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Myocardial infarction : a study of the effects on patient compliance of structured education and participation… Kirk, Rhonda Rae 1985

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MYOCARDIAL INFARCTION: A STUDY OF THE EFFECTS ON PATIENT COMPLIANCE OF STRUCTURED EDUCATION AND PARTICIPATION OF A SIGNIFICANT OTHER By RHONDA RAE KIRK B.Sc.N., Lakehead University, 1977 B.B.A., Lakehead University, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (SCHOOL OF NURSING)  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA August 1985 © Rhonda Rae Kirk, 1985  In  presenting  requirements of  British  it  freely  agree for  this f o r an  in partial  advanced  Columbia, I agree available  that  scholarly  understood  that  financial  that  f o r extensive  p u r p o s e s may  o r by  degree  f o r reference  permission  department  for  thesis  be  fulfilment of at the  University  the Library  shall  and  I  study.  copying  granted  by  gain  or publication  shall  n o t be  allowed  further  t h e head  of this  of Graduate  Studies  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date  r>v-C  (9  /7cn  August  31,  1985  (School  Columbia  thesis  of  my  I t i s thesis  w i t h o u t my  permission.  Department  make  of this  h i s or her representatives. copying  the  of Nursing)  written  ii Abstract Myocardial Infarction:  A Study of the Effects On Patient  Compliance of Structured Education and Participation of the Significant Other This study was designed to explore the effects of the independent variables of patient education and the significant other on compliance.  The purpose of the study was to test three hypotheses  predicting that subjects who receive structured education with their significant other would have higher compliance rates with health care recommendations than would subjects who receive structured and unstructured education without their significant other. The study was conducted with a convenience sample of 1 2 male patients who had a significant other and had not experienced a previous myocardial infarction within five years.  The  convenience  sample was then randomly and equally allocated into three groups. The control group received unstructured education as currently practiced by nursing staff.  One experimental group received  structured education from the investigator and the other experimental group of subjects and their significant other received structured education from the investigator. Using a semi-structured interview guide, the investigator interviewed each subject at one month and at three to four months postdischarge from hospital to determine compliance rates with physical activity, dietary, and medication health care  iii recommendations as prescribed by the subject's physician. Open-ended questions were used to determine recommendations and difficulties encountered by noncompliers.  More specific questions  were used to allow subjects to rate their compliance.  Results were  subjected to the Kruskal-Wallis rank-sum test with one-way analysis of variance. Statistically significant differences (p_ < . 0 5 ) were not found suggesting that method of patient education was not a valid prediction of compliant behaviour.  The insignificant findings of  this study need to be interpreted with caution because of the small sample size and between group differences of the demographic variables of age and employment. From general observations of the total sample, personal definitions of health, simultaneous demands and the extent of behavioural changes required, and the demographic variables of education and employment appear to influence compliance.  These findings suggest  that individual differences have an impact on compliant behaviour. Findings also suggest that the significant others of patients with myocardial infarctions are actively involved with the therapeutic regimen prescribed for their mates. The study discusses implications and recommendations for nurse practitioners and researchers who wish to improve their care of myocardial infarction patients and their significant others.  iv TABLE OF CONTENTS Page ABSTRACT  i i  TABLE OF CONTENTS  iv  LIST OF TABLES  vi  ACKNOWLEDGEMENTS  vii  CHAPTER 1 - INTRODUCTION . .  1  Statement of the Problem Purpose of the Study Definition of Terms Assumptions and Limitations of the Study  1 2 3 5  CHAPTER 2 - REVIEW OF THE LITERATURE Theoretical Background Theoretical Frameworks Orem's model for nursing Dubos' theory of adaptation Bandura's social learning theory . Summary of theoretical frameworks Compliance Knowledge Patient Education Influence of the Significant Other Summary . . . . . . . . . .  7 7 9 9 11 12 13 14 18 21 27 30  .  CHAPTER 3 - METHODOLOGY Research Design . . The Setting Sample Selection Criteria for selection of patients Rationale for criteria Patient Education Program . . Program delivery on cardiac ward Treatment  32 . . . . . . .  32 33 34 35 35 37 39 43  V  Page CHAPTER 3 - METHODOLOGY (cont'd) Data Collection Instrument Development of data collection instrument . . . . Test of the interview guide Administration of data collection instrument . . . Ethics and Human Rights CHAPTER 4 - PRESENTATION AND DISCUSSION OF FINDINGS  . . . .  Characteristics of the Sample Nonparametric Statistical Analyses of Compliance Scores General Observations of the Sample Self-care abilities Self-care Therapeutic demands General Observations of Significant Others Summary CHAPTER 5 - SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS  45 46 49 49 52 54 54 57 60 60 67 68 72 73  75  Overview of the Study . . . . . . . . . . . . . . . . . Problem, design and implementation Results Conclusions Implications Nursing practice Nursing research Recommendations  75 75 77 80 81 81 82 83  REFERENCES  84  APPENDICES  89  Appendix A - Structured Patient Education Objectives Appendix B - Discharge Guidelines of Cardiac Teaching Unit Appendix C - Data Collection Instrument Appendix D - Demographic Data Appendix E - Group 1 Introductory Letter Appendix F - Group 2 Introductory Letter Appendix G - Group 3 Introductory Letter Appendix H - Patient Consent Form Appendix I - Physician Consent Form  .  89 92 94 99 100 101 102 103 104  vi LIST OF TABLES Table 1  Page Summary of Two Methods of Program Delivery on Cardiac Ward  2 Number of Days Between Discharge and Interviews  40 ...  3 Characteristics of the Sample Groups 4 Summary of H Values for Compliance with Recommendations During Two Interviews 5  6  7  8  9  50 56 59  Raw Data, Number of Recommendations, and Scores for Compliance with Physical Activity Recommendations During First Interview  61  Raw Data, Number of Recommendations, and Scores for Compliance with Physical Activity Recommendations During Second Interview  62  Raw Data, Number of Recommendations, and Scores for Compliance with Dietary Recommendations During First Interview  ...  63  Raw Data, Number of Recommendations, and Scores for Compliance with Dietary Recommendations During Second Interview  64  Number of Recommendations and Scores for Compliance with Medication Recommendations During First and Second Interviews  65  vii Acknowledgements  I would like to express my sincere appreciation to my thesis advisors, Carol Jillings (Chairperson) and Sheila Stanton for their willing and helpful guidance in the development of this thesis. I feel very deep gratitude to a l l the patients who shared with me their time and thoughts and to the significant others who participated in this study.  I would also like to thank the nursing  and medical staff on the unit where the study was conducted, for a l l their assistance and co-operation. I would finally like to express my deep appreciation for the love and support offered by my husband, Allan, my sons, James and Kirk, who were born during this process, my parents, and my sisters, Brenda and Donna. A l l have continued to offer encouragement in the pursuit of my academic goals.  CHAPTER 1 Introduction In 1982, cardiovascular diseases were identified as the number one k i l l e r of Canadians with 28,865 deaths caused by myocardial infarctions (Statistics Canada, 1984).  Survivors of a myocardial  infarction, the result of chronic coronary artery disease, are required to alter behavioural patterns to accommodate changes in lifestyle.  In order to maintain or improve health, individuals  recovering from a myocardial infarction are required to comply with therapeutic regimens such as dietary and activity restrictions, and the daily ingestion of medication  (Rahe, Scalzi & Shine,  1975;  Stokols, 1975). "One of the major unsolved problems confronting health care workers is patients' poor compliance with their prescribed therapeutic regimens" (Hoepfel-Harris, 1980, p. 449).  Health care  workers cannot ignore the fact that approximately one-half of a l l patients do not comply with the therapeutic regimens prescribed for them (Davis, 1968; Gillum & Barsky, 1974; Rosenstock, 1975).  Statement of the Problem A plethora of studies of noncompliant patient behaviour suggest that an enigma continues about the types of interventions that are most appropriate to enhance compliance and facilitate the effectiveness of the therapeutic regimen (Vincent, 1971).  Numerous studies have investigated the effect of structured versus unstructured educational interventions on patient knowledge of and/or compliance with a therapeutic regimen following a myocardial infarction (Bille, 1977; Milazzo, 1980; Scalzi, Burke & Greenland, 1980; Sivarajan, Newton, Almes, Kempf, Mansfield & Bruce, 1983).  Therapeutic regimens involving lifestyle changes  such as medication-taking, dietary restriction, and prescribed physical activity, are activities usually shared with a significant other; however, few studies have investigated the education of the significant other or the impact of the significant other on compliance  (Mayou, Foster & Williamson, 1978; Tyzenhouse, 1973).  Therefore, this study was designed to explore the effects of structured education, for male patients and their significant others, on compliance with health care recommendations for patients recovering from a myocardial infarction after discharge from the hospital.  Purpose of the Study The purpose of this study was to test the following hypotheses: 1.  Myocardial infarction patients receiving structured  education with the significant other will have higher rates of" compliance with health care recommendations than myocardial infarction patients receiving structured education without their significant other.  3 2.  Myocardial infarction patients receiving structured  education with their significant other w i l l have higher rates of compliance with health care recommendations than myocardial infarction patients receiving unstructured education. 3.  Myocardial infarction patients receiving structured  education will have higher rates of compliance than myocardial infarction patients receiving unstructured education.  Definition of Terms The following terms are f i r s t defined according to the literature and are then operationally defined for the purpose of this study. Education program. A program including slides, audiotapes, and manual which was designed and produced by the American Heart Association and t i t l e d , "An active partnership for the health of your heart (after your heart attack)". The purpose of the program was to increase patient knowledge of coronary heart disease and methods of risk factor reduction (Barbarowicz, Miller, Haskell & DeBusk, 1976). Structured education.  An organized method of imparting  specific knowledge to another (Toth, 1980).  Structured education  was operationally defined as a sequential delivery of the program by the investigator to the subject, or to the subject and significant other over a two to three day time span.  The content  and i t s relationship to the subject's lifestyle were discussed  4  after each tape as directed by educational objectives developed by the investigator (see Appendix A). Unstructured education.  An unorganized or incidental method  of imparting specific knowledge to another (Toth, 1980). Unstructured education was operationally defined as the random delivery of a portion or the total program by one or more nursing staff as a routine nursing assignment to one individual or to groups.  Delivery of the program and individual discussion were  unorganized or incidental as dictated by the environment of the ward and as practiced by nursing staff. Myocardial infarction.  Death of myocardial tissue  demonstrated by electrocardiographic findings and elevated serum levels of the cardiac enzymes (Toth, 1980). Myocardial infarction was operationally defined as the death of myocardial tissue demonstrated by diagnosis of the cardiologist, electrocardiographic findings, and elevated serum levels of the cardiac enzymes: serum glutamic oxaloacetic transaminase, lactic dehydrogenase, and creatine phosphokinase. Health care recommendations. by the physician (Marston, 1970).  The medical regimen prescribed Health care recommendations were  operationally defined as the documented regimen prescribed by the attending cardiologist at discharge with the intention of maintaining or improving the subject's cardiac status (see Appendix B).  The independent variables for this study were recommendations  5  related to physical activity restrictions, dietary restrictions, and medication-taking (oral drugs). Compliance.  Follow-through on health care recommendations  prescribed by the appropriate health care provider (Linde & Janz, 1979).  Compliance was operationally defined as the subject's  estimates of follow-through on recommendations prescribed by the cardiologist a l l of the time. Noncompliance.  The lack of follow-through on health care  recommendations (Linde & Janz, 1979). Noncompliance was operationally defined as the subject's estimates of follow-through on health care recommendations prescribed by the cardiologist less than a l l of the time. Significant other.  The significant other was operationally  defined as the wife of the subject or the common-law wife where the couple had co-habitated for a time period of three years or more.  Assumptions and Limitations of the Study This study assumed that: 1.  The goal of each individual recovering from myocardial  infarction was the independent practice of activities to perform self-care. 2.  Each individual encountered a deficit relationship between  the needs for self-care and the ability to perform self-care when diagnosed as having a myocardial infarction.  6  3.  Structured patient education using a slide-tape format and  manuals as produced by the American Heart Association with the guidance of a nurse was an effective method to impart knowledge about recovering from a myocardial infarction. This study was limited by: 1.  Personal confounding variables of age, education,  employment, and complicating physical factors. 2.  Lack of final discharge instructions in terms of dietary  and medication health care recommendations at the time of the educational sessions. 3.  Interpretation of compliance with health care  recommendations by the subjects whose estimates may not have been accurate. 4.  Contact with the researcher during patient education  sessions and following discharge which may have influenced the compliance rates of the subjects in the experimental groups. 5.  The small sample size studied.  7  CHAPTER 2 Review of the Literature An abundance of valuable literature has been written about individuals recovering from a myocardial infarction.  A theoretical  background i s presented in this chapter leading into a description of the three theoretical frameworks chosen to provide guidance for this study.  This literature review was limited to the effects of  knowledge and patient education and the influence of the significant other on compliance as guided by the theoretical frameworks.  The literature that will be discussed was largely  limited to myocardial infarctions but some other studies appeared relevant and have been included. Despite the contemporary usage of the terms family and significant other, most studies pursued male subjects and their wives or spouses so these terms will be addressed as such throughout the review.  Theoretical Background To maintain or improve health following a myocardial infarction and to reduce risk factors associated with heart disease, health care workers expect an individual to change or adapt behavioural patterns by complying with health care recommendations.  