lowest mean scores were found for question 7, suggesting that the program did not show participants ways to deal with emotional aspects of heart disease, and item 8, which indicated that the program did not help subjects t a l k to t h e i r doctors about heart disease concerns. These findings were supported by the q u a l i t a t i v e data which i d e n t i f i e d three aspects of the program that p a r t i c i p a n t s found h e l p f u l . The i n d i v i d u a l care plan for recovery, the supervised exercise program, and the provision of information about physical and emotional changes, were areas that respondents found h e l p f u l . 67 CHAPTER FIVE Summary, Conclusions, and Implications The findings of the questionnaire and the discussion of the r e s u l t s have been outlined i n the previous chapter. The summary and conclusions from the findings are presented i n t h i s chapter. Additionally, implications of the findings for nursing practice, education, and research w i l l be presented. Summary of the Findings Both the quantitative and q u a l i t a t i v e data from the questionnaire implied that post MI p a r t i c i p a n t s , i n the Cardiac Home Follow Up program, found many elements of the program h e l p f u l to them i n t h e i r recovery at home during the f i r s t 6 weeks afte r discharge from the h o s p i t a l . Mean scores suggested that the program provided an i n d i v i d u a l i z e d recovery plan to the participants, which included information about physical changes, r i s k factors, and exercise. The program was viewed by the majority of subjects as a source of support during the recovery period, and they perceived that the problem solving content of the program was c l e a r l y presented. However, lower mean scores f o r items which focused on strategies which helped p a r t i c i p a n t s deal with the emotional aspects of heart and t a l k with doctors about t h e i r heart disease, indicated that cardiac programs need to focus attention on t h i s c r i t i c a l element to recovery. The lower scores for the items which asked about the impact of the heart attack on family functioning also 68 suggests that the program concentrate more resources i n t h i s area. Although the respondents were generally s a t i s f i e d with the program, they indicated several areas for improvement. These subjects f e l t the need for extended contact with nurses or doctors beyond the 6 week period a f t e r discharge from the h o s p i t a l . As well, a peer support program was of i n t e r e s t to several participants. The majority of respondents viewed the weekly v i s i t s from the cardiac nurse as welcomed opportunities to c l a r i f y information or ask new questions related to t h e i r post MI recovery. Conclusions These data propose that the Cardiac Home Follow Up Program successfully communicates physiological based content and problem solving s k i l l development to post MI patients. However, the program needs to enhance the psychosocial and family content to the same degree, i n order to help patients deal with the emotional aspects of chronic cardiovascular disease. Implications for Nursing Practice The r e s u l t s from the survey emphasize the need for nurses to continue to provide clear, c r i t i c a l information i n the content areas of physical and emotional changes, exercise regimes, and problem solving strategies to deal with physical complications to patients who have experienced a MI. The survey scores indicate that the majority of 69 p a r t i c i p a n t s i n a community based hospital sponsored cardiac program were s a t i s f i e d with the program they attended immediately a f t e r discharge from hospi t a l , and f i n i s h e d 6 weeks post discharge. These re s u l t s i l l u s t r a t e that t h i s program meets the needs of the community and, as well, may be used as a model for other programs. The highest scored elements of the program include the importance of an i n d i v i d u a l i z e d plan for recovery, the exercise component of the program and repeated contact with the cardiac nurse. Although the scores concerned family involvement items were s l i g h t l y lower than other factors, they nevertheless d i r e c t nurses to