Health care workers recommend that the individual  consume diets low in calories, sodium, cholesterol, and fats; gradually resume physical activities to a similar or more advanced level than experienced prior to the attack, and ingest a variety of  8 drugs t o promote e f f e c t i v e f u n c t i o n i n g of the h e a r t al.,  1976).  is,  p.  (Linde & J a n z ,  1979).  given t o the  The outcome of p a t i e n t e d u c a t i o n  " . . . independence a c h i e v e d through  assumption  et  In o r d e r t o promote a p p r o p r i a t e b e h a v i o u r a l changes,  i n f o r m a t i o n c o n c e r n i n g the recommendations must be individual  (Barbarowicz  knowledge, and  of r e s p o n s i b i l i t y f o r s e l f - c a r e "  the  ( B e l l & Whiting,  1981,  28). D i e t a r y and a c t i v i t y  r e s t r i c t i o n s and the use of  medications  are b e h a v i o u r a l changes t h a t b e g i n w i t h i n the h o s p i t a l environment and  c o n t i n u e i n t o the home environment where the i n d i v i d u a l  s i g n i f i c a n t other r e s i d e .  Litman  (1974) s t a t e s ,  c o n s t i t u t e s perhaps the most important  "the f a m i l y  s o c i a l context w i t h i n which  i l l n e s s o c c u r s and i s r e s o l v e d " (p. 495). a myocardial  T h e r e f o r e , the e f f e c t o f  i n f a r c t i o n on an i n d i v i d u a l cannot  be c o n s i d e r e d i n  i s o l a t i o n as the event i s bound t o have an impact  on  s i g n i f i c a n t o t h e r which i n t u r n enhances or depresses individual's rehabilitation  (Davidson,  and  1979;  the the  S k e l t o n & Dominian,  1973). Baden (1972) emphasizes the importance  of f a m i l y e d u c a t i o n  the r e h a b i l i t a t i o n of an i n d i v i d u a l with a m y o c a r d i a l i n f a r c t i o n saying: An i n t e g r a l p a r t of a p a t i e n t ' s c a r e and r e h a b i l i t a t i o n i s the e d u c a t i o n of h i s f a m i l y so t h a t they can be a h e l p r a t h e r than a detriment t o him. The f a m i l y and f r i e n d s of the p a t i e n t can have a d i r e c t i n f l u e n c e n o t o n l y upon h i s acceptance and u n d e r s t a n d i n g of h i s h e a r t c o n d i t i o n , but a l s o upon h i s a d a p t a t i o n t o m o d i f i c a t i o n s i n h i s l i f e s t y l e , (p. 565)  on by  9 Therefore, to enhance patient compliance, information should be communicated to the individual and the significant other via an education program designed to promote appropriate behavioural changes.  Theoretical Frameworks Three theoretical frameworks were selected to provide direction for this study: Orem's (Orem, 1980) model for nursing was chosen to provide guidance for investigating the concepts of knowledge, patient education, and compliance. Dubos' (Dubos, 1965) theory of adaptation was selected to provide direction for studying the significant other as the individual's social support system. Bandura's (Bandura, 1977b) social learning theory was chosen to provide direction for the use of structured teaching tools and the influence of the significant other as a teaching aid for patient education. Orem's model for nursing.  Orem's model for nursing as  described by Orem (1980) and Joseph (1980) recognizes an individual as a self-care agent who is capable of performing self-care activities that are acquired via learning. Inherent within the framework are four concepts:  self-care, therapeutic self-care  demands, self-care agency, and nursing agency.  10  Orem (1980) defines self care as, "the practice of activities that individuals initiate and perform on their own behalf in maintaining l i f e , health, and well-being" (p. 35). Within the context of this definition, compliance with a therapeutic regimen is considered to be self-care.  With the introduction of a health  deviation such as myocardial infarction, self-care demands for diet, activity, and safety via the use of medication evolve into therapeutic demands which require satisfaction via specific patient actions to ensure an improved level of health. The self care agency i s the individual's capability to engage in and perform the self-care actions.  If an individual with a  myocardial infarction i s unable to meet the therapeutic self-care demands, then a deficit relationship exists between the demands and the self-care agency in the form of lack of knowledge and/or ability. The nursing agency i s the ability of the nurse to perform nursing actions to improve or eliminate the deficit relationship that exists between the therapeutic self-care demands and the self-care agency. Nursing actions are designed to facilitate and increase the self-care abilities of an individual and these abilities can be enhanced through patient education.  By teaching  an individual with a myocardial infarction about the disease process, risk factors associated with heart disease, and methods to reduce the risk factors, the self-care agency should be equipped with knowledge and s k i l l s rendering the individual capable of  11 performing self-care activities to meet the therapeutic self-care demands for diet, activity, and the use of medication.  The outcome  of patient education i s self-care or compliance with a therapeutic regimen following the acquisition of knowledge. Orem's model for nursing provides a framework to investigate the concepts of knowledge, patient education, and compliance. Orem predicts that by providing the individual with knowledge, via patient education, compliance will occur (Orem, 1980). This framework can also be applied to the significant other of an individual whose knowledge may be limited when required to assist an individual recovering from a myocardial infarction. Orem's model for nursing was used by Marten (1978) to study a patient experiencing a radical change in body image, and by Toth (1980) who studied patient anxiety on leaving the coronary care unit following education.  The model provided a satisfactory  framework to investigate the independent variables. Dubos' theory of adaptation.  According to the writings of  Dubos (1965) and additional descriptions of Dubos' work (Smith, 1981), health is the state of an individual that permits effective interaction with the physical and social environment. Each individual defines his/her health state and attains this state by adaptive behaviour. According to Dubos, an individual with a myocardial infarction is in an unhealthy state which i s the direct result of his/her failure to adapt to the illness.  The individual must change living  12 patterns and adapt these patterns to meet the needs for nutrition, activity, and recovery through medication-taking.  The stimulus to  adapt and modes of adaptation are located within the individual and his/her social support system.  The individual's social  relationships are of paramount importance for the support and encouragement to complete adaptation and attain a state of health. Within the social support system, the individual senses a feeling of belonging and togetherness engendering a feeling of security which increases the chances for success and happiness. Dubos' theory of adaptation provides a framework for investigating the importance of the significant other as an individual's social support system. Bandura's social learning theory.  Bandura's social learning  theory (1977a, 1977b), views learning as a reciprocal interaction among personal, behavioural, and environmental  determinants.  Learning i s a cognitive ability; however, stimuli for learning are located in the environment.  Individuals with myocardial  infarctions are motivated to learn as a result of their physiological state. persuasion of others.  Individuals learn vicariously or by verbal Vicarious learning occurs from verbal or  visual methods and within this definition, slides, audiotapes, and manuals are considered to be beneficial teaching tools.  Verbal  persuasion by others, such as the nurse and significant other, provides stimuli of reinforcement and support during the learning process and enhances learning. An individual can learn from one  13 stimulus; however, learning will occur at a more rapid rate and the behavioural changes w i l l endure longer i f more than one source of stimuli is presented. Bandura's social learning theory provides direction for the use of structured teaching tools and the use of the significant other as a teaching aid to enhance patient learning and compliance. Summary of theoretical frameworks.  A combination of Orem's  model for nursing, Dubos' theory of adaptation, and Bandura's social learning theory provided direction for this study. The theories suggest that an individual with a myocardial infarction has a knowledge deficit during hospitalization, and is unable to meet his/her needs for lifestyle change in the areas of physical activity, diet, and medication-taking.  By manipulating  the structure of the educational format and introducing a variety of stimuli for learning, compliance with health care recommendations should be enhanced accordingly. Thus, structured education should have a greater effect on the patient's ability to perform self-care than unstructured education.  Furthermore,  individuals who receive structured education with their significant other in attendance should achieve higher rates of compliance than subjects who received structured education alone, and subjects who received unstructured education alone.  14 The combination of frameworks directs this study to review the literature in the areas of compliance, knowledge, patient education, and the influence of the significant other. Compliance The word "compliance" is accepted terminology in the f i e l d of health care despite the negative connotation. The term compliance tends to imply a certain relationship in which the physician gives instructions and the patient complies, co-operates, and/or obeys (Kasl, 1975). Adopting this perspective of the patient-physician relationship, noncompliers are considered to be deviants. That i s , adherence to prescribed recommendations is "normal" and variations from the recommendations are considered to be "deviant" (Porterfield, 1981); however, current usage of the word tends to be taken in a much broader context.  Regardless of the terminology,  compliance with health care recommendations i s essential in the control and prevention of disease (Hogue, 1979). Difficulties literature.  with compliance have been well-documented in the  Davis (1968) reported that 40% of the patients who  attended a general medical clinic never intended to comply with their prescribed regimen.  Patient noncompliance with health care  recommendations has continued to be a major unsolved problem confronting health care workers (Gillum & Barsky,  1974;  Hoepfel-Harris, 1980). Numerous studies have reported compliance rates with health care recommendations; however, studies are difficult to compare as  a result of the variety of compliance definitions, the variation of measurement tools, and the diversity of recommendations being measured (Marston, 1970). Several studies have examined compliance with risk factor recommendations.  Rosenstock (1975) concluded that 50% of a l l  patients under a physician's care, will not comply with prescribed regimens for the f u l l time period or precisely as ordered. Structured and unstructured education and their relationship to compliance have been examined. Using both teaching formats for individuals with myocardial infarctions, Bille (1977) reported rates of 74% and 79% respectively for compliance with coronary risk factors prescribed by the physician at one month following discharge from hospital.  Linde and Janz (1979) documented rates of  86% at one month and 93% at three to four months postdischarge from hospital for compliance with coronary risk factor reduction prescribed by the attending health care worker.  Subjects had  undergone coronary artery bypasses and were exposed to structured teaching methods. Several studies have examined compliance with physical activity recommendations for individuals with myocardial infarctions.  Oldridge, Wicks, Hanley, Sutton and Jones (1978)  found that 43% of subjects were noncompliers with a rehabilitation program of physical activity during the f i r s t year of the program. Royle (1973) measured attitudes to activity recommendations one month after discharge and found that 12% of the subjects complied,  16 70% complied as well as able, and 18% disregarded the recommendations.  Rudy (1980) examined causal explanations for  myocardial infarction and reported that 32% of her sample engaged in preplanned exercise. Bloch, Maeder, and Haissly (1975) studied resumption of sexual activity one year after a myocardial infarction.  Of the subjects  who were sexually active prior to the infarction, 22% of the sample abstained from sexual relations, 53% diminished activity, and 25% maintained or increased the frequency of sexual activity.  Subjects  had not received education. Other studies have investigated compliance with dietary recommendations for individuals with myocardial infarctions.  Royle  (1973) measured attitudes to dietary recommendations and found that 18% of the sample complied with the recommendations and 41% complied as well as they were able. changed dietary habits.  Rudy (1980) reported that 76%  Scalzi et a l . (1980) examined adherence to  a combination of low sodium and low cholesterol diets and found that subjects who received structured education reported optimal compliance at one month post discharge declining to good compliance at three months whereas subjects who received unstructured education reported fair to good compliance at both times. Sivarajan et a l . (1980) found that consumption of high-cholesterol, high-saturated fat, and high sodium foods decreased over a six month time span following structured and unstructured education; however, results were not significant.  Linde and Janz (1979)  17 r e p o r t e d a 93.3% compliance  r a t e w i t h d i e t a r y recommendations a t  one month p o s t d i s c h a r g e and an 83.3% compliance  rate a t three  months f o r coronary bypass s u b j e c t s f o l l o w i n g an e d u c a t i o n program. Some s t u d i e s have i n v e s t i g a t e d compliance recommendations.  with m e d i c a t i o n  From a l a r g e study of t h e c h r o n i c a l l y  ill,  Greene, Weinberger, J e r i n , and Mamlin (1982) found t h a t 26% of t h e sample always complied with m e d i c a t i o n regimens, of  t h e time, and 26% complied  46% complied most  l e s s than h a l f of t h e time.  s t u d i e s of i n d i v i d u a l s with m y o c a r d i a l i n f a r c t i o n s , Royle  From (1973)  r e p o r t e d t h a t 93% o f t h e sample complied a l l of t h e time and o n l y 7% d i s r e g a r d e d some o f t h e i n s t r u c t i o n s . r e p o r t e d near o p t i m a l compliance  S c a l z i e t a l . (1980)  f o r s u b j e c t s who r e c e i v e d  u n s t r u c t u r e d e d u c a t i o n with m e d i c a t i o n  recommendations.  From t h e p r e c e d i n g review, i t i s e v i d e n t t h a t s t u d i e s i n v e s t i g a t i n g compliance 100%  compliance  more l i k e l y  rates.  Some s t u d i e s suggested  t h a t compliance was  T a k i n g o r a l m e d i c a t i o n s appeared  t o be t h e l e a s t  behaviour t o change whereas d i e t a r y changes appeared t o  be t h e most d i f f i c u l t 1978).  t o compare and none r e p o r t e d  t o o c c u r with h e a l t h c a r e recommendations t h a t r e q u i r e  t h e l e a s t change. difficult  are d i f f i c u l t  Important  ( G i l l u m & Barsky,  1974; O l d r i d g e e t a l . ,  f a c t o r s i d e n t i f i e d t o enhance compliance  were  p a t i e n t e d u c a t i o n , f a m i l y encouragement, support, and r e i n f o r c e m e n t (Davis,  1968; G i l l u m & Barsky,  1974; O l d r i d g e e t a l . , 1978).  18 Knowledge Numerous s t u d i e s have i d e n t i f i e d l a c k of knowledge as a of noncompliance.  Royle (1973) i n t e r v i e w e d 20 male s u b j e c t s  myocardial i n f a r c t i o n s discharge  and s i x  from h o s p i t a l .  instructions  S u b j e c t s and t h e i r  wives i d e n t i f i e d p h y s i c a l a c t i v i t y and d i e t a r y Low a n x i e t y  the s u b j e c t s when s p e c i f i c r e c e i v e d and h i g h a n x i e t y Royle found t h a t f a i l u r e result  levels  instructions levels  l i m i t a t i o n s as  major  were e x p e r i e n c e d by  about the regimen were  resulted  from vague  to f o l l o w a t h e r a p e u t i c  instructions.  