assess the individual's family contribution to programs, rather than to assume that a l l families can, and should be included i n the process of r e h a b i l i t a t i o n . The findings also d i r e c t nurses to help patients communicate with t h e i r physicians about concerns related to t h e i r heart disease. F i n a l l y , these factors can provide guidance on relevant content and e f f e c t i v e patient education processes for nurses who teach cardiac patients i n h o s p i t a l and the community settings. Implications for Nursing Education In order to prepare nurses to develop and d e l i v e r e f f e c t i v e programs with components on relevant information, exercise, and support, nursing c u r r i c u l a should provide a conceptualization of cardiovascular disease as a chronic i l l n e s s . Subsequently the issues on confidence i n regime 70 management, dealing with the complexities of health care systems, and e f f e c t i v e problem solving can be addressed within an appropriate context. Nurses who work with cardiac r e h a b i l i t a t i o n patients require spec i a l i z e d c l i n i c a l s k i l l s i n monitoring parameters, i n order to provide comprehensive care and provide intervention i n emergency s i t u a t i o n s . Furthermore, the process of patient education must continue to be patient centred and patient driven, with emphasis on c l e a r and e f f e c t i v e , caring, communication. While a t h e o r e t i c a l base on progressive educative theory i s e s s e n t i a l , practice sessions, opportunities to hear patients' experiences, and f i e l d work with an experienced mentor can reinforce the concepts and provide e x p e r i e n t i a l learning opportunity. In addition to c l i n i c a l and educational expertise about the care of individuals, the survey d i r e c t s nurses to develop s k i l l s i n the area of family nursing. Implications for Nursing Research The extant research on i n d i v i d u a l i z e d interventions f o r MI patients and families i n the immediate post discharge patients during the post MI period i s limited. Patients continue to t e l l us what they need and the challenge for researchers i s to develop and test strategies which are e f f e c t i v e i n providing patients with the knowledge and s k i l l s required to manage chronic cardiovascular disease. Longitudinal studies of post MI individuals and f a m i l i e s 71 w i l l a s s i s t the exploration of improved ways to provide the support t h i s population requires. As well, the low scores for items on the survey concerned with ways to deal with the emotional aspects of heart disease indicate a need f o r further research to pursue t h i s area with post MI patients. Since MI patients value the opportunity to t e l l of t h e i r experience, a focus group to explore items 7, 8, 15 and 16, may c l a r i f y how important these topics are i n t h e i r recovery and also i d e n t i f y learning needs r e l a t i v e to the items. Summary In t h i s chapter a summary , conclusions and methodological issues of the research were reviewed. The implications of the survey findings i n the areas of nursing pra c t i c e , nursing education, and nursing research were described. 72 References American Heart Association Writing Group (1994). Cardiac r e h a b i l i t a t i o n programs: a statement for healthcare professionals from the American Heart Association. Circulation,90(3), 1602-1610. Beckie, T. (1989). A supportive educative telephone program:Impact on knowledge and anxiety a f t e r coronary artery bypass surgery. Heart & Lung, 18(1), 46-55. Bopp, A.,& Lubkin, I. (1990). Teaching. In I. M. Lubkin (Ed.).Chronic i l l n e s s : Impact and interventions,(2nd ed!)(pp. 279-299). Boston: Jones and B a r t l e t t . Brannon, F. J., Geyer, M. J., Foley, M. W, & Wolf, L. (1988). Cardiac r e h a b i l i t a t i o n : Basic theory and applic a t i o n . Philadelphia: F.A.Davis Company. Brink, P. J., &. Wood, M. J. (1988). Basic steps i n planning nursing research: From question to proposal(3rd ed). Boston: Jones and B a r t l e t t . Brink, P. J., &. Wood, M. J. (1989). Advanced design i n nursing research. Newbury Park: Sage Publications. Christman, N. J., McConnell, E. A., P f e i f f e r , C , Webster, K. K., Schmitt, M.,& Ries, J.