regimen was  the  of l a c k o f u n d e r s t a n d i n g of the regimen and l i m i t e d s u p p o r t  from s p o u s e s .  The i n a b i l i t y of the wives t o p r o v i d e support  a t t r i b u t e d t o l a c k of i n f o r m a t i o n . out of  limited  regimen and complained of vague  given by h e a l t h c a r e w o r k e r s .  sources of a p p r e h e n s i o n .  with  of the s u b j e c t s ' wives f o l l o w i n g  Most s u b j e c t s demonstrated  knowledge of t h e i r t h e r a p e u t i c  source  seven s u b j e c t s demonstrated  A s i m i l a r study found t h a t  1975).  From i n t e r v i e w s w i t h m y o c a r d i a l i n f a r c t i o n p a t i e n t s others,  four  needs f o r i n f o r m a t i o n d u r i n g the  e a r l y r e c o v e r y p e r i o d at home ( P f i s t e r e r ,  spouses or s i g n i f i c a n t  was  and t h e i r  Rudy (1980) found the f o l l o w i n g :  When p a t i e n t s resumed everyday a c t i v i t i e s , p a t i e n t s and spouses became aware t h a t d e c i s i o n s c o n f r o n t e d them and t h a t they l a c k e d r e l e v a n t i n f o r m a t i o n . Wives f r e q u e n t l y expressed the f a c t t h a t they had not been i n c l u d e d i n p a t i e n t e d u c a t i o n s e s s i o n s and i n d i s c h a r g e p l a n n i n g to a s i g n i f i c a n t degree. I n c l u s i o n of spouses i n d i s c h a r g e p l a n n i n g was u s u a l l y l i m i t e d t o d i e t and m e d i c a t i o n i n s t r u c t i o n s , (pp. 355-356) Crawshaw (1974) a t t r i b u t e d  severe v o c a t i o n a l  f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n to f e a r  disabilities  and t o vague  instructions  19 about  employment r e s u m p t i o n .  deficits  Vague i n s t r u c t i o n s  created  r e s u l t i n g i n minimum e x e r t i o n by p a t i e n t s  which  their vocational a b i l i t i e s .  The m a j o r i t y of p a t i e n t s  vocational  w i t h i n the u n s k i l l e d ,  disabilities  and s k i l l e d t r a d e s . prime reason  fell  support  e d u c a t i o n be given t o the  r e s e a r c h e r s have e x p l o r e d the area of  myocardial i n f a r c t i o n s .  natural a c t i v i t i e s indicated that  Sexual r e l a t i o n s  couple  one member s u f f e r e d  research  intercourse  a myocardial i n f a r c t i o n .  f o r m a r i t a l d i s c o r d was the e q u a t i o n of s e x u a l  w i t h strenuous  sexual  are  w i t h i n a m a r i t a l or common-law dyad y e t  frequency and p l e a s u r e a s s o c i a t e d w i t h  diminished after  The  behaviour  a c t i v i t y imposing the a s s o c i a t e d r i s k of  sudden  The cause of t h i s m i s c o n c e p t i o n was l a c k of i n f o r m a t i o n  which c r e a t e d Whitley,  fear  & Young, Henrick  i n both the p a t i e n t 1979;  Mims,  their partners,  1980;  and p a r t n e r  Puksta,  1977;  Scalzi  Levin, S Dracup,  received  a c t i v i t y without the i n c l u s i o n o f  t h e i r r e h a b i l i t a t i o n was s e v e r e l y  of l a c k of support and knowledge from the  Several  (Cole,  (1979) r e p o r t e d t h a t when male s u b j e c t s  i n s t r u c t i o n r e g a r d i n g sexual  result  the  S i m i l a r f i n d i n g s were r e p o r t e d by Segev and  several  activity after  1978).  semi-skilled,  (1981).  Recently,  death.  with  f o r the i n a b i l i t y of the wives to p r o v i d e  t o promote r e c o v e r y .  reason  retarded  Crawshaw a l s o blamed l a c k of knowledge as  d u r i n g r e c o v e r y and suggested t h a t  Schlesinger  knowledge  s t u d i e s found t h a t  hampered as  a  partner.  the emotional trauma  associated  with a m y o c a r d i a l i n f a r c t i o n d u r i n g the acute phase r e s u l t e d  in  20 patients  forgetting,  misinterpreting,  information to f a m i l i e s  d e s p i t e the f a c t  were given t o the p a t i e n t information,  patients  t h e i r attempts t o et  al.,  1975;  and r e l a y i n g i n c o r r e c t  by h e a l t h c a r e workers.  and f a m i l i e s  S c a l z i et a l . ,  relatives,  1980;  Toth & T o t h ,  life  f u r t h e r h i n d e r e d the p a t i e n t s '  therapeutic others Larter,  1976;  Royle,  As a group,  1973;  result  of  workers, their  of the  others  1981).  with a c t i v i t y ,  f o l l o w i n g discharge  to follow a therapeutic  regimen was a  by h e a l t h care  from the s i g n i f i c a n t  However, many p a t i e n t s  from  o t h e r s because o f and t h e i r  wanted and expected t o r e c e i v e i n f o r m a t i o n ,  during h o s p i t a l i z a t i o n , future  1974;  i n d i v i d u a l s with  l a c k of knowledge, vague i n s t r u c t i o n s  l i m i t e d knowledge.  significant  (Crawshaw,  Segev & S c h l e s i n g e r ,  and l i m i t e d support  disease,  to follow a  during r e h a b i l i t a t i o n  and m e d i c a t i o n recommendations  significant  their  abilities  encountered d i f f i c u l t i e s  h o s p i t a l and t h a t f a i l u r e  friends,  and demands t o make of  the s t u d i e s suggested t h a t  myocardial i n f a r c t i o n s dietary,  with m y o c a r d i a l  regimen and l i m i t e d the a b i l i t i e s  to p r o v i d e support  Rahe  regimen was n o t  M i s c o n c e p t i o n s about h e a r t expectancy,  with  1972;  and t h e i r spouses tended t o seek a d v i c e from and c o - w o r k e r s .  relevant  1977).  i n f o r m a t i o n about a t h e r a p e u t i c  expected b e h a v i o u r s , others  Without  regimen (Baden,  p r o v i d e d by h e a l t h c a r e workers, p a t i e n t s infarctions  instructions  encountered d i f f i c u l t i e s  follow a therapeutic  When r e l e v a n t  that verbal  (Baden,  about h e a r t  1972;  Royle,  d i s e a s e and i t s  1973).  effects  on  Recently, health care  21 workers have e x p l o r e d the a r e a of p a t i e n t e d u c a t i o n and i t s r e l a t i o n s h i p to  Patient  rehabilitation.  Education  From the l i t e r a t u r e , two d e f i n e d and  investigated:  types of p a t i e n t e d u c a t i o n were  s t r u c t u r e d and  S t r u c t u r e d p a t i e n t e d u c a t i o n tended  unstructured. to be d e f i n e d as  an  o r g a n i z e d and s e q u e n t i a l d e l i v e r y of i n f o r m a t i o n .  Numerous  approaches have been d i s c u s s e d i n the l i t e r a t u r e .  The  were d i r e c t e d by b e h a v i o u r a l o b j e c t i v e s and individual,  f a m i l y , o r group.  induce h e a l t h enhancing f o l l o w i n g a myocardial  i n f a r c t i o n v i a the p r o v i s i o n of knowledge Content  of a s t r u c t u r e d program f o r  i n f a r c t i o n p a t i e n t s addressed  anatomy and p h y s i o l o g y of emotional  r i s k f a c t o r s such as d i e t , o b e s i t y , a c t i v i t y ,  stress.  Teaching  slides,  format  audiotapes,  nurse  factors,  smoking, and  c o n s i s t e d of l e c t u r e s , d i s c u s s i o n s ,  v i d e o t a p e s , and/or f i l m s and was  w i t h manuals o r pamphlets f o r home use. t o one  supplemented  I n s t r u c t o r s were  p r o v i d e d some form of  i n d i v i d u a l d i s c u s s i o n and f o l l o w - u p a f t e r p r e s e n t a t i o n of  Milazzo,  limited  or a s e l e c t e d group of h e a l t h care workers with  s p e c i a l i z e d e d u c a t i o n a l t r a i n i n g who  (Bille,  to  to achieve optimal h e a l t h  the h e a r t , the h e a l i n g p r o c e s s , drug t h e r a p y , and  t o the  The purpose of the program was  behaviours  about a t h e r a p e u t i c regimen. myocardial  imparted  programs  1977; 1980;  Bracken, Bracken, & Landry, S c a l z i et a l . , 1980;  1977;  Linde  content  & Janz,  S i v a r a j a n et a l . , 1983).  1979;  Unstructured patient education was any type of teaching that the nurse or physician devised and instituted on a more informal basis.  The instructors did not follow set behavioural objectives  or sequential patterns.  Style, timing, and content were at the  discretion of the instructor which tended to result in spontaneous, fragmented, and disorganized teaching sessions (Barbarowicz et a l . 1980;  Bille, 1977).  Patient education was part of a routine  nursing assignment, performed at the nurse's convenience, and eliminated i f staffing shortages or time constraints occurred.  The  target of instruction was the patient and the instructors tended to be several nurses as a result of rotating shifts.  Individual  patient discussions and follow-up tended to be poorly documented (Barbarowicz et a l . , 1980; Bille, 1977; Milazzo, 1980; Scalzi et al.,  1980).  "Teaching patients about the characteristics of their disease is a time honoured nursing approach to enhancing compliance" (Hogue, 1979, p. 252). Nurses advocate patient education as a primary method to promote compliance; however, in the literature there are conflicting reports about the efficacy of patient education programs on patients' knowledge and subsequent compliance. Using a three-group before-and-after design, Milazzo (1980) studied male subjects recovering from a myocardial infarction to determine the effects of structured teaching on knowledge levels. Milazzo found a significant difference (p_<.05) in the test scores  23 among groups and concluded  t h a t s u b j e c t s had g r e a t e r knowledge  l e v e l s about t h e i r i l l n e s s  f o l l o w i n g s t r u c t u r e d education  unstructured  education.  Milazzo  than  d i d not r e l a t e knowledge scores t o  compliance. i n a s i m i l a r study,  Bille  of i n d i v i d u a l s with m y o c a r d i a l without  (1977) found t h a t knowledge  levels  i n f a r c t i o n s were s i m i l a r with o r  the use of a s t r u c t u r e d t e a c h i n g format.  He a l s o  reported  t h a t compliance with a t h e r a p e u t i c regimen p r e s c r i b e d by t h e p h y s i c i a n was not s i g n i f i c a n t l y r e l a t e d t o knowledge l e v e l s o r t o the e d u c a t i o n a l format.  B i l l e used an i n t e r e s t i n g  q u e s t i o n n a i r e t o determine the p h y s i c i a n ' s compliance r a t e , and d i f f i c u l t i e s  compliance  recommendation,  a s s o c i a t e d with  noncompliance;  however, he d i d not break the recommendations i n t o f i n e r c a t e g o r i e s , r e p o r t e d o n l y group mean compliance r a t e s , and d i d n o t discuss d i f f i c u l t i e s t h i s study,  encountered by noncompliant i n d i v i d u a l s .  no attempts were made t o v a l i d a t e s u b j e c t s '  In  perceptions  o f t h e i r i n s t r u c t i o n s w i t h the p h y s i c i a n and t h e i n v e s t i g a t o r d i d not p a r t i c i p a t e i n e d u c a t i o n a l In a s i m i l a r study t h a t covered insignificant and to  sessions.  of i n d i v i d u a l s with myocardial  infarctions  a two year time span, S c a l z i e t a l . (1980) a l s o found d i f f e r e n c e s between knowledge l e v e l s and s t r u c t u r e d  u n s t r u c t u r e d t e a c h i n g methods, and a t t r i b u t e d n e g a t i v e l i m i t e d knowledge r e t e n t i o n of the s u b j e c t s  hospitalization. education  findings  during  However, s u b j e c t s who r e c e i v e d s t r u c t u r e d  demonstrated b e t t e r compliance w i t h m e d i c a t i o n and  24 p h y s i c a l a c t i v i t y recommendations.  S i g n i f i c a n t d i f f e r e n c e s were  not o b t a i n e d f o r d i e t a r y recommendations.  S u b j e c t s who r e c e i v e d  s t r u c t u r e d e d u c a t i o n c o n s i s t e n t l y had h i g h e r compliance all  t h r e e recommendations; however, the l e v e l s tended  t h r e e months p o s t d i s c h a r g e . b e t t e r compliance  scores  with  t o d e c l i n e by  The i n v e s t i g a t o r s suggested  that  i n t h e s t r u c t u r e d t e a c h i n g group was t h e r e s u l t  of c o n t i n u e d i n s t r u c t i o n d u r i n g f o l l o w - u p v i s i t s by t h e r e s e a r c h e r . S c a l z i e t a l . found  t h a t t h e d i s t r i b u t i o n of p r i n t e d m a t e r i a l f o r  home use p r o v i d e d convenient  reference material a f t e r  S i v a r a j a n e t a l . (1983) concluded  discharge.  that a s t r u c t u r e d education  program on r i s k f a c t o r s i n s t i t u t e d a f t e r d i s c h a r g e from h o s p i t a l demonstrated l i m i t e d e f f e c t i v e n e s s on b e h a v i o u r a l changes w i t h d i e t a r y recommendations f o l l o w i n g a m y o c a r d i a l  infarction.  However, a l l s u b j e c t s had p a r t i c i p a t e d i n e d u c a t i o n programs d u r i n g h o s p i t a l i z a t i o n t h a t v a r i e d from i n f o r m a t i o n p r o v i d e d i n b o o k l e t s and  c a s s e t t e s t o d e t a i l e d t e a c h i n g s e s s i o n s w i t h p r e and  posttesting.  The i n v e s t i g a t o r s made no attempt t o compare t h e type  of t e a c h i n g d u r i n g h o s p i t a l i z a t i o n t o study r e s u l t s o b t a i n e d the c o n t r o l and e x p e r i m e n t a l  groups.  from  They measured b e h a v i o u r a l  changes from p r e h o s p i t a l i z a t i o n t o p o s t d i s c h a r g e  without  c o n s i d e r i n g whether o r n o t t h e s u b j e c t s were s p e c i f i c a l l y i n s t r u c t e d by h e a l t h care workers t o change p a r t i c u l a r  behaviours.  S i m i l a r s t u d i e s u s i n g coronary a r t e r y bypass s u b j e c t s were reviewed  because o f t h e semblance of the t h e r a p e u t i c regimen.  Barbarowicz  e t a l . (1980) found t h a t knowledge scores were twice as  25 great  f o r subjects  who r e c e i v e d s t r u c t u r e d e d u c a t i o n  remained s i g n i f i c a n t l y h i g h e r scores  of s u b j e c t s  (p_<.001) and  f o r three months when compared t o  who r e c e i v e d u n s t r u c t u r e d  education.  When  knowledge s c o r e s were r e l a t e d t o h e a l t h enhancing b e h a v i o u r s ,  there  were no s i g n i f i c a n t d i f f e r e n c e s between t h e groups. L i n d e and Janz (1979) r e p o r t e d  s i m i l a r f i n d i n g s f o r knowledge  l e v e l s but a l s o found t h a t s t r u c t u r e d e d u c a t i o n compliance.  enhanced  L i m i t i n g e f f e c t s of the study were t h a t no c o n t r o l  group was used and compliance r a t e s were compared t o and were s i g n i f i c a n t l y higher  than a s i m i l a r study conducted i n 1963.  problem encountered by t h e r e s e a r c h e r s a s s e s s i n g whether t h e h i g h e r s t r u c t u r e d education by  One  was t h e d i f f i c u l t y i n  compliance r a t e s were a r e s u l t of the  program and/or the c o n t i n u i t y of care  provided  the i n v e s t i g a t o r s . Other r e s e a r c h e r s  have r e p o r t e d p o s i t i v e a s s o c i a t i o n s between  s t r u c t u r e d p a t i e n t education noncardiovascular with d i a b e t e s  and compliance f o r p a t i e n t s  disorders.  Bowen e t a l . (1961) s t u d i e d  m e l l i t u s and d i s c o v e r e d  s t r u c t u r e d education  t h a t p a t i e n t s who  demonstrated a s i g n i f i c a n t l y  knowledge about t h e i r d i s e a s e  with  and i n c r e a s e d  patients  received  greater  gain i n  s k i l l performance w i t h  t h e i r treatment than p a t i e n t s who r e c e i v e d u n s t r u c t u r e d  patient  education. Hecht (1974) randomly d i v i d e d p a t i e n t s w i t h a d i a g n o s i s of t u b e r c u l o s i s i n t o f o u r groups.  The e x p e r i m e n t a l groups  staggered l e v e l s of s t r u c t u r e d education  received  and t h e c o n t r o l group  26 r e c e i v e d no s p e c i a l  teaching.  Results  showed t h a t p a t i e n t s  e x p e r i m e n t a l group made fewer drug e r r o r s the c o n t r o l group.  i n the  than those p a t i e n t s  Compliance was measured by p i l l  in  count where  s e r i o u s e r r o r s were reduced from 53% i n the c o n t r o l group to 17% i n the group t h a t  r e c e i v e d the most i n t e n s i v e  From the l i t e r a t u r e suggested t h a t  review on p a t i e n t  structured patient  knowledge l e v e l s  about c a r d i a c  education,  evidence  education r e s u l t e d i n higher  illness  than u n s t r u c t u r e d  (Barbarowicz e t a l . ,  1980).  C o n f l i c t i n g r e s u l t s were r e p o r t e d f o r the e f f i c a c y  positive  e d u c a t i o n on c o m p l i a n c e .  