(1988). Uncertainty, coping, and d i s t r e s s following myocardial i n f a r c t i o n : t r a n s i t i o n from hospital to home. Research i n Nursing & Health. 11. 71-82. Cornett, S. J., & Watson, J. E. (1984). Cardiac r e h a b i l i t a t i o n : An i n t e r d i s c i p l i n a r y team approach. New York: John Wiley & Sons. Dillman, D. A. (1983). Mail and other s e l f administered questionnaires. In P. H. Rossi, J. D. Wright, & A. B. Anderson (Eds.), Handbook of Survey Research.(p. 5). New York: John Wiley & Sons. 73 Dracup, K., Meleis, A., Baker, K., & Edlefsen, P.(1984) . Family-focused cardiac r e h a b i l i t a t i o n . Nursing C l i n i c s of North America.19(1) . 113-124. Dracup, K. (1995). Meltzer's Intensive Coronary Care: A manual for nurses (5th ed.). Conneticut: Appleton & Lange. E l l e r s , B. (1993). Innovations i n patient centered education. In M. Gertis, S. Edgman-Levitan, J. Daley, & T. L. Delbanco,(eds). Through the patient's eyes: Understanding and promoting patient centered care, (pp. 96-118) San Fransico: Jossey-Bass. Fahlberg, L. L., Poulin, A. L., Girdano, D. A., & Dusek, D. E. (1991). Empowerment as an emerging approach i n health education. Journal of Health Education,22(3). 185-193. F a i r , J . M. & Berra, K.(1995). L i f e s t y l e change and coronary heart disease: The influence of non pharmacologic interventions d i e t and exercise. Journal of Cardiovascular Nursing,9(2). 12-24. Fridlund, B., Hogstedt, B., L i d e l l , E., & Larsson P. A. (1991). Recovery aft e r myocardial i n f a r c t i o n : E f f e c t s of a caring r e h a b i l i t a t i o n programme.Scandinavian Journal of Caring Science,5(1), 23-32. Garding B.S, Kerr, C. J., & Bay, K. (1988). Effectiveness of a program of information and support for myocardial i n f a r c t i o n patients recovering at home. Heart & Lung.17(4). 355-362. G i l l i s s , C. L., Gortner, S. R., Hauck, W. W., Shinn, J . A., Sparacino, P. A. , & Thompkins, C. (1993). A randomized c l i n i c a l t r i a l of nursing care for recovery from cardiac surgery. Heart & Lung,22(2), 125-133. G i l l i s s , C. L., Neuhaus, J. M., & Hauck, W. W. (1990). Improving family functioning af t e r cardiac surgery: A randomized t r i a l . Heart & Lung,19(6). 648-654. 74 Hawthorne, M. H.(1991).Using the traj e c t o r y framework: reconceptualizing cardiac i l l n e s s . Scholarly Inquiry for Nursing Practice,5(3), 185-195. Heart and Stroke Foundation of Canada (199 3). Cardiovascular Disease i n Canada. Ottawa,Ontario: Heart and Stroke Foundation. Hilgenberg, C., Liddy, K. G., Standerfer, J.,& Schraeder, C. (1992) Uncertainty, coping, and d i s t r e s s following myocardial i n f a r c t i o n : Transition from h o s p i t a l to home. Journal of Cardiovascular Nursing,6(2), 46-56. Holden, G. (1991). The relationship of s e l f - e f f i c a c y appraisals to subsequent health related outcomes: a meta-analysis. Social Work i n Health Care,16(1), 53-93. Jaarsma, T., Kastermans, M., Dassen, T., & Philipsen, H. (1995). Problems of cardiac patients i n early recovery. Journal of Advanced Nursing, 21,21-27. Jenny, J . (1993). A future perspective on patient/health education i n Canada. Journal of Advanced Nursing. 18, 1408-1414. Keeler, H. K. (1991). Incorporating patient education into p r a c t i c e . In L. S. Baas (Ed.). Essentials of Cardiovascular Nursing (pp. 109-118). Maryland: Aspen . Keeling, A. W. &. Dennison, P. D. (1995). Nurse i n i t i a t e d telephone follow up after acute myocardial i n f a r c t i o n : a p i l o t study. Heart & Lung,24(1), 45-49. Litherland, 0. K., & Costanzo, G. A. (1984). Myocardial i n f a r c t i o n : Replacement of several days i n h o s p i t a l with supervision at home. Vancouver: Lions Gate Hospital. 75 Mayou, A., MacMahon, D., Sleight, P.,& Florencio, M. J . (1981). Early r e h a b i l i t a t i o n a f t e r myocardial i n f a r c t i o n . Lancet. 2.1399-1301. Milazzo, J.(1980). A study of the difference i n health knowledge gained through formal and informal teaching. Heart & Lung.9(4). 355-361. M i l l s , G., Barnes, R., Rodell, D. E., & Terry, L (1985). An evaluation of an inpatient cardiac patient/family education program. Heart & Lung,14(4), 400-406. Mullen, P. D., Maines, D. A., & Velez, R. (1992). A meta analysis of controlled t r i a l s of cardiac patient education. Patient Education and Counseling, 19, 143-162. Newton, M., N.,& Sivarajan Froelicher, E. S. (1989). L i f e s t y l e adjustments. In S. L. Underhill, S. L. Woods, E. S. Sivarajan Froelicher, & C. J. Halpenny.(pp. 715-738).Cardiac nursing(2nd ed.)(pp.715-738). Philadelphia: J. B. Lippincott. N i c k l i n , W. (1986). Postdischarge concerns of cardiac patients as presented v i a a telephone callback system. Heart & Lung.15(3).268-272. Pashkow, F. J., & Pashkow, P. S. (1993). Community based cardiac r e h a b i l i t a t i o n . In F. J. Pashkow, & W. A. Dafoe,(Eds.). C l i n i c a l cardiac r e h a b i l i t a t i o n : A ca r d i o l o g i s t ' s guide.(pp. 315-340). Baltimore: William & Wilkins. P o l i t , D. F., &. Hungler, B. P. (1991). Nursing research: P r i n c i p l e s and methods (4th ed.). Philadelphia: J.B. Lippincott Company. Pozen, M. W., Stechmiller, J. A., Harris, W. H., Smith, S.,& Fried, D. D.,& . Voigt, G. C. (1977). A nurse r e h a b i l i t a t o r ' s impact on patients with myocardial i n f a r c t i o n . Medical Care,15(10),830-837. 76 Rahe, R., S c a l z i , C.,& Shine, K. (1975). A teaching evaluation questionnaire for post myocardial i n f a r c t i o n patients. Heart & Lung,4(5).759-766. Rankin, S. H.(1992). Psychosocial adjustments of coronary artery disease patients and t h e i r spouses: Nursing implications. Nursing C l i n i c s of North America,27(1),271-284. Redman, B. K. (1993). A process model for patient education. In B. K. Redman The process of patient education.(7th ed.)(pp.10-15).St. Louis: Mosby Year Book. Ruzicki, D. A. (1987). Evaluating patient education-a v i t a l part of the process. In C. E. Smith (Ed.).Patient education: Nurses i n partnership with other health professionals (pp.233-248). Orlando: Grune & Stratton. S c a l z i , C. C., & Burke, L. E. (1982). Myocardial i n f a r c t i o n : Behavioral responses of patients and spouse. In S. L. Underhill, S. L. Woods, E.S. Sivarajan, & C. J. Halpenny. Cardiac nursing (pp. 571-581). Philadelphia: J. B. Lippincott. Schott, T., & Badura, B.(1988). Wives of heart attack patients: The stress of caring. In R. Anderson & M. Burg (Eds.). Living with chronic i l l n e s s : The experience of patients and t h e i r families (pp. 117-136). London: Unwin Hyman. Schumacher, K. L., & Meleis, A. I. (1994). Transitions: a central concept i n nursing. Image:Journal of Nursing Scholarship.26(2),119-127. Smith, C. E. (1989). Overview of patient education: opportunities and challenges for the twenty-first century. Nursing C l i n i c s of North America,24(3) , 583-587. Tack, B. B. &. G i l l i s s , C. L. (1990). Nurse monitored cardiac recovery: A description of the f i r s t 8 weeks. Heart & Lung,19(5), 491-499 77 Thorne, S. E. (1993). Negotiating health care: The s o c i a l context of chronic i l l n e s s . Newbury Park: Sage. Wenger, N. K. (1986). Quality of l i f e : concept and approach to measurement. Advances i n Cardiology,33. 122-130. Wenger, N. K. (1993). Improvement of qua l i t y of l i f e i n the framework of coronary r e h a b i l i t a t i o n . In F. J. Pashkow, & W. A. Dafoe (Eds.). C l i n i c a l cardiac r e h a b i l i t a t i o n : A c a r d i o l o g i s t ' s guide, (pp.40-46). Baltimore: William & Wilkins. Wilson-Barnett, J., & Osborne, J. (1983). Studies evaluating patient teaching: implications for p r a c t i c e . International Journal of Nursing Studies,20f1), 33-44. Wishnie, H. A., Hackett, T. P., & Cassem, N. H. (1977). Psychological hazards of convalescence following myocardial i n f a r c t i o n (pp. 103-112). In R. H. Moos (Ed.). Coping with physical i l l n e s s . New York: Plenum Medical Book. Younger, J. B. (1991). A theory of mastery. Advances i n Nursing Science,14(1), 76-89. Young, D.R., Haskell,W.L., J a t l u l i s , D.E.,& Fortmann,S.P.(1993). Associations between changes i n physical a c t i v i t y and r i s k factors for coronary heart disease i n a community-based sample of men and women: The Stanford Five City Project. American Journal of Epidemiology,138(4). 