relationships  Bowen et a l . , (Barbarowicz  (Linde & J a n z ,  1979;  1979;  et a l . ,  1980;  Bille,  suggests t h a t  insufficient  1977;  Milazzo,  Some s t u d i e s  Sivarajan  et a l . ,  1983).  i n enhancing compliance with h e a l t h care  1980;  Hogue,  documentation of the e f f i c a c y reaching p o s i t i v e  1980;  i n c r e a s e d h e a l t h knowledge was  r e a d i n e s s to undertake  (Barbarowicz et a l . ,  found  relationships  recommendations but was shown t o be an i n f l u e n t i a l f a c t o r increasing  of  S c a l z i et a l . ,  1961), whereas o t h e r s t u d i e s found no  The l i t e r a t u r e frequently  Linde & Janz,  teaching  methods  structured patient  1980;  teaching.  treatment  recommended h e a l t h 1979;  Milazzo,  outcomes  is  required  behaviours  1980).  of s t r u c t u r e d p a t i e n t  in  Further  education i n  (Lee & Garvey,  1977). It  was i n t e r e s t i n g  education,  several  the s i g n i f i c a n t  to note t h a t  from the r e s e a r c h  on p a t i e n t  s t u d i e s n e g l e c t e d t o mention the i n c l u s i o n o f  other i n educational  sessions  (Bille,  1977;  Bowen  e t a l . , 1961;  M i l a z z o , 1980).  Other  s t u d i e s encouraged the  s i g n i f i c a n t o t h e r t o a t t e n d e d u c a t i o n a l s e s s i o n s ; however, p a r t i c i p a t i o n or attendance  was  1980;  Bracken  Linde & Janz,  1980;  S i v a r a j a n e t a l . , 1983).  e t a l . , 1977;  I n f l u e n c e of the S i g n i f i c a n t  not e n f o r c e d  (Barbarowicz  1979;  S c a l z i et a l . ,  Other  S e v e r a l r e s e a r c h e r s have suggested  t h a t the l i m i t e d knowledge  of a s i g n i f i c a n t o t h e r about the t h e r a p e u t i c regimen was pertinent factor a f f e c t i n g t h e i r partner's i n a b i l i t y the regimen Schlesinger, Few  (Crawshaw, 1974;  Royle,  1973;  a  t o comply with  Rudy, 1980;  Segev &  1983).  s t u d i e s have examined the e f f e c t of the s i g n i f i c a n t  l e v e l of knowledge on the h e a l t h - r e l a t e d behaviours partner.  et a l . ,  Tyzenhouse  of  others  their  (1973) i n t e r v i e w e d male s u b j e c t s w i t h  m y o c a r d i a l i n f a r c t i o n s and t h e i r wives p o s t h o s p i t a l i z a t i o n  and  found t h a t wives w i t h the most knowledge d i d not have husbands showed a c o r r e s p o n d i n g improvement i n h e a l t h .  who  None of the wives  s t a t e d t h a t she i n f l u e n c e d the a c t i v i t i e s of her husband. Tyzenhouse concluded t h a t a wife needs t o understand t h e r a p e u t i c regimen and r e c o v e r y b e s t through  i t s importance  but may  the  serve the husband's  s u p p o r t i v e r a t h e r than d i r e c t i v e  activities.  Tyzenhouse e s t i m a t e d knowledge and h e a l t h improvement and d i d not r e l a t e her f i n d i n g s t o any  type of p a t i e n t e d u c a t i o n .  28 Research has shown that the attitudes of the wife have a considerable effect on the partner's emotional adaptation to heart disease, compliance with the associated therapeutic regimen, and successful rehabilitation during the convalescent period (Adsett & Bruhn, 1968; Bedsworth & Molen, 1982; Davidson, 1979). Heinzelmann and Bagley (1970) found that male subjects with coronary artery disease had compliant behavioural patterns with a physical fitness program, and that this was directly related to the wife's attitude toward the program, Aho (1977) interviewed married women and discovered that these women had strong beliefs about playing a role in the prevention of heart disease in their husbands, that heart disease was preventable, and that treatment was effective.  However, most wives  did not worry about their husbands developing heart disease and few had suggested health related behaviours to them. Wives of husbands with myocardial infarctions saw their role during recovery as preparing recommended foods, protecting their husbands against future infarctions, and generally helping their husbands follow the treatment regimen (Adsett & Bruhn, 1968; Baden, 1972; Royle, 1973). Mayou et a l . (1978) found that one-half of the wives in their sample consulted the physician about their husbands' progress, administered medication, and participated or actively encouraged their husbands with their efforts to diet or take exercise.  Mayou et a l . found that the wives influenced the rate  and extent of convalescence of their husbands up to one year  following the myocardial infarction and that the attitudes and behaviours of the wives were important factors in the successful recovery of their husbands.  Mayou et a l . recommended that advice  about the therapeutic regimen be given to the wives during recovery to exert a positive influence on their partners. Becker and Green (1975) found that wives influenced the behaviour of their husbands by communication, pressure, or acting as role models and stated that within the family unit, compliant behaviour would likely be performed by the partners i f the wives supported the prescribed therapeutic regimen. Ruskin, Stein, Shelsky, and Bailey (1970) tested individuals with myocardial infarctions and their wives using the Minnesota Multiphasic Personality Inventory.  When test results were  compared, the wives demonstrated a greater ego strength, a better sense of reality, and stronger feelings of personal adequacy when compared to their husbands.  The wives were psychologically  healthier, less socially introverted, and were more able to influence the behaviour of others.  Inclusion of wives i n patient  education was recommended for the successful rehabilitation of their husbands. Prom a review of family studies, Litman (1974) stated, "the ultimate success of the family's involvement in home treatment may in large part revolve around i t s ability and preparation to do so" (p. 506). The literature suggested that a significant other was capable of exerting a positive influence on her partner's  30  compliance with physical activity, dietary, and medication recommendations i f provided with knowledge about the therapeutic regimen (Adsett & Bruhn, 1968; Becker & Green, 1975; Mayou et a l . 1978).  Significant others were physically and psychologically  healthier than their partners (Ruskin et a l . , 1970), perhaps suggesting that significant others could acquire and retain information more readily than their mates during the acute phase of a myocardial infarction and could be capable of reinforcing health enhancing behaviours during recovery at home when health care workers are not available.  Summary From the literature review of compliance, knowledge, patient education, and the influence of the significant other, the studies as a group suggested that patient compliance with health care recommendations continues to be a major problem confronting health care workers and that noncompliance can be related to lack of knowledge of both the individual and his significant other, vague instructions, and lack of support from the significant other. Research to determine the best method of structured versus unstructured teaching methods and the effect on enhancing compliance has not been attained. Although research indicated that significant others were capable of positively influencing compliance of their partners when provided with relevant knowledge, no scientific evidence was found to substantiate improved  compliance when s i g n i f i c a n t education.  others  are i n c l u d e d i n p a t i e n t  32 CHAPTER 3 Methodology D e s c r i p t i o n s of the r e s e a r c h this  chapter,  design,  This lays  the groundwork t o  the m a n i p u l a t i o n of the independent v a r i a b l e s .  c o l l e c t i o n instrument i s  then d e s c r i b e d as w e l l as  and a d m i n i s t r a t i o n of the i n s t r u m e n t . considerations  5  and sample b e g i n  f o l l o w e d by a d e s c r i p t i o n of the e d u c a t i o n program i n  p r o g r e s s at the h o s p i t a l under s t u d y . describe  setting  concludes t h i s  The data  the  development  A d e s c r i p t i o n of  ethical  chapter.  Research D e s i g n T h i s study employed an e x p l a n a t o r y accept  or r e j e c t the s t a t e d  experimental  design  hypotheses.  E x p l a n a t o r y designs are used to p r e d i c t and e x p l a i n i n t e r a c t i o n of v a r i a b l e s a r e known.  strategies  when s u f f i c i e n t  data about the  The i n t e r a c t i o n of the v a r i a b l e s  c o n c e p t u a l or t h e o r e t i c a l  framework.  must be guided by a  or r e j e c t  to d i f f e r e n t  experimental  and can manipulate the independent v a r i a b l e s . can l i m i t the i n t e r f e r e n c e of  two e q u i v a l e n t  hypotheses  designs are used when the i n v e s t i g a t o r  c o n t r o l of s u b j e c t assignment  assignment  variables  1978).  Experimental  groups  the  E x p l a n a t o r y designs p r o v i d e  f o r examining evidence t o accept  ( B r i n k & Wood,  to  has conditions  Use of c o n t r o l  of o t h e r v a r i a b l e s .  By random  s u b j e c t s to e i t h e r a c o n t r o l or e x p e r i m e n t a l groups at  group,  the s t a r t of the study are p o s s i b l e .  By  33 subjecting possible  one of the groups  to a t t r i b u t e  to the e x p e r i m e n t a l v a r i a b l e ,  changes t h a t occur i n the e x p e r i m e n t a l  and not i n the c o n t r o l group t o the e f f e c t variable  (Brink & Wood,  d e s c r i b e d the p o t e n t i a l e f f e c t s  i n the second  structured patient  e d u c a t i o n and the s i g n i f i c a n t  dependent v a r i a b l e  of compliance with h e a l t h c a r e  of Orem's model f o r n u r s i n g , social  Extraneous  The  of  o t h e r on the recommendations.  was guided by a combination and  learning theory. variables  w i t h i n the c o n f i n e s  will  chapter,  Dubos' t h e o r y of a d a p t a t i o n ,  such as  previous myocardial i n f a r c t i o n s  used as a r e s u l t  group  independent  of the independent v a r i a b l e s  The s e l e c t i o n of independent v a r i a b l e s  »  of the  is  1978).  P r e v i o u s study f i n d i n g s p r e s e n t e d  Bandura's  it  of t h i s  age,  occupation,  c o u l d not be f u l l y  e d u c a t i o n and controlled  study even though random assignment  of the s m a l l sample s i z e .  Demographic  was  variables  be addressed i n Chapter 4.  Setting The s e t t i n g  for this  study was one c a r d i a c ward of a l a r g e  metropolitan teaching h o s p i t a l .  The h o s p i t a l  served  individuals  who r e s i d e d or worked i n the downtown core or s u r r o u n d i n g a r e a s . The h o s p i t a l p r o v i d e d h i g h l y s k i l l e d s t a f f  and modern equipment  perform c a r d i a c m o n i t o r i n g , a wide range of d i a g n o s t i c pacemaker  insertions,  experienced cardiac  and open-heart  complications.  surgery  tests,  f o r i n d i v i d u a l s who  The h o s p i t a l was a major  to  34 r e f e r r a l c e n t r e f o r c a r d i a c p a t i e n t s from s m a l l e r , r e g i o n a l institutions. I n d i v i d u a l s w i t h suspected m y o c a r d i a l  i n f a r c t i o n s were  r o u t i n e l y admitted t o t h e coronary c a r e u n i t where e l e c t r o c a r d i o g r a m s and serum enzyme t e s t s were performed the d i a g n o s i s . myocardial  Approximately  250 i n d i v i d u a l s with  to confirm  confirmed  i n f a r c t i o n s were e n t e r e d i n t o t h e census of the coronary  c a r e u n i t over t h e p r e c e d i n g y e a r s . When t h e i r c o n d i t i o n became more s t a b l e , i n d i v i d u a l s were t r a n s f e r r e d t o p r i v a t e or s e m i - p r i v a t e rooms on a 35-bed c a r d i a c ward u n t i l  d i s c h a r g e d by the a t t e n d i n g c a r d i o l o g i s t .  Individuals  with c a r d i a c problems o t h e r than m y o c a r d i a l i n f a r c t i o n , as w e l l as p r e and postopen  h e a r t s u r g i c a l p a t i e n t s , were admitted  t o the  c a r d i a c ward.  Sample S e l e c t i o n The  t a r g e t p o p u l a t i o n f o r t h i s study i n c l u d e d male p a t i e n t s  between t h e ages o f 30 and 70, with s i g n i f i c a n t o t h e r s , who sustained a myocardial  i n f a r c t i o n and were admitted  to the c a r d i a c  ward of one h o s p i t a l d u r i n g the time p e r i o d f o r p a t i e n t s e l e c t i o n i n t o the study. February  The time p e r i o d was from January  29, 1984.  confirmed myocardial  Although  the h o s p i t a l admitted  1, 1983 t o l a r g e numbers o f  i n f a r c t i o n s d u r i n g the time frame of the  study, the h o s p i t a l ' s census was down and few i n d i v i d u a l s met t h e c r i t e r i a e s t a b l i s h e d f o r t h i s study.  The r e s e a r c h e r a n t i c i p a t e d  o b t a i n i n g a sample o f 15 p a t i e n t s ; however,  l a c k of s u b j e c t s  meeting s p e c i f i e d c r i t e r i a r e s u l t e d i n a sample of 12 p a t i e n t s . C r i t e r i a f o r Selection of Patients.  As o r i g i n a l l y  e i g h t c r i t e r i a were e s t a b l i s h e d f o r p a t i e n t study.  Criteria  planned,  s e l e c t i o n i n t o the  f o r study i n c l u s i o n were:  1.  The p a t i e n t was male between t h e ages of 30 and 70.  2.  The p a t i e n t had not s u f f e r e d a p r e v i o u s m y o c a r d i a l  i n f a r c t i o n within the l a s t f i v e  years.  3.  The p a t i e n t was a t t e n d e d t o by a c a r d i o l o g i s t .  4.  The p a t i e n t r e s i d e d w i t h a s i g n i f i c a n t  5.  The p a t i e n t was l i t e r a t e and spoke t h e E n g l i s h  6.  The p a t i e n t was o r i e n t e d .  7.  The p a t i e n t r e s i d e d w i t h i n t h e G r e a t e r Vancouver  8.  The p a t i e n t was w i l l i n g t o p a r t i c i p a t e i n t h e s t u d y .  Rationale  for Criteria.  language.  area.  A v a r i e t y o f reasons prompted t h e  investigator to select specific c r i t e r i a Male s u b j e c t s  other.  f o r study i n c l u s i o n .  were s e l e c t e d because t h e l i t e r a t u r e  suggested  t h a t more men t h a t women e x p e r i e n c e d m y o c a r d i a l i n f a r c t i o n s (Barbarowicz e t a l . , 1976; M c D i l l ,  1975).  Studies  investigating  both sexes with m y o c a r d i a l i n f a r c t i o n s supported t h e above findings.  Sivarajan  e t a l . (1983) s t u d i e d 219 men and 39 women.  Rahe e t a l . (1975) had a study sample o f 19 men and 5 women. Bracken e t a l . (1977) i n v e s t i g a t e d a sample group of 31 p a t i e n t s w i t h 74.2% b e i n g men.  R e s t r i c t i n g the t a r g e t population  t o males  c o n t r o l l e d f o r t h e i n f l u e n c i n g f a c t o r of sex, and p o t e n t i a l  36 b e n e f i t s d e r i v e d from the study might be group of p a t i e n t s with m y o c a r d i a l The primary  reason  f o r age  i n t e r e s t i n s t u d y i n g men retired.  The  who  g e n e r a l i z e d t o the  infarctions.  l i m i t a t i o n s was  the  investigator's  were c u r r e n t l y employed or r e c e n t l y  i n v e s t i g a t o r assumed t h a t a m y o c a r d i a l  would have a major impact w i t h i n the s p e c i f i e d age  on men group.  infarction  and t h e i r s i g n i f i c a n t  the study.  others  Lack of s u b j e c t s meeting t h e  s e l e c t e d c r i t e r i a r e s u l t e d i n an i n c r e a s e of the age years midway through  larger  Only one  l i m i t t o 80  s u b j e c t met  the  revised  criteria. P a t i e n t s experiencing a f i r s t myocardial  i n f a r c t i o n were,  s e l e c t e d t o c o n t r o l f o r the v a r i a b l e of knowledge. had  s u f f e r e d a myocardial  Patients  who  i n f a r c t i o n more than f i v e y e a r s ago were  i n c l u d e d i n the study as t h e i r r e c a l l of i n f o r m a t i o n and p a t i e n t e d u c a t i o n program i f a p p l i c a b l e , was  probably  the  limited.  T h i s p a r t i c u l a r c r i t e r i o n e l i m i n a t e d numerous s u b j e c t s from p o s s i b l e study i n c l u s i o n .  