205-215. Zemke, S. L. (1991).Cardiac r e h a b i l i t a t i o n . In D. K. Dressier & K. V. Gettrust (Eds.),Plans of care for sp e c i a l t y practice: Cardiovascular c r i t i c a l care nursing.(pp.287-292). Albany: Delmar Publishers. 78 APPENDIX A Dear Former Participant i n the XXXXXXXXXXX Hospital Cardiac Home Follow Up Program. My name i s G a i l Gleason and I am a nurse and also a student i n the Masters of Nursing program at The Unive r s i t y of B r i t i s h Columbia. For my Thesis, I am conducting a survey to describe parts of the Cardiac Program which patients and fam i l i e s f i n d h e l p f u l i n the management of heart disease. Because of your valuable experience with heart disease and the Cardiac Program, I am i n v i t i n g you to p a r t i c i p a t e i n t h i s survey. Your p a r t i c i p a t i o n would include f i l l i n g out a questionnaire which would take approximately 20 minutes to complete. Your questionnaire i s i d e n t i f i e d by a code number only. To guarantee anonymity of your responses, no names are used.All r e p l i e s w i l l be conf i d e n t i a l and the information from your questionnaire w i l l be s t a t i s t i c a l l y analyzed and summarized i n a research report.The report findings w i l l also be shared with the Cardiac Program Planners.After the analysis, the questionnaires w i l l be destroyed. When you have f i l l e d out the survey, please return i t i n the stamped,addressed envelope provided. The completion of the survey w i l l be taken as consent to p a r t i c i p a t e i n the survey. Your p a r t i c i p a t i o n i n t h i s research project i s voluntary and completely dependent on your decision to return the questionnaire. Your re f u s a l to p a r t i c i p a t e i n t h i s project w i l l not af f e c t any future treatment you may require. I would welcome any questions or comments regarding t h i s survey project. Please contact me for further c l a r i f i c a t i o n at the following address and telephone number. Thank you for considering sharing your experience to benefit other Cardiac Program p a r t i c i p a n t s . You may also receive a copy of the r e s u l t s by contacting me. G a i l Gleason XXXXXXXXXXXXXXXXXX. Vancouver BC, XXXX Phone: XXXXXXXX My survey i s supervised by Dr. Carol J i l l i n g s and she can be contacted at The University of B r i t i s h Columbia School of Nursing at t h i s phone number: XXX-XXXX. Sincerely G a i l Gleason RN BSN 79 APPENDIX B CARDIAC HOME FOLLOW UP PROGRAM PARTICIPANT SURVEY CODE I . D . Thank y o u f o r f i l l i n g o u t t h i s s u r v e y . To answer t h e f i r s t s e t o f s t a t e m e n t s , p l e a s e p l a c e an X i n t h e s p a c e t h a t b e s t d e s c r i b e s y o u r o p i n i o n a b o u t t h e s t a t e m e n t . T h e r e a r e no r i g h t o r w r o n g r e s p o n s e s and I w o u l d a p p r e c i a t e y o u r o p i n i o n s on a l l s t a t e m e n t s . E X A M P L E ; a . W a l k i n g i s t h e b e s t way t o e x e r c i s e y o u r b o d y . [ _ —] [ ][ ][ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e I f y o u f e e l s t r o n g l y t h a t w a l k i n g i s t h e b e s t way t o e x e r c i s e t h e body p l a c e an X i n t h e s t r o n g l y ag ree b o x . a . [ ] [ ] [ ] [ X —] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e PART 1 STATEMENTS ABOUT THE LION'S GATE HOSPITAL CARDIAC PROGRAM l . T h e p r o g r a m p r o v i d e d i n f o r m a t i o n abou t p h y s i c a l changes t h a t I m i g h t e x p e r i e n c e a f t e r a h e a r t a t t a c k . [ ] r j r ] r ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 2. The p r o g r a m o f f e r e d i n f o r m a t i o n about e m o t i o n a l changes t h a t I m i g h t e x p e r i e n c e a f t e r a h e a r t a t t a c k . [ H ] [ ][ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 3 . D u r i n g t h e p r o g r a m I had a chance t o t a l k abou t what i t was l i k e f o r me t o have a h e a r t a t t a c k . [ H ] t ] [ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 4. My f a m i l y were i n c l u d e d i n t h e p rog ram s e s s i o n s and r e h a b i l i t a t i o n p l a n . [ H ] [ ][ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 5 . The p r o g r a m examined my i n d i v i d u a l h e a r t d i s e a s e r i s k f a c t o r s . [ ] [ j r ] r ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 80 P . 2 6 . The p r o g r a m showed me ways t o p r o b l e m s o l v e m e d i c a l c o m p l i c a t i o n s o f my h e a r t d i s e a s e . [ ] r ] r ] [ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 7 . The p r o g r a m showed me ways t o d e a l w i t h e m o t i o n a l a s p e c t s o f my h e a r t d i s e a s e . t j r j [ j [ j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 8 . The p r o g r a m h e l p e d me t a l k t o my d o c t o r abou t my h e a r t d i s e a s e c o n c e r n s . t j [ j [ j [ j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 9 . I am more c o n f i d e n t about managing my h e a r t d i s e a s e t h a n I was b e f o r e t a k i n g t h e p r o g r a m . t j r j r j [ j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 0 . The f r e q u e n t c o n t a c t w i t h t h e c a r d i a c n u r s e r e d u c e d some o f t h e s t r e s s abou t r e c o v e r i n g a t home a f t e r my h e a r t a t t a c k . t j [ j f j [ j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 1 . The p r o g r a m was a s o u r c e o f s u p p o r t f o r me w h i l e I was r e c o v e r i n g a t home. [ ] [ ][ ][ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 2 . The e x e r c i s e p a r t o f t h e p rog ram h e l p e d me t o resume a c t i v i t i e s d u r i n g my r e c o v e r y . t —] [ ] [ ] [ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 3 . The p r o g r a m i n f o r m a t i o n and p r o b l e m s o l v i n g i d e a s were p r e s e n t e d i n a way t h a t was c l e a r and e a s i l y u n d e r s t o o d . [ ][ ][ ][ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 81 P . 3 1 4 . The i n d i v i d u a l i z e d p l a n f o r r e c o v e r y i s e s s e n t i a l a f t e r a h e a r t a t t a c k . r _ ] [ ] [ ] [ ] s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 5 . My h e a r t a t t a c k a f f e c t e d t h e w o r k i n g s o f my w h o l e f a m i l y . [ j t j r j r j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1 6 . The p r o g r a m h e l p e d us u n d e r s t a n d t h e changes w i t h i n my f a m i l y a f t e r my h e a r t a t t a c k . [ ] r j r .. ] r j s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e P A R T 2 I n t h i s s e c t i o n p l e a s e f i l l i n t h e spaces w i t h y o u r o p i n i o n s on t h e Q u e s t i o n s . 1 7 . What p a r t ( s ) o f t h e p rog ram h e l p e d y o u f e e l p h y s i c a l l y b e t t e r ? 1 8 . What p a r t ( s ) o f t h e p rog ram h e l p e d y o u f e e l e m o t i o n a l l y b e t t e r ? 1 9 . What p r o g r a m changes c o u l d you s u g g e s t t o h e l p p e o p l e r e c o v e r i n g a t home a f t e r a h e a r t a t t a c k ? 2 0 . O t h e r comments abou t y o u r e x p e r i e n c e w i t h t h e C a r d i a c P r o g r a m 82 P . 4 PART 3 W h i l e a l l y o u r comments a r e anonymous and c o n f i d e n t i a l , i t i s h e l p f u l t o have some b a s i c i n f o r m a t i o n abou t t h e p e o p l e who t a k e t h e t i m e t o f i l l o u t t h i s s u r v e y . P l e a s e make a X b e s i d e t h e s t a t e m e n t w h i c h b e s t d e s c r i b e s y o u . A . AGE AT THE TIME ENROLED IN THE CARDIAC PROGRAM: 75 YEARS OR MORE 65-74 YEARS 5 5 - 6 4 YEARS 4 5 - 5 4 YEARS 35-44 YEARS 2 5 - 3 4 YEARS 24 YEARS OR L E S S . B. GENDER MALE FEMALE C . EXPERIENCE WITH THE CARDIAC PROGRAM: F I R S T TIME SECOND TIME THIRD TIME OTHER p l e a s e s p e c i f y D . I COMPLETED THE HOME FOLLOW UP PROGRAM Y E S / P L E A S E INCLUDE HOW MANY MONTHS SINCE YOU TOOK THE PROGRAM NO p l e a s e i n c l u d e r e a s o n ( s ) E . MY FAMILY WAS INVOLVED IN THE HOME FOLLOW UP PROGRAM — YES — NO F . I HAVE MADE LIFESTYLE CHANGES SINCE MY HEART ATTACK — YES — NO G . THE CARDIAC HOME FOLLOW UP PROGRAM HELPED ME MAINTAIN THE LIFESTYLE CHANGES I HAVE MADE SINCE MY HEART ATTACK. — YES — NO H . I WOULD RECOMMEND THIS PROGRAM TO OTHER PEOPLE WHO HAVE HEART DISEASE. YES — NO Thank y o u f o r y o u r v a l u a b l e comments 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0087220/manifest

Comment

Related Items