A l a r g e number of p a t i e n t s admitted  the c a r d i a c ward were e x p e r i e n c i n g second  and t h i r d  to  myocardial  i n f a r c t i o n s w i t h i n a s h o r t e r time span than f i v e y e a r s which f u r t h e r j u s t i f i e d the i n v e s t i g a t i o n of adequate p a t i e n t e d u c a t i o n t o enhance compliance,  p r e v e n t r e o c c u r r e n c e , and reduce m o r t a l i t y  figures. S u b j e c t s r e q u i r e d an a t t e n d i n g c a r d i o l o g i s t who  was  e x p e r t a t d i a g n o s i n g and t r e a t i n g m y o c a r d i a l i n f a r c t i o n s . c a r d i o l o g i s t s on s t a f f a t the h o s p i t a l supported p a t i e n t  deemed an All  p a r t i c i p a t i o n i n the e d u c a t i o n i n s t r u c t i o n s as p r e v i o u s l y The by  program and  described  wrote  discharge  f o r the p a t i e n t s to take home.  documented h e a l t h care recommendations were used as a the  investigator for providing factual  The  subjects  literature  e f f e c t on the r e c o v e r y h e a l t h care subjects  s i g n i f i c a n t other p r o c e s s and  recommendations.  who  data.  required a s i g n i f i c a n t other.  review, the  From the  appeared to have the most  the p a t i e n t ' s compliance  Only the  s i g n i f i c a n t others  were t o p a r t i c i p a t e i n the e d u c a t i o n a l  approached by the  reference  with  of  s e s s i o n were  i n v e s t i g a t o r f o r consent to p a r t i c i p a t e i n the  study. Subjects  were r e q u i r e d to be  E n g l i s h language i n order education  literate,  o r i e n t e d , and  speak  t o p a r t i c i p a t e i n the a u d i o v i s u a l  program, t o r e f e r t o the p a t i e n t manual, and  the  patient  to  communicate with the i n v e s t i g a t o r . G e o g r a p h i c a l r e s t r i c t i o n s were necessary to p e r m i t  follow-up  v i s i t s i n the s u b j e c t s ' homes.  P a t i e n t E d u c a t i o n Program The  program i n p r o g r e s s a t the h o s p i t a l c o n s i s t e d of  s l i d e - t a p e s and a take-home p a t i e n t manual.  The  tapes and  were produced by the American Heart A s s o c i a t i o n and active partnership attack)".  The  f o r the h e a l t h of your h e a r t  s l i d e - t a p e s imparted i n f o r m a t i o n  about anatomy and p h y s i o l o g y  of the h e a r t  seven  titled  ( a f t e r your to the  as r e l a t e d t o  manual "An heart  patients coronary  38 a r t e r y d i s e a s e , angina and m y o c a r d i a l i n f a r c t i o n s , r i s k such as smoking, s t r e s s , d i e t , p h y s i c a l a c t i v i t y , and such as the i n g e s t i o n of  factors  treatment,  medication.  Because the outcome of the study measured compliance  with  d i e t a r y , a c t i v i t y , and m e d i c a t i o n h e a l t h c a r e recommendations, because knowledge of the anatomy and p h y s i o l o g y of the h e a r t e s s e n t i a l f o r p r e p a r i n g the p a t i e n t t o understand  and  was  the  recommendations, d i s c u s s i o n i n the s t r u c t u r e d e d u c a t i o n s e s s i o n s and  f o l l o w - u p i n t e r v i e w s was  d u r a t i o n of each tape was Content  of the f i r s t  l i m i t e d t o these f o u r t a p e s .  The  20 t o 25 minutes. tape i n c l u d e d an e x p l a n a t i o n of t h e  anatomy and p h y s i o l o g y of the h e a r t , d e f i n e d a m y o c a r d i a l i n f a r c t i o n , d e s c r i b e d the h e a l i n g p r o c e s s of the h e a r t a f t e r a myocardial  i n f a r c t i o n , d e s c r i b e d the cause of  myocardial  i n f a r c t i o n s i n the terms of coronary a r t e r y d i s e a s e , and i n t r o d u c e d the r i s k f a c t o r s a s s o c i a t e d w i t h h e a r t d i s e a s e . The  t o p i c of the second tape was  c o n s i s t e d of the r a t i o n a l e and of  activities.  p h y s i c a l a c t i v i t y and  d i r e c t i o n s f o r a gradual  content  resumption  I n f o r m a t i o n c o n c e r n i n g a c t i v i t i e s t o do and not t o  do d u r i n g the f i r s t  t h r e e weeks a t home were l i s t e d .  Restricted  a c t i v i t i e s such as s e x u a l i n t e r c o u r s e , d r i v i n g a c a r , r e t u r n i n g t o a job, hobbies,  and s p o r t s were addressed.  Chest p a i n s a s s o c i a t e d  w i t h e x e r t i o n were a l s o d e s c r i b e d with accompanying d i r e c t i o n s f o r treatment. activities  The  i n t e n d e d message of the tape was  to l i m i t  d u r i n g r e c o v e r y with a g r a d u a l r e t u r n t o a  physical  similar  39 or b e t t e r p h y s i c a l c a p a b i l i t y than e x p e r i e n c e d by t h e i n d i v i d u a l p r i o r t o the m y o c a r d i a l i n f a r c t i o n . The habits.  t h i r d tape i n t r o d u c e d Diets  discussed.  dietary  low i n c a l o r i e s , c h o l e s t e r o l , f a t , and sodium were  Foods t o e a t and foods t o a v o i d were l i s t e d f o r each  d i e t as w e l l as g e n e r a l diet.  the p a t i e n t t o proper  t i p s t o a s s i s t the p a t i e n t t o f o l l o w  The tape s t r e s s e d moderation f o r p a r t i c u l a r food  r a t h e r than t o t a l The  each  consumption  elimination.  t o p i c of the f o u r t h tape was m e d i c a t i o n .  drugs were d e s c r i b e d ,  however, the tape d i s c u s s e d  No s p e c i f i c general  about the "do's" and "don'ts" of m e d i c a t i o n i n g e s t i o n . i n s t r u c t e d the p a t i e n t t o q u e s t i o n  tips  The tape  the name, purpose, method,  f r e q u e n c y , dosage, and s i d e e f f e c t s f o r each m e d i c a t i o n prescribed. A manual f o r home use was given included and  the p e r t i n e n t  activity  t o each p a t i e n t .  f a c t s from the tapes and l i s t s  Content of d i e t a r y  restrictions.  Program D e l i v e r y on t h e C a r d i a c  Ward.  W i t h i n the time  parameters of t h i s study, two methods o f program d e l i v e r y were implemented by n u r s i n g nursing  staff.  s t a f f was d e f i n e d  unstructured  The d e l i v e r y of the program by  f o r the purpose of t h i s study, as  e d u c a t i o n by t h e i n v e s t i g a t o r .  The u s u a l  method was  i n d i v i d u a l d e l i v e r y ; however, a group d e l i v e r y method was p u t i n t o p r a c t i c e f o r two months midway through the study.  The methods of  program d e l i v e r y and t h e d e l i v e r y v a r i a b l e s a r e shown i n T a b l e One.  40  Table 1 Summary o f Two  Methods o f Program D e l i v e r y on C a r d i a c Ward  D e l i v e r y Methods Program V a r i a b l e s  Individual  Group  Content  1-7  7 tapes  Manuals  given  given  if  invited  Significant  other  tapes  present  more than 1 nurse  nursing assistant more t h a n 1 nurse  Discussion  possibly  possibly  Learning Objectives  none  none  Location  h o s p i t a l room  patients'  Time of day  usually  a f t e r n o o n and  Frequency  1-7 tapes shown over s e v e r a l days or a l l a t once  1-2 per  Sequenced  possibly  sequenced from Monday t o F r i d a y  Additional l e a r n i n g sources  possibly d i e t i t i a n and m e d i c a t i o n cards  possibly d i e t i t i a n and m e d i c a t i o n cards  Physician's regimen  at discharge  at discharge  Staff  involvement  written  day  shift  lounge evening  day  41 S e v e r a l problems were i d e n t i f i e d with both methods from o b s e r v a t i o n and comments from s t a f f  and p a t i e n t s  who were i n v o l v e d w i t h the  u n s t r u c t u r e d t e a c h i n g methods. Problems encountered w i t h the i n d i v i d u a l approach tended to be a t t r i b u t e d to s t a f f responsible  shortages and more than one nurse b e i n g  f o r the program.  The p r e s e n t a t i o n  o c c u r r e d at the convenience of the n u r s e ,  of the tapes  r e s u l t i n g i n the  v i e w i n g a l l of the tapes d u r i n g one s e s s i o n ,  were p r e s e n t ;  absent.  however, the s i g n i f i c a n t  were  when more n u r s i n g  others were f r e q u e n t l y  The tapes were u s u a l l y out of sequence  discussions  patient  more o f t e n than n o t .  The tapes were u s u a l l y shown d u r i n g the day s h i f t staff  usually  and i n d i v i d u a l  rare.  Problems encountered w i t h the group method were poor attendance visitors,  as a r e s u l t discharge  l a c k of sequence midweek.  of d i s i n t e r e s t  before  the e n t i r e program was p r e s e n t e d ,  t o tapes i f t r a n s f e r  Patients  seldom a r r i v e d to t u r n on  with the nurse f o l l o w i n g the  rare.  P r i o r to d i s c h a r g e ,  patients  r e c e i v e d m e d i c a t i o n cards  d e s c r i b i n g each of t h e i r p r e s c r i b e d drugs. i n c l u d e d the name, the p u r p o s e , effects.  and  t o the c a r d i a c ward o c c u r r e d  complained t h a t s t a f f  the equipment and t h a t d i s c u s s i o n s tapes were  or c o n f l i c t with t e s t s and  Some p a t i e n t s  tips  for ingestion,  r e c e i v e d the c a r d s ,  the cards w i t h a d i s c u s s i o n with the n u r s e , not r e c e i v e the  cards.  Content of the  cards  and s i d e  some p a t i e n t s  received  and some p a t i e n t s  did  P a t i e n t s with d i e t a r y r e s t r i c t i o n s r e c e i v e d a v i s i t d i e t i t i a n p r i o r to d i s c h a r g e . "do's" and the  If  i f the  foods f o r each d i e t .  p a t i e n t was occurred At  were p r e s e n t  busy, the p a t i e n t was I f the  between d i e t a r y discharge,  significant  d u r i n g the  handed the  visit.  lists  of  and  the  d i e t f o r the i n d i v i d u a l , the  f o r e l i m i n a t i n g c o n f l i c t i n g foods t h a t overlaps.  the p a t i e n t s were given a standard  c a r d i o l o g i s t which l i s t e d the  dietary restrictions,  form by  of m e d i c a t i o n s , and  recommended times f o r  appointments w i t h the p h y s i c i a n . d i s c u s s the  significant  the unorganized and  d e l i v e r y of the program c o n s t i t u t e d u n s t r u c t u r e d end  r e s u l t was  follow-up  format of the program met  for structured education,  other. the random  education.  t h a t some p a t i e n t s r e c e i v e d the t o t a l program  whereas other p a t i e n t s r e c e i v e d p a r t s or none of the o f f e r e d by the h o s p i t a l .  a  c a r d i o l o g i s t attempted t o  form with both the p a t i e n t and  Although the content and criteria  The  the  activity  r e s t r i c t i o n s w i t h dates s p e c i f y i n g when to resume a c t i v i t i e s , list  of  permitted,  l a t t e r s i t u a t i o n occurred  p r e s c r i b e d more than one  responsible  I f time  d i e t s with p a t i e n t s and  s i g n i f i c a n t others  the d i e t i t i o n was  p h y s i c i a n had  the  the  dietitian distributed lists  "don'ts" f o r each d i e t p r e s c r i b e d .  d i e t i t i o n discussed  others,  The  from  services  The  43 Treatment V a r i a b l e s to be manipulated were the method of p a t i e n t education  and  the  involvement of the s i g n i f i c a n t other  t o determine  t h e i r e f f e c t s on compliance r a t e s . P a t i e n t s who one  of t h r e e  met  the sample c r i t e r i a were randomly a s s i g n e d  groups.  P r i o r t o the  i n i t i a t i o n of the  s u b j e c t numbers were drawn from a hat and  (2),  or to the  drawn was  assigned  group 3, the  first  In o t h e r  words, the  to group 1, the  assigned  e x p e r i m e n t a l group  second e x p e r i m e n t a l group (3) u n t i l  numbers were e l i m i n a t e d .  study, twenty  repeatedly  s e q u e n t i a l l y to the c o n t r o l group (1), the  the  first  so f o r t h .  subject  subject  second to group 2,  f o u r t h t o group 1, and  Twenty  the  groups, the  i n v e s t i g a t o r introduced  the  number  the t h i r d  to  subject  numbers were drawn t o cover p o s s i b l e a t t r i t i o n from the Within  to  sample.  following  variables: 1.  The  c o n t r o l group r e c e i v e d u n s t r u c t u r e d  as p r a c t i c e d by the in  the p r e c e d i n g  other  may  nursing  section.  have seen the  d i s c u s s i o n s by n u r s i n g d i e t with the  The  p a t i e n t and p o s s i b l y the  slide-tape presentation, s t a f f , may  d i e t i t i a n , may  have d i s c u s s e d  day  or over s e v e r a l  may  have  received  the  prescribed cards,  have watched the tapes on  one  days.  first  s t r u c t u r e d education  described  significant  have r e c e i v e d the m e d i c a t i o n  have r e c e i v e d the manual, and may  In the  education  s t a f f on the c a r d i a c ward and  may  2.  patient  e x p e r i m e n t a l group, p a t i e n t s from the  investigator.  received  A l l subjects,  without  44 their  significant  presentations. first  others  i n attendance,  The i n v e s t i g a t o r  the h e a r t , tape,  The sequence  with the i n v e s t i g a t o r teaching objectives  the  f o r the second, t h i r d and  diet,  and m e d i c a t i o n .  r e l a t i o n s h i p to l i f e s t y l e  g u i d i n g the d i s c u s s i o n  (see  for  of tapes was anatomy and p h y s i o l o g y of  physical activity,  the conte'nt and i t s  slide-tape  may have been p r e s e n t  tape and was d e f i n i t e l y p r e s e n t  fourth tapes.  viewed four  Appendix A ) .  to each s u b j e c t p r i o r to the f i r s t b o t h s u b j e c t and i n v e s t i g a t o r ,  F o l l o w i n g each were  discussed  from s t r u c t u r e d  The p a t i e n t manual was g i v e n  tape and was r e f e r r e d t o ,  after  each t a p e .  by  Program times were  arranged with the p a t i e n t at h i s c o n v e n i e n c e , with the program b e i n g shown i n the p r i v a c y of the p a t i e n t ' s room was c l o s e d t o reduce d i s t r a c t i o n s . were viewed each day as primary purpose  The door to  the  A maximum of two tapes  d i c t a t e d by the p a t i e n t ' s  condition.  The  f o r l i m i t i n g the tapes t o one or two per day was  p r e v e n t the p a t i e n t a b i l i t y to  room.  from becoming o v e r t i r e d and c l o u d i n g h i s  learn.  3. , The second e x p e r i m e n t a l group c o n s i s t e d of the p a t i e n t his significant  other.  The couple r e c e i v e d s t r u c t u r e d  from the i n v e s t i g a t o r  and the i n v e s t i g a t o r  tapes.  was i d e n t i c a l to t h a t  The treatment  only difference  was p r e s e n t  discharge  education for a l l  b e i n g the i n t r o d u c t i o n of the s i g n i f i c a n t  e d u c a t i o n program. with f i n a l  and  four  of group 2, with the  L i m i t a t i o n s were a s s o c i a t e d with the t i m i n g of the patient  to  other.  structured  The program was conducted p r i o r to  discharge  i n s t r u c t i o n s b e i n g unknown.  As a  45 result,  a l l d i e t s were d i s c u s s e d as per l e a r n i n g o b j e c t i v e s (see  Appendix A ) , w i t h a p a r t i c u l a r emphasis on the d i e t t h a t the p a t i e n t was b e i n g s e r v e d d u r i n g h o s p i t a l i z a t i o n .  Current  m e d i c a t i o n s were d i s c u s s e d w i t h r e l a t i o n t o name and purpose of the drug.  P a t i e n t s were encouraged t o q u e s t i o n t h e p h y s i c i a n o r nurse  about p r e s c r i b e d m e d i c a t i o n and t o ask f o r m e d i c a t i o n cards on the day  of d i s c h a r g e .  received v i s i t s  P a t i e n t s i n the e x p e r i m e n t a l groups a l s o  from the d i e t i t i a n i f r e q u i r e d and a d i s c u s s i o n  with the c a r d i o l o g i s t p r i o r t o d i s c h a r g e as d e s c r i b e d f o r t h e control  group.  T h i s explanatory experimental compliance  study was designed t o measure  r a t e s o f p a t i e n t s i n the c o n t r o l group (group  1) who  r e c e i v e d u n s t r u c t u r e d p a t i e n t e d u c a t i o n , p a t i e n t s i n group 2 who r e c e i v e d s t r u c t u r e d p a t i e n t e d u c a t i o n , and p a t i e n t s i n group 3 who r e c e i v e d s t r u c t u r e d p a t i e n t e d u c a t i o n with t h e i r s i g n i f i c a n t t o determine  t h e e f f e c t s of p a t i e n t e d u c a t i o n methods and t h e  e f f e c t s of t h e s i g n i f i c a n t o t h e r on  Data C o l l e c t i o n  compliance.  Instrument  An i n t e r v i e w schedule was chosen f o r t h i s experimental  study.  Polit  and Hungler  explanatory  (1978) recommended  i n t e r v i e w s t o o b t a i n s e l f - r e p o r t i n f o r m a t i o n from s u b j e c t s i n f a c e - t o - f a c e s i t u a t i o n s f o r t h e r e s e a r c h d e s i g n used study.  i n this  other,  46 The  i n t e r v i e w schedule c o n t a i n e d some closed-ended  questions  which p e r m i t t e d s u b j e c t s to s e l e c t from a number of a l t e r n a t i v e responses  and  some open-ended q u e s t i o n s t o p e r m i t the  t o r e p l y t o q u e s t i o n s i n t h e i r own  words.  The  respondents  closed-ended  q u e s t i o n s measured the dependent v a r i a b l e of compliance  rates  and  t h e open-ended q u e s t i o n s encouraged the s u b j e c t s to i d e n t i f y h e a l t h c a r e recommendations and t o i d e n t i f y problems encountered l e a d i n g to noncompliance with the  recommendations.  Development of the Data C o l l e c t i o n Instrument. v a r i a b l e t o be measured was activity,  d e f i n e d as compliance  The  d i e t a r y , and m e d i c a t i o n h e a l t h care recommendations.  medication  were developed  t o measure the dependent  content of each g e n e r a l content area was  c o l l e c t i o n instrument  i s presented  i n Appendix  d e r i v e d from the  f o r s t a i r c l i m b i n g , walking  driving a car.  The  data  suggested  o b j e c t s , s e x u a l a c t i v i t y , r e t u r n t o work, hobbies  s p o r t s , t r a v e l l i n g , and  The  C.  As p r e v i o u s l y d i s c u s s e d , the tape on a c t i v i t y limiting physical activities  and  variable.  s l i d e - t a p e p r e s e n t a t i o n s used i n the e d u c a t i o n program.  lifting  dependent  r a t e s with  T h e r e f o r e , t h r e e g e n e r a l content areas of a c t i v i t y , d i e t ,  Specific  and  outdoors, or  activity  recommendations from the tapes a l s o corresponded  to  activity  c a t e g o r i e s on the d i s c h a r g e i n s t r u c t i o n form given to the p a t i e n t by the  cardiologist.  The  dependent v a r i a b l e was  q u e s t i o n with an o r d i n a l s c a l e .  measured by a m u l t i p l e c h o i c e S u b j e c t s were asked  i f they  47 f o l l o w e d the a c t i v i t y  recommendations a l l of the time, h a l f the  time, some of the time, o r never. t o each answer c h o i c e .  Numerical v a l u e s were a s s i g n e d  S i n c e the d e s i r e d b e h a v i o u r was  a l l of t h e  time, t h i s answer m e r i t e d t h r e e p o i n t s , the maximum p o i n t s achievable.  None of the time m e r i t e d zero p o i n t s .  The use of t h i s  s c a l e a s s i s t e d the i n v e s t i g a t o r t o p r o v i d e n u m e r i c a l data about compliance r a t e s .  Two  " o t h e r " c a t e g o r i e s i n the s p e c i f i c c o n t e n t  a r e a were i n c l u d e d i n the event t h a t the p h y s i c i a n p r e s c r i b e d a d d i t i o n a l l i m i t a t i o n s o t h e r than those d e f i n e d .  The  closed-ended  q u e s t i o n u s i n g o r d i n a l s c a l i n g p e r m i t t e d the summation of t o t a l compliance  s c o r e s and comparison  groups u s i n g a percentage The diets  of the s c o r e s among s u b j e c t s and  analysis.  s l i d e - t a p e on d i e t suggested foods t o eat and a v o i d  on  low i n c a l o r i e s , low i n sodium, and low i n f a t / c h o l e s t e r o l .  Reference was  made t o s a l t f r e e d i e t s and r e d u c i n g a l c o h o l  consumption.  Compliance  r a t e s were measured u s i n g the same format  as d e s c r i b e d f o r a c t i v i t y recommendations with the b e s t response b e i n g a l l of the time and b e i n g awarded t h r e e p o i n t s .  Two  c a t e g o r i e s were i n c l u d e d i n the event t h a t the p h y s i c i a n additional dietary The  "other"  prescribed  l i m i t a t i o n s o t h e r than those d e f i n e d .  s l i d e - t a p e on m e d i c a t i o n d i d not r e f e r t o s p e c i f i c  except f o r n i t r o g l y c e r i n .  The tape encouraged  drugs  p a t i e n t s to question  h e a l t h c a r e workers about the name, purpose, method, f r e q u e n c y , dosage, and s i d e e f f e c t s f o r each m e d i c a t i o n p r e s c r i b e d . p r e s c r i b e d drugs such as n i t r o g l y c e r i n ,  Commonly  d i g o x i n , furosemide,  and  48 potassium "other"  c h l o r i d e were i n c o r p o r a t e d i n t o c a t e g o r i e s with  categories allocated  medications.  to cover a d d i t i o n a l  S u b j e c t s were asked t o e s t i m a t e i f  to follow directions  recommendations.  awarded t h r e e  prescribed they had been a b l e  f o r each of the m e d i c a t i o n s p r e s c r i b e d and  responses were measured u s i n g the same format as activity  five  described  for  The b e s t response of a l l of the time was  points.  In o r d e r to measure compliance r a t e s , open-ended q u e s t i o n s  s u b j e c t s were  t o i d e n t i f y h e a l t h care  asked  recommendations.  A c t i v i t y recommendations were determined by a s k i n g the s u b j e c t the d o c t o r had suggested l i m i t i n g a c t i v i t i e s  i n any way.  recommendations were i d e n t i f i e d by a s k i n g the s u b j e c t i f had suggested r e s t r i c t i n g the d i e t i n any way.  if  Dietary the  doctor  Medication  recommendations were determined by a s k i n g the s u b j e c t i f  the  doctor  o r d e r e d any m e d i c a t i o n t o take a t home. In o r d e r to o b t a i n data about causes f o r noncompliance, s u b j e c t s were asked i f  any d i f f i c u l t i e s  f o l l o w i n g the d o c t o r ' s  recommendations and to d e s c r i b e  difficulty. diet,  were encountered with  The open-ended q u e s t i o n was asked  the  f o r each  activity,  and m e d i c a t i o n p r e s c r i b e d . In a d d i t i o n , s u b j e c t s were asked  marital status,  occupation,  infarction  Appendix D ) .  Bille  (see  education,  demographic data r e l a t e d and prevous m y o c a r d i a l  (1977) used a s i m i l a r instrument to a s s e s s  compliance i n h i s s t u d y .  to  patient  Although he was a b l e t o draw c o n c l u s i o n s  49 from assessments u s i n g the s c a l e , no i n f o r m a t i o n was o f f e r e d regarding v a l i d i t y  or r e l i a b i l i t y .  Test of the Interview for  the e d u c a t i o n  Content v a l i d i t y was  accepted  program produced by t h e American Heart  A s s o c i a t i o n and t i t l e d , your h e a r t  Guide.  "An a c t i v e p a r t n e r s h i p f o r the h e a l t h o f  ( a f t e r your h e a r t a t t a c k ) " .  i n t e r v i e w guide was c r i t i c a l l y  The f i r s t  d r a f t of t h e  d i s c u s s e d with e x p e r t s  i n t h e areas  of r e s e a r c h and c a r d i o v a s c u l a r d i s o r d e r s r e s u l t i n g i n minor changes b e i n g made t o t h e guide.  The instrument  i n d i v i d u a l who r e c e i v e d u n s t r u c t u r e d  was p r e - t e s t e d on one  t e a c h i n g with compliance  measured a t one and t h r e e months f o l l o w i n g d i s c h a r g e These checks supported content the  the b e l i e f  being  from h o s p i t a l .  t h a t the i n t e r v i e w guide had  v a l i d i t y and was i n a form t h a t p e r m i t t e d  responses from  subject. A d m i n i s t r a t i o n o f Data C o l l e c t i o n Instrument.  The  instrument  was used f o r two i n t e r v i e w s i n the s u b j e c t s ' homes a t one and a t t h r e e t o f o u r months p o s t d i s c h a r g e  (see Table 2 ) . The  instrument  was completed by the i n v e s t i g a t o r as d i r e c t e d by the s u b j e c t s interviewed. instrument.  being  A l l responses were b r i e f and were noted on the The s u b j e c t was the focus of the i n t e r v i e w .  s i g n i f i c a n t o t h e r was p r e s e n t ,  questions  If the  were d i r e c t e d t o t h e  s u b j e c t and, i f a p p l i c a b l e , the s u b j e c t would ask the s i g n i f i c a n t o t h e r t o respond. One week p r i o r t o the scheduled i n v e s t i g a t o r telephoned  i n t e r v i e w time, the  the s u b j e c t t o arrange a convenient  hour  50 Table 2 Number o f Days between D i s c h a r g e and I n t e r v i e w s  Number of Days  Subject  First  Interview  Second I n t e r v i e w  1  29  105  2  30  107  3  35  89  4  32  101  5  35  82  6  25  68  7  30  71  8  34  94  9  33  97  10  31  86  11  30  87  12  32  77  51 f o r the i n t e r v i e w .  H o l i d a y s , appointments, p r e v i o u s  commitments,  and  deaths w i t h i n the f a m i l y c r e a t e d d i s c r e p a n c i e s i n the t i m i n g of  the  interviews. General  the  c o n v e r s a t i o n between the  s i g n i f i c a n t other, i f present,  i n v e s t i g a t o r and  preceded data c o l l e c t i o n .  i n v e s t i g a t o r always i n q u i r e d about the s u b j e c t and  the  The  asked t o show the  i n s t r u c t i o n s to the i n v e s t i g a t o r and Subjects  The the  obtained  from  the  physician's with  were reminded t h a t a l l i n f o r m a t i o n would the purpose of t h i s  be  study  reintroduced. The  i n t e r v i e w f o l l o w e d the sequence as o u t l i n e d by the  c o l l e c t i o n instrument. and  and  program.  a l l s u b j e c t s complied  kept c o n f i d e n t i a l by the i n v e s t i g a t o r and was  c o n d i t i o n of  i n t e r v i e w , demographic data was  s u b j e c t was  t h i s request.  general  g e n e r a l value of the p a t i e n t e d u c a t i o n  At the f i r s t subject.  subject  data  Questions were asked about a c t i v i t y ,  diet  medication. A f t e r the h e a l t h care recommendations were i d e n t i f i e d ,  i n v e s t i g a t o r prompted a d i s c u s s i o n c o n c e r n i n g  the content  of each  s l i d e - t a p e and p a t i e n t manual w i t h r e g a r d to the p a r t i c u l a r care recommendation.  The  t h e s u b j e c t about content  purpose of the d i s c u s s i o n was from the p a t i e n t e d u c a t i o n  F o l l o w i n g the d i s c u s s i o n , the i n v e s t i g a t o r asked the question  concerning  t h e n asked i f any  The  health  to remind  program. closed-ended  compliance w i t h each s u b j e c t choosing  response t h a t b e s t s u i t e d t h e i r compliance r a t e .  the  a  subject  was  d i f f i c u l t i e s were encountered w i t h f o l l o w i n g the  recommendation and t o d e s c r i b e t h e d i f f i c u l t i e s . recommendation was pursued for  each g e n e r a l c o n t e n t  i n t h i s manner u n t i l  Each h e a l t h c a r e data was c o l l e c t e d  area.  D u r i n g t h e second i n t e r v i e w , r e f e r e n c e was made t o h e a l t h care recommendations i d e n t i f i e d d u r i n g t h e f i r s t was  asked  interview.  The s u b j e c t  i f t h e recommendations c o n t i n u e d t o be r e i n f o r c e d by t h e  p h y s i c i a n , i f t h e recommendations had changed, o r i f new recommendations were p r e s c r i b e d .  E t h i c s and Human R i g h t s F o l l o w i n g acceptance  of t h e r e s e a r c h p r o p o s a l by the  U n i v e r s i t y of B r i t i s h Columbia s c r e e n i n g committee f o r r e s e a r c h and o t h e r s t u d i e s i n v o l v i n g human s u b j e c t s and by t h e r e s e a r c h committee of t h e i n s t i t u t i o n where t h e study was t o be the i n v e s t i g a t o r approached t h e head nurses u n i t and c a r d i a c ward.  conducted,  of t h e coronary  care  The i n v e s t i g a t o r was p e r m i t t e d access t o  the kardex and c h a r t i n g system t o l o c a t e p o t e n t i a l s u b j e c t s w i t h myocardial  i n f a r c t i o n s meeting s p e c i f i c  p e r t i n e n t data about the s u b j e c t s under  criteria,  and t o o b t a i n  study.  S u b j e c t s were approached by t h e i n v e s t i g a t o r one t o t h r e e days p o s t t r a n s f e r from t h e coronary  care u n i t , with t h e assumption t h a t  t h e p a t i e n t was i n a s t a b l e c o n d i t i o n . by t h e i n v e s t i g a t o r and a statement visit,  F o l l o w i n g an i n t r o d u c t i o n  of t h e g e n e r a l purpose of t h e  s u b j e c t s were g i v e n an i n t r o d u c t o r y l e t t e r e x p l a i n i n g the  purpose and a c t i v i t y of the study  (see Appendices E, F, G ) .  53 S u b j e c t s were g i v e n f i f t e e n minutes i n v e s t i g a t o r i n attendance.  t o r e a d the l e t t e r without t h e  S u b j e c t s who agreed t o p a r t i c i p a t e  were asked t o read and s i g n a consent form  (see Appendix H).  W r i t t e n consent was r e c e i v e d from s u b j e c t s i n groups  1 and 2.  W r i t t e n consent was o b t a i n e d from s u b j e c t s and t h e i r  significant  o t h e r s i n group 3.  A t o t a l of t h r e e s u b j e c t s r e f u s e d t o  p a r t i c i p a t e i n the s t u d y . A consent form was a l s o s i g n e d by t h e a t t e n d i n g c a r d i o l o g i s t as p a r t of the r e s e a r c h p r o t o c o l e s t a b l i s h e d by t h e h o s p i t a l (see Appendix I ) . C o n f i d e n t i a l i t y was m a i n t a i n e d by a s s i g n i n g each s u b j e c t a number.  The i n v e s t i g a t o r had a c c e s s t o name, address and t e l e p h o n e  number of the s u b j e c t s t o p e r m i t two home v i s i t s .  54 CHAPTER 4 P r e s e n t a t i o n and D i s c u s s i o n of The five  p r e s e n t a t i o n and  Findings  d i s c u s s i o n of f i n d i n g s i s p r e s e n t e d  in  s e c t i o n s b e g i n n i n g w i t h a d e s c r i p t i o n of sample  characteristics.  Nonparametric s t a t i s t i c a l  s c o r e s w i l l be p r e s e n t e d the t o t a l sample and by  next,  of  compliance  f o l l o w e d by g e n e r a l o b s e r v a t i o n s  general observations  the s i g n i f i c a n t o t h e r s .  analyses  A summary w i l l  of  r e g a r d i n g the r o l e o f  conclude  the  chapter.  C h a r a c t e r i s t i c s o f the Sample The to  one  sample c o n s i s t e d of 12 s u b j e c t s who  of t h r e e methods of p r e d i s c h a r g e  s t r u c t u r e d , and  education —  present.  s e s s i o n s i n c l u d e d anatomy  of the h e a r t , s u g g e s t i o n s  assigned  unstructured,  s t r u c t u r e d w i t h the s i g n i f i c a n t other  Content of the p a t i e n t e d u c a t i o n physiology  were randomly  and  for medication-taking,  and  methods f o r management of r i s k f a c t o r s r e l a t e d t o d i e t and p h y s i c a l activity. Sample c h a r a c t e r i s t i c s are p r e s e n t e d employment, e d u c a t i o n , infarctions  and h i s t o r y of p r e v i o u s  (see Table 3 ) .  the optimum way  age,  myocardial  Random assignment to groups was  done as  t o e q u a l i z e groups on c h a r a c t e r i s t i c s t h a t might  i n f l u e n c e compliance,  independent of whether or not  received structured teaching. however, T a b l e 3 suggests two  on the b a s i s of  subjects  Because of the s m a l l group s i z e ,  t h a t groups were markedly unequal on  demographic v a r i a b l e s of age  and  employment.  the  55 Ages in group 1 ranged from 40 to 61 years with the median age being 51.5 years.  Ages in group 2 ranged from 67 to 74 years with  the median age being 69 years.  Ages in group 3 ranged from 36 to  70 years with the median age being 54 years.  The median ages of  subjects in groups 1 and 3 were similar whereas subjects in group 2 tended to be older. Age characteristics in groups 1 and 3 were similar to mean ages from other studies investigating control and experimental groups with cardiac problems (Barbarowicz et a l . , 1980; Bracken et a l . , 1977; Scalzi et a l . , 1980). using three-way-designs  Similar studies  did not publish data concerning sampling  characteristics; however, sample criteria consisted of subjects who were below the age of 65 years (Milazzo, 1980) and 70 years (Sivarajan et a l . , 1983). A l l subjects in group 1 were employed whereas a l l subjects in group 2 were retired.  In group 3, three subjects were employed  with one subject being retired.  Again, similarities of employment  status were, evident between groups 1 and 3. Few studies reported employment status as part of their sample characteristics (Barbarowicz et a l . , 1980; Bille, 1977; Scalzi et a l . , 1980). Bracken et a l . (1977) reported that 23 of 31 subjects in the control group and 25 of 45 subjects in the experimental group were employed.  In the present sample, 7 of 12 subjects were employed  and 5 of 12 subjects were retired. Education levels ranged from high school to university with no predominant patterns emerging between or among the groups.  These  56 Table 3 Characteristics  Group  Subject  of t h e Sample Groups  Age  Employment  Education  1  40  employed  university  2  52  employed  university  3  61  employed  university  5  51  employed  high  2  6  67  retired  high school  1  2  8  70  retired  trade school  1  2  11  68  retired  college  0  2  12  74  retired  high school  0  4  56  employed  high school  0  7  70  retired  high school  2  9  52  employed  university  0  10  36  employed  university  0  Previous Infarction  school  57 sample c h a r a c t e r i s t i c s studies al.,  (Barbarowicz  are s i m i l a r t o c h a r a c t e r i s t i c s  e t a l . , 1980;  from o t h e r  Bracken e t a l . , 1977;  S c a l z i et  1980). Three s u b j e c t s i n the sample had m y o c a r d i a l  than f i v e years p r i o r t o the study. randomly a s s i g n e d to group 2 and  Two  one was  i n f a r c t i o n s more  of these s u b j e c t s were a s s i g n e d to group 3.  o t h e r s u b j e c t s were e x p e r i e n c i n g t h e i r f i r s t m y o c a r d i a l a t the time  the study was  conducted.  infarction.  were e x p e r i e n c i n g  Subjects with  i n f a r c t i o n s were e l i m i n a t e d from sample s e l e c t i o n Scalzi  e t a l . , 1980;  previous (Milazzo,  1980;  S i v a r a j a n e t a l . , 1983).  D e s p i t e random a l l o c a t i o n , groups were unequal on the two employment which may  infarctions  Similar studies that  i n v e s t i g a t e d c a r d i a c problems used s u b j e c t s who t h e i r f i r s t myocardial  All  sample c h a r a c t e r i s t i c s  of the  demographic v a r i a b l e s of age  have confounded f i n d i n g s of the  Nonparametric S t a t i s t i c a l A n a l y s e s  of Compliance  To a s s e s s group d i f f e r e n c e s , compliance  three  and  study.  Scores  scores with h e a l t h  c a r e recommendations of p h y s i c a l a c t i v i t y , d i e t , and  medication  were s u b j e c t e d t o t h e K r u s k a l - W a l l i s rank-sum t e s t , a one-way a n a l y s i s of v a r i a n c e t e s t , f o r nonparametric Wright,  1976).  The  l e v e l of s t a t i s t i c a l  data  (Siegel,  significance  was  1956; set at  p_<.05. A summary of  v a l u e s u s i n g the K r u s k a l - W a l l i s rank-sum t e s t  with one-way a n a l y s i s of v a r i a n c e on compliance  scores i s presented  i n T a b l e 4.  Compliance with p h y s i c a l a c t i v i t y , d i e t a r y ,  and  m e d i c a t i o n recommendations d u r i n g both i n t e r v i e w s were not statistically  significant  and the f o l l o w i n g hypotheses were  rejected: 1.  Myocardial i n f a r c t i o n patients receiving structured  e d u c a t i o n with the s i g n i f i c a n t compliance  o t h e r w i l l have h i g h e r r a t e s o f  w i t h h e a l t h c a r e recommendations than  myocardial  i n f a r c t i o n p a t i e n t s r e c e i v i n g s t r u c t u r e d e d u c a t i o n without significant 2.  their  other.  Myocardial i n f a r c t i o n p a t i e n t s r e c e i v i n g s t r u c t u r e d  e d u c a t i o n with t h e i r compliance  significant  o t h e r w i l l have h i g h e r r a t e s o f  w i t h h e a l t h c a r e recommendations than  myocardial  i n f a r c t i o n patients receiving unstructured education. 3.  Myocardial i n f a r c t i o n p a t i e n t s r e c e i v i n g structured  e d u c a t i o n w i l l have h i g h e r r a t e s of compliance  than  myocardial  i n f a r c t i o n p a t i e n t s r e c e i v i n g unstructured education. Insignificant results  f i n d i n g s from t h i s study are s i m i l a r  t o the  o b t a i n e d from o t h e r s t u d i e s t h a t i n v e s t i g a t e d p a t i e n t  e d u c a t i o n formats  for myocardial  i n f a r c t i o n p a t i e n t s and  w i t h a t h e r a p e u t i c regimen  (Bille,  S i l v a r a j a n e t a l . , 1983).  Although  statistically compliance  significant  1977;  Scalzi  et a l . ,  compliance 1980;  S c a l z i e t a l . (1980) r e p o r t e d  differences  (p_<.05) f o r knowledge  with m e d i c a t i o n and p h y s i c a l a c t i v i t y  t r e n d s over time were not found t o be  and  recommendations,  significant.  59 Table 4 Summary of H. Values f o r Compliance w i t h Recommendations d u r i n g two I n t e r v i e w s  Recommendations  Interview  Schedule  H Values  Significance  Activity  1  2.67  NS  Activity  2  1.44  NS  Diet  1  1.87  NS  Diet  2  0.40  NS  Medication  1  3.39  NS  Medication  2  3.39  NS  H Values rounded  t o two decimal  points.  60 The  i n s i g n i f i c a n t findings  interpreted  of t h i s study need t o be  with c a u t i o n because of the s m a l l sample s i z e  between group  and  differences.  G e n e r a l O b s e r v a t i o n s o f the Sample Numerous o b s e r v a t i o n s were made of the t o t a l sample which suggested Raw  that  compliance  was  r e l a t e d to i n d i v i d u a l  differences.  data, number of recommendations, and compliance  physical  scores f o r  a c t i v i t y recommendations d u r i n g both i n t e r v i e w s are  p r e s e n t e d i n T a b l e s 5 and 6, data r e l a t e d t o  dietary  recommendations are p r e s e n t e d i n T a b l e s 7 and 8, and  data  t o m e d i c a t i o n recommendations are p r e s e n t e d i n T a b l e 9. variability  of compliance  form of p a t i e n t  that  compliance  that  abilities.  eight  state.  states  s u b j e c t s who  patient  Bandura's  caused  study.  S u b j e c t s i n t h i s study had by the m y o c a r d i a l  One  altered  infarction.  were approached t o p a r t i c i p a t e i n  i t s treatment.  theory  t o l e a r n as a r e s u l t of  e d u c a t i o n , f i v e s u b j e c t s were eager  d i s e a s e and  directed  (1977b) s o c i a l l e a r n i n g  i n d i v i d u a l s were m o t i v a t e d  their physiological physiological  influenced  s e l f - c a r e , and t h e r a p e u t i c demands as  by the t h e o r e t i c a l frameworks chosen t o guide t h i s  suggested  was  These f a c t o r s w i l l be d i s c u s s e d a c c o r d i n g to  self-care a b i l i t i e s ,  Self-care  The  s c o r e s among i n d i v i d u a l s d e s p i t e some  e d u c a t i o n suggests  by o t h e r f a c t o r s .  related  Of  the  structured  t o l e a r n about the  subject delayed discharge f o r a  hours u n t i l the l a s t tape had been p r e s e n t e d .  The o t h e r t h r e e  few  Table 5 Raw Data, No. of Recommendations, and Scores f o r Compliance with P h y s i c a l A c t i v i t y Recommendations d u r i n g f i r s t i n t e r v i e w Recommendations H 0 c  W c o-  r pi-h ft p. 3 iQ  i-9 >-!  01  < (D P-  O  < 3  w 3  TS  0  1CD  to i-  0  3  pCD 0)  1  •x p-  CT  cr  >-3 0 rt DJ P-  1 2 3 5  -  2 2 2 2  6 8 11 12  3 3  3 3 3 3  4 7 9 10  NOTE:  —  2 2 3 3  -3  3 3 3 ~  _  3  2  -3  -3  2  3  -  —  3 3  3 3  --  DJ 0 rt p-  >  3 ft  1 1 1 1  if  onal  0 rt  W rt DJ p!-! 0)  Scores  3 2 3 3  2 0 2 3  2 1 2 3  2 1 1 3  6 5 5 5  14/18 6/15 11/15 15/15  58 40 73 100  3 3 2 3  _  3 2 3 1  3  6 5 3 3  18/18 14/15 8/9 7/9  100 93 89 78  _  4 4 5 6  12/12 11/12 14/15 17/18  100 92 93 94  3 3 3 3  3  -3 3  3 3 2 3  —  -  -3  A l l recommendation scores have a denominator of 3. A=no. a c t i v i t y recommendations. a p e r c e n t a g e scores rounded to nearest whole number.  of  Table 6 Raw Data, No. of Recommendations, and Scores f o r Compliance w i t h P h y s i c a l A c t i v i t y Recommendations d u r i n g second i n t e r v i e w Recommendations 0)  c  >-!  0 c  xs  1 1 1 1  w  r pHi  P-  rt P-  rt 0)  CD  tn  o  2 2 2 2  3 3 3 3  NOTE:  <  -  6  8 11 12  7 10  3 3 3  4 3 9 3  2 3 3  3  -  3 3 3 -  -  -  3 -  -  -  3 3  3  3 "0 1—' 0  •< 3  S 1—  1  P-  3  C6 3  -  3  <  1—'  5  P-  CD  3 iQ  1 2 3  Scores O  1  -  tc 0 cr w.  (D CO  i-3 0  rt  *! DJ  QJ P-  0  >  0 3  rt  Cu  3 3 3  2 3 3 0  2 3 3 3  2 2 2 3  5 5 5 5  11/15 14/15 14/15 12/15  73 93 93 80  3 3 3 3  _  3 2 3 1  3  5 4 3 3  15/15 1 1/12 9/9 7/9  100 92 100 78  4 3 4  12/12 8/9 1 1/12 18/18  100 89 92 100  3 3 3 3  — 3  -2  3  3 2 3 3  -  -3  6  A l l recommendation scores have a denominator o f 3. A=no. of a c t i v i t y recommendations. a p e r c e n t a g e s c o r e s rounded to nearest whole number.  Table 7 Raw Data, No. of Recommendations, and Scores f o r Compliance with D i e t a r y Recommendations d u r i n g f i r s t i n t e r v i e w Recommendations w 0  c n  c cr <t>  rt  1 1 1 1  1 2 3 5  2 2 2 2  6 a 11 12  3 3 3 3  4 7 9 10  NOTE:  w  OJ  a c 0 p-  H  1  rt Hi  t-! (t> CD  ng  n  -  -  2 2 1  3  —  -  _  _  _  -  -3  3  3  —  -  **  3  Scores  O  -  -  -  3 3  -  1 3  -  -  3" 0 r y-' 0 CD to  K  Hi rt CD CD rt \  > Po  o  rt 3"  0 3" . 0  (t>  2 0  -  p,  ^3 0  rt Ol  3 2 3  3  3 2 2 2  -  —  3  -  -  3  3 2  —  2 3  -  3  rt p0 3 0)  0 M  1 2 3 3  0i n  _  -  3 3 2 3  5/9 4/9 4/6 9/9  56 44 67 100  2 2 4 2  6/6 5/6 12/12 5/6  100 83 100 83  4 3 2 3  11/12 8/9 3/6 8/9  92 89 50 89  A l l recommendation scores have a denominator of 3. R=no. of d i e t a r y recommendations. a p e r c e n t a g e scores rounded to n e a r e s t whole number.  64  •£>  CM  in  v u c <0 •H rH a, e o o  Fractional  0>  \  r-\ CN  o  O  O  o  o  O  <Tt  10  ro  \  m in cn  \  ID  ro O 00 O T—  ro  0>  cn  CO  cn in cn co ID  \  o  o  o  \  ro  o ot — in  00  cn ID W cn ID  ID  ro  CD  in  <u 0  e  *—  •  W  ro  Total  R  ro  <3"  ro  CN  »-  CN ro  ro  ro  CN  CN  CN  0  to CD ^ o o to  Other  -  c  Alcohol  M  Low f a t / Cholesterol  01  rcj c0 CCJ •H •P  10  o ai  05 0 0  z CO CD  r—1  A  lO  E-i  <0  I  I  i  i  ro  ro  1  1  1  1  CN  O  I  I  i  i-  «-  ro  ro  ro  1  1  1  1  1  l  CN ro  ro  ro  ro  CN  ro  i  -H  T3  0  I  •P  (0  0  c  jC  0  •p 01 CD  c  rj • (0 ai ai c0 c -H > JJ 4Jo ,C TJrd TS <0  3 0 tJ  •P  I  0  T3  c <B tn c 01  c a > i-H  u  T3  C  V 0 0  « M  (0  •P  a) .p •QH (0  Salt  free  l  l i l t  ro  1  1  1  1  1  1  05  C -4-r>H Low 0  (0  sodium  CN  CN  ro  I  1  1  ro  CN  ro  ro  1  1  T3  C  | Reducing  I  CN  ro  ro  0  l  l  1  |  ro  |  «-  CN  oCO  Subject  T-  CN  ro  in  <X>  CO  T—  CN T—  *  h  01  O  Q  C CD  0 CO  o 0 oCD n  u 0 a  CN  CN CN  CM  ro  ro  ro  ro  M  -0  a3  01 0)  u 0  (0  U as 4J  o 01  CO  •H  0)  • 0  u  -ac  T) cn 10 g0 -P o o CDc  rH r-l < E-i  Group  s§  o •-PH >i  w  X!  3 •P  <a •H  CD  0) CD  O  2  C II  0  CD  ft  Table 9 No. of Recommendations and Scores f o r Compliance with M e d i c a t i o n Recommendations d u r i n g f i r s t and second i n t e r v i e w s  >-3 0 rt  cn  CD  c V  o c  Xi  OJ  i-3 0 ri-  OJ O  ai  0 rt  0)  o rt  no  CD  0  D OJ  3 0)  1 1 1 1  1 2 3 5  5 4 3 5  14/15 10/12 9/9 13/15  93 83 100 87  5 4 2 3  14/15 11/12 6/6 9/9  93 92 100 100  2 2 2 2  6 8 11 12  4 3 5 6  12/12 9/9 15/15 18/18  100 100 100 100  3 2 5 7  9/9 6/6 15/15 21/21  100 100 100 100  3 3 3 3  4 7 9 10  2 3 3 3  6/6 9/9 9/9 9/9  100 100 100 100  2 4 3 3  6/6 12/12 9/9 9/9  100 100 100 100  NOTE:  M=no. of medication recommendations. p e r c e n t a g e scores rounded to n e a r e s t whole number.  a  66 s u b j e c t s were i n t e r e s t e d i n the program, however, an eagerness t o p a r t i c i p a t e was not as e v i d e n t .  These o b s e r v a t i o n s suggest  that  p a t i e n t s are motivated t o l e a r n d u r i n g t h e i r r e c o v e r y on a c a r d i a c ward f o l l o w i n g t r a n s f e r from a coronary a l s o support Baden's  care u n i t .  These f i n d i n g s  (1972) recommendations t h a t p a t i e n t e d u c a t i o n  on a c a r d i a c ward i s an i d e a l time f o r p a t i e n t l e a r n i n g . Although abilities,  p a t i e n t e d u c a t i o n was p r o v i d e d t o enhance  self-care  e d u c a t i o n alone was not a v a l i d p r e d i c t o r of compliant  behaviour. Orem (1980) i d e n t i f i e d e d u c a t i o n as a f a c t o r t h a t i n f l u e n c e s an i n d i v i d u a l s ' s a b i l i t y t o engage i n s e l f - c a r e .  When compliance  s c o r e s w i t h d i e t a r y recommendations d u r i n g the f i r s t  i n t e r v i e w (see  T a b l e 7) were compared with the demographic v a r i a b l e of e d u c a t i o n , s i g n i f i c a n t d i f f e r e n c e s were o b t a i n e d  (H_ = 5.95, df = 2, p_<.05).  Scores were s u b j e c t e d t o t h e K r u s k a l - W a l l i s rank-sum t e s t one-way a n a l y s i s of v a r i a n c e ( S i e g e l ,  1956).  with  The f i n d i n g s  t h a t s u b j e c t s with h i g h s c h o o l e d u c a t i o n had h i g h e r  suggest  dietary  compliance s c o r e s than d i d s u b j e c t s w i t h c o l l e g e and u n i v e r s i t y preparation.  Dubos (1965) i d e n t i f i e d e d u c a t i o n as a p e r s o n a l  f a c t o r i n d e f i n i n g one's s t a t e of h e a l t h and Bandura (1977b) a l s o r e c o g n i z e d e d u c a t i o n as a p e r s o n a l s t i m u l u s f o r l e a r n i n g . t h e s e f i n d i n g s suggest  Perhaps  t h a t i n d i v i d u a l s w i t h lower e d u c a t i o n a l  p r e p a r a t i o n have l e s s e x p e r i e n c e with d e c i s i o n - m a k i n g  and comply  w i t h recommendations more r e a d i l y than do i n d i v i d u a l s with g r e a t e r education.  These f i n d i n g s a r e not supported by p r e v i o u s r e s e a r c h .  67 Marston  (1970) concluded from a review of the l i t e r a t u r e  e d u c a t i o n was not an i n f l u e n c i n g f a c t o r findings  suggest t h a t more r e s e a r c h  determine i f  education i s  that  of c o m p l i a n c e .  These  s h o u l d be conducted  a significant  p r e d i c t o r of  to  compliant  behaviour. Self-care. activities behalf  that  Orem (1980) d e f i n e d s e l f - c a r e as, individuals initiate  i n maintaining l i f e ,  Orem and Dubos  health,  (1965) supported  t h e i r own h e a l t h s t a t e .  one s u b j e c t ,  as  a result  of  and perform on t h e i r own and w e l l - b e i n g "  the n o t i o n t h a t  Observations  idea t h a t h e a l t h d e f i n i t i o n s  "the p r a c t i c e  from t h i s  (p.  individuals study  define  supported  vary among i n d i v i d u a l s .  of extraneous c i r c u m s t a n c e s ,  by f e a r of death to a t t a i n a s t a t e of  3 5 ) . Both  the  For  example,  was  motivated  improved h e a l t h and tended  to  comply w i t h h e a l t h c a r e recommendations.  Fear has been found to be  a prime m o t i v a t o r  (Crawshaw,  1970).  f o r compliant behaviour  At the o t h e r end of the spectrum,  h i s h e a l t h s t a t e as happiness with l i v i n g . happy; c o n s e q u e n t l y , altered his  he r e f u s e d  observations  t h e i r own s t a t e of h e a l t h ,  appeared  He p r e f e r r e d  defined to  die  t o comply w i t h recommendations  of the sample,  life,  subjects  that  to d i f f e r  defined  and w e l l - b e i n g and subsequent  D e f i n i t i o n s of h e a l t h and improved h e a l t h ,  however,  among h e a l t h care workers and s u b j e c t s .  c a r e workers tended to p r e s c r i b e patients'  another s u b j e c t  lifestyle.  From g e n e r a l  compliance.  1974; M a r s t o n ,  h e a l t h and expected  recommendations  to improve  Health the  compliant behaviour from s u b j e c t s  68 without a p r i o r c o n s u l t a t i o n observations  regarding  suggest t h a t p e r s o n a l  compliance and  that health  health  definitions.  d e f i n i t i o n s of h e a l t h  l i f e s t y l e changes.  i n d i v i d u a l i z e d nursing his  influence  c a r e workers s h o u l d v a l i d a t e t h e s e  d e f i n i t i o n s t o enhance communication b e f o r e implementing e d u c a t i o n on  These  patient  These f i n d i n g s a l s o suggest  c a r e p l a n s may  b e n e f i t the p a t i e n t  that  during  recovery. T h e r a p e u t i c demands.  demands as p e r s o n a l  Orem (1980) i d e n t i f i e d  needs t h a t are  i n d i v i d u a l ' s s t a t e of h e a l t h . were i n t e r p r e t e d as the workers i n the  therapeutic  a l t e r e d as a r e s u l t of  T h e r a p e u t i c demands f o r t h i s study  recommendations p r e s c r i b e d  areas of p h y s i c a l a c t i v i t y , d i e t ,  by h e a l t h  individual's  a l t e r e d needs r e s u l t i n g from a m y o c a r d i a l i n f a r c t i o n .  influence  of the  compliance. has  recommendations p r e s c r i b e d 1974;  found no  suggested t h a t the number of had  a n e g a t i v e e f f e c t on  compliance  Marston, 1970); however, f i n d i n g s from t h i s study  r e l a t i o n s h i p between compliance and  recommendations p r e s c r i b e d .  When the  each c a t e g o r y of p h y s i c a l a c t i v i t y , o v e r two  From  sample, demands made of p a t i e n t s appeared t o  Previous research  (Ball,  care  and  m e d i c a t i o n - t a k i n g f o r the purpose of s a t i s f y i n g the  observations  the  interviews  were s u b j e c t e d  number of recommendations f o r  d i e t , and  obtained  medication-taking  t o the K r u s k a l - W a l l i s  t e s t with one-way a n a l y s i s of v a r i a n c e , the p_<.05 l e v e l were not  the number of  rank-sum  s i g n i f i c a n t differences  ( S i e g e l , 1956).  at  These f i n d i n g s  69 are p o s s i b l y the r e s u l t of the e x t e n t of b e h a v i o u r a l changes t h a t s u b j e c t s were expected  t o make r a t h e r than t o the number.  I n d i v i d u a l b e h a v i o u r a l changes were not measured i n t h i s  study.  S u b j e c t s who i d e n t i f i e d t h e i r o c c u p a t i o n as r e t i r e d to  have few l i f e s t y l e  recommendations.  changes t o make with d i e t a r y and m e d i c a t i o n  R e t i r e d s u b j e c t s i n t h i s study were o l d e r than 65  y e a r s and had e x p e r i e n c e d p r e v i o u s medical  c o m p l i c a t i o n s so  s p e c i f i c c h a r a c t e r i s t i c s i n f l u e n c i n g compliance ascertained.  appeared  cannot be  Three of f i v e r e t i r e d s u b j e c t s had e x p e r i e n c e d  previous myocardial  i n f a r c t i o n s and were f o l l o w i n g low sodium  and/or low f a t / c h o l e s t e r o l d i e t s p r i o r t o t h e i r c u r r e n t h o s p i t a l admission.  Two of t h e o t h e r r e t i r e d s u b j e c t s had h i s t o r i e s of  r e n a l d i s e a s e o r d i a b e t e s m e l l i t u s and appeared t o have o p t i m a l compliance  with s p e c i a l d i e t s .  A l l s u b j e c t s i n t h i s study who were  o l d e r t h a n 65 y e a r s , r e t i r e d , and had p r e v i o u s m e d i c a l problems had developed  d a i l y medication  schedules  as a r e s u l t of t h e i r  c o n d i t i o n s so few b e h a v i o u r a l changes had t o be implemented.  Bille  (1977) a l s o found t h a t r e t i r e d s u b j e c t s had r e l a t i v e l y few f a c t o r s i n t e r f e r i n g with compliance These f i n d i n g s suggest  with h e a l t h c a r e recommendations.  t h a t o l d e r r e t i r e d s u b j e c t s with  previous  m e d i c a l problems had few b e h a v i o u r a l changes t o make with d i e t a r y and m e d i c a t i o n  recommendations and t h a t h e a l t h care workers s h o u l d  a s s e s s t h e e x t e n t o f changes t h a t a f f e c t each i n d i v i d u a l and t a k e t h i s i n t o c o n s i d e r a t i o n when p l a n n i n g c a r e .  70 In a d d i t i o n to the extent simultaneous  of b e h a v i o u r a l changes r e q u i r e d ,  changes appeared t o a f f e c t  dietary  compliance  S i x s u b j e c t s were a d v i s e d t o f o l l o w r e d u c i n g d i e t s by the interview all  (see  Table 8 ) .  of the time and ate  scores. second  Three of these s u b j e c t s d i d not comply foods  that  contraindicated in their diet.  were h i g h i n c a l o r i e s  The most f r e q u e n t  and  source  of  difficulty  f o r noncompliance with r e d u c i n g d i e t recommendations  attributed  to c e s s a t i o n  of c i g a r e t t e smoking.  Two of the  s u b j e c t s who d i d not comply a l l of the time f e l t more d e t r i m e n t a l e f f e c t s t o eat  foods  on t h e i r h e a r t s than o b e s i t y  t h a t were h i g h i n c a l o r i e s .  t h a t when simultaneous  that  three  smoking had and c o n t i n u e d  These f i n d i n g s  suggest  demands are made of an i n d i v i d u a l ,  d e c i s i o n - m a k i n g occurs and the predominant tendency i s w i t h one demand.  was  These f i n d i n g s  r e s u l t s r e p o r t e d by Marston  are  t o comply  supported by s i m i l a r  research  (1970).  The event of a m y o c a r d i a l i n f a r c t i o n p l a c e d demands on a l l employed s u b j e c t s .  During the f i r s t  interview, subjects  a d v i s e d to r e s t at home and a v o i d t h e i r p l a c e the second i n t e r v i e w , s i x  professional  of employment.  By  of the seven employed s u b j e c t s were  a d v i s e d t o r e t u r n t o work v i a p a r t - t i m e differences  were  employment; however,  were noted f o r employment resumption between and n o n p r o f e s s i o n a l  subjects.  s u b j e c t s who i d e n t i f i e d t h e i r o c c u p a t i o n as and managers e a s i l y  Four of the educators,  resumed employment v i a p a r t - t i m e  six engineers,  positions.  Two s u b j e c t s who performed s k i l l e d and u n s k i l l e d labour had t o  71 resume f u l l - t i m e employment i n o r d e r t o keep t h e i r companies.  Part-time  s u b j e c t s expressed  jobs with  employment was not company p o l i c y .  f e a r d u r i n g the f i r s t  heavy labour would induce  infarction.  second i n t e r v i e w , p h y s i c i a n s had a d v i s e d both of these t h a t they  c o u l d resume f u l l - t i m e employment s i n c e  employment was not f e a s i b l e . f e a r s ; however, the o t h e r employment and c o n t i n u e d those  Both  i n t e r v i e w and f e l t  another m y o c a r d i a l  One s u b j e c t complied  their  that  By the  subjects  part-time despite h i s  s u b j e c t p r e f e r r e d not to resume on s i c k l e a v e .  These f i n d i n g s  support  r e p o r t e d by Crawshaw (1974) and Tyzenhouse (1973) who  found  t h a t i n d i v i d u a l s who performed manual l a b o u r encountered more d i f f i c u l t i e s w i t h resumption of employment than i n d i v i d u a l s who performed p r o f e s s i o n a l t a s k s . E i g h t s u b j e c t s were a d v i s e d by t h e i r p h y s i c i a n s t h a t  they  c o u l d resume s e x u a l a c t i v i t y w i t h i n two t o t h r e e weeks f o l l o w i n g discharge  from h o s p i t a l .  The recommendation merely served as a  g u i d e l i n e r a t h e r than a compliance item and p r o v i d e d subjects to a l l a y apprehension.  V a r i a b l e s i n f l u e n c i n g the  resumption of s e x u a l a c t i v i t y were not i n v e s t i g a t e d . r e l a t e d to these it and  information t o  recommendations were excluded  Although  from t o t a l  data  scores,  was i n t e r e s t i n g t o note t h a t one s u b j e c t f o l l o w e d the g u i d e l i n e s had resumed s e x u a l a c t i v i t y , one s u b j e c t resumed the a c t i v i t y  on the day of d i s c h a r g e  from the h o s p i t a l , and s i x s u b j e c t s had n o t  resumed the a c t i v i t y by the f i r s t  interview.  By the second  i n t e r v i e w , a l l s u b j e c t s but two had resumed s e x u a l a c t i v i t y .  Fear  72 of a r e c u r r e n t m y o c a r d i a l c i t e d as reasons  i n f a r c t i o n and medical  f o r not resuming s e x u a l  c o m p l i c a t i o n s were  activity.  From g e n e r a l o b s e r v a t i o n s of the sample,  individual  d i f f e r e n c e s were noted t h a t had  an i n f l u e n c i n g e f f e c t  compliance.  t o d e f i n e t h e i r own  I n d i v i d u a l s tended  on  s t a t e of h e a l t h  which i n f l u e n c e d whether or not they would comply w i t h t h e r a p e u t i c regimen.  The  recommended, simultaneous of e d u c a t i o n , and  e x t e n t of b e h a v i o u r a l changes recommendations p r e s c r i b e d , the v a r i a b l e  demands f o r resumption  i n d i v i d u a l s responses 1  the  of employment  affected  to t h e r a p e u t i c demands and i n f l u e n c e d  compliance.  General Observations Bandura's  of S i g n i f i c a n t  Others  (1977b) s o c i a l l e a r n i n g t h e o r y and Dubos' (1965)  t h e o r y of a d a p t a t i o n r e c o g n i z e d the s i g n i f i c a n t o t h e r as a s t i m u l u s for reinforcement myocardial  and  infarction.  support t o an i n d i v i d u a l r e c o v e r i n g from a Although  o n l y f o u r s i g n i f i c a n t o t h e r s were  i n v i t e d to p a r t i c i p a t e i n p a t i e n t education sessions, general o b s e r v a t i o n s were made of nine s i g n i f i c a n t o t h e r s who  participated  i n both i n t e r v i e w s i n t h e i r homes. With r e f e r e n c e t o p h y s i c a l a c t i v i t y  recommendations, a l l nine  s i g n i f i c a n t o t h e r s assumed l i f t i n g and d r i v i n g chores five  when a b l e ,  j o i n e d t h e i r mates f o r d a i l y walks, and t h r e e p a r t i c i p a t e d i n  t h e i r mate's h o b b i e s / s p o r t s . With r e f e r e n c e to d i e t a r y recommendations, a l l nine  73 significant  o t h e r s purchased  and p r e p a r e d  food, a l l n i n e used t h e  take-home manual as a d i e t a r y guide, and s i x used cooking resources.  One s i g n i f i c a n t  additional  o t h e r had h e r mate's  diet  a n a l y z e d by computer t o d e t e c t flaws w i t h recommended f o o d consumption and another marked meals on a c a l e n d a r i n an e f f o r t t o e l i m i n a t e c o n t r a i n d i c a t e d foods from t h e p r e s c r i b e d d i e t . With r e f e r e n c e t o m e d i c a t i o n recommendations, f i v e  significant  o t h e r s reminded t h e i r mates t o take m e d i c a t i o n and two of these five significant  others placed d a i l y p i l l s  i n a d i s h and checked  the d i s h a t bedtime t o a s s u r e t h a t m e d i c a t i o n s were taken by t h e i r mates. Although t h i s study, suggest  s i g n i f i c a n t o t h e r s ' behaviours were not t h e f o c u s of  g e n e r a l o b s e r v a t i o n s of nine of t h e s i g n i f i c a n t  t h a t these women were a c t i v e l y  i n v o l v e d w i t h and supported  and r e i n f o r c e d t h e i r mates' t h e r a p e u t i c regimens.  These f i n d i n g s  support those r e p o r t e d by Mayou e t a l . (1978) where h a l f women i n t h e sample p a r t i c i p a t e d  others  of the  o r encouraged t h e i r husbands t o  comply w i t h h e a l t h c a r e recommendations.  Summary D e s p i t e random a l l o c a t i o n groups,  of s u b j e c t s t o t h r e e  t h e groups were markedly unequal  v a r i a b l e s of age and employment. were not o b t a i n e d f o r compliance  different  on t h e two demographic  Statistically  significant  results  between groups with p h y s i c a l  a c t i v i t y , d i e t a r y , and m e d i c a t i o n recommendations and t h e  74 hypotheses of the study were r e j e c t e d .  I n s i g n i f i c a n t f i n d i n g s are  p o s s i b l y the r e s u l t of a s m a l l sample s i z e thus i n f e r e n c e s drawn from the s t a t i s t i c a l  a n a l y s e s may  be  questionable.  G e n e r a l o b s e r v a t i o n s of the t o t a l  sample suggested  i n d i v i d u a l d i f f e r e n c e s i n f l u e n c e compliance.  that  H e a l t h care workers  s h o u l d be aware of the p a t i e n t ' s d e f i n i t i o n of h e a l t h , the of  and  simultaneous  b e h a v i o u r a l changes a f f e c t i n g each p a t i e n t , and  the demographic v a r i a b l e s of e d u c a t i o n and p r o v i d e q u a l i t y of care t o p a t i e n t s and compliance;  F i n d i n g s a l s o suggest  employment i n o r d e r to  enhance  individual  t h a t the s i g n i f i c a n t  others  p a r t i c i p a t e with and encourage t h e i r mates t o comply with a therapeutic  extent  regimen.  75 CHAPTER 5 Summary, C o n c l u s i o n s / I m p l i c a t i o n s , and Recommendations T h i s study was designed t o e x p l o r e the independent  variables  o f p a t i e n t e d u c a t i o n and t h e s i g n i f i c a n t o t h e r on compliance. overview  An  of the study i s p r e s e n t e d i n t h i s chapter f o l l o w e d by a  conclusion.  In a d d i t i o n , i m p l i c a t i o n s and recommendations f o r  n u r s i n g p r a c t i c e and n u r s i n g r e s e a r c h a r e d e l i n e a t e d .  Overview o f t h e Study A summary of the study w i l l be d e s c r i b e d i n r e l a t i o n t o problem, d e s i g n , implementation,  and r e s u l t s .  Problem, d e s i g n , and implementation. experimental  study was conducted  An e x p l a n a t o r y  to i n v e s t i g a t e the e f f e c t s o f  s t r u c t u r e d e d u c a t i o n f o r the p a t i e n t , and the s i g n i f i c a n t o t h e r , on compliance  with h e a l t h c a r e recommendations f o r p a t i e n t s r e c o v e r i n g  from a m y o c a r d i a l The  i n f a r c t i o n a f t e r d i s c h a r g e from  hospital.  t h e o r e t i c a l framework of the study was a combination o f  Orem's.model f o r n u r s i n g , Dubos' t h e o r y of a d a p t a t i o n , and Bandura's s o c i a l l e a r n i n g t h e o r y .  The framework p r e d i c t e d t h a t  subjects r e c e i v i n g s t r u c t u r e d education with t h e i r o t h e r s , would have h i g h e r compliance  significant  r a t e s with h e a l t h c a r e  recommendations than would s u b j e c t s r e c e i v i n g s t r u c t u r e d e d u c a t i o n alone and u n s t r u c t u r e d e d u c a t i o n a l o n e . The  study was conducted  with a convenience  sample of twelve  male p a t i e n t s who were admitted t o a c a r d i a c ward o f one  76 metropolitan teaching h o s p i t a l .  S u b j e c t s had a s i g n i f i c a n t  and had not e x p e r i e n c e d a m y o c a r d i a l f i v e years.  other  i n f a r c t i o n w i t h i n the p r e v i o u s  Four s i g n i f i c a n t o t h e r s p a r t i c i p a t e d i n the s t u d y .  Agreement was o b t a i n e d from the a t t e n d i n g c a r d i o l o g i s t and consent was given by each s u b j e c t , and the f o u r s i g n i f i c a n t o t h e r s , p r i o r t o study The  participation. convenience  i n t o t h r e e groups. and  sample was then randomly and e q u a l l y a l l o c a t e d S u b j e c t s i n group 1 s e r v e d as t h e c o n t r o l  group  r e c e i v e d u n s t r u c t u r e d e d u c a t i o n as c u r r e n t l y p r a c t i c e d by  nursing s t a f f .  S u b j e c t s i n group 2 r e c e i v e d s t r u c t u r e d e d u c a t i o n  by the i n v e s t i g a t o r .  S u b j e c t s i n group 3 r e c e i v e d s t r u c t u r e d  e d u c a t i o n by the i n v e s t i g a t o r with t h e i r s i g n i f i c a n t o t h e r s i n attendance. U s i n g a s e m i - s t r u c t u r e d i n t e r v i e w guide with some open and some closed-ended  q u e s t i o n s , the i n v e s t i g a t o r i n t e r v i e w e d each  s u b j e c t t w i c e i n t h e i r home a t approximately months f o l l o w i n g d i s c h a r g e from h o s p i t a l . three content areas:  physical activity,  Open-ended q u e s t i o n s were used t o e l i c i t  one, and t h r e e t o f o u r  Each i n t e r v i e w c o v e r e d d i e t , and m e d i c a t i o n s . data on the h e a l t h c a r e  recommendations p r e s c r i b e d by the p h y s i c i a n and t o o b t a i n data c o n c e r n i n g d i f f i c u l t i e s with noncompliance.  Closed-ended  were used t o e s t i m a t e the s u b j e c t ' s compliance scale.  questions  u s i n g an o r d i n a l  Responses were l a t e r t a b u l a t e d and c o n v e r t e d t o n u m e r i c a l  percentage  scores.  77 Results.  Compliance scores with h e a l t h care recommendations  o f p h y s i c a l a c t i v i t y , d i e t , and m e d i c a t i o n  were s u b j e c t e d to the  K r u s k a l - W a l l i s rank-sum t e s t with one-way a n a l y s i s of v a r i a n c e . Compliance s c o r e s d u r i n g both statistically  i n t e r v i e w s showed no between group  s i g n i f i c a n t d i f f e r e n c e s (p_ < .05)  o f the study were r e j e c t e d .  The  and the hypotheses  i n s i g n i f i c a n t f i n d i n g s of  study need t o be i n t e r p r e t e d with c a u t i o n because of the sample s i z e and between group d i f f e r e n c e s on the two v a r i a b l e s of age Although abilities,  and  p a t i e n t e d u c a t i o n was  The  small  demographic  employment.  e d u c a t i o n alone was  behaviour.  this  variability  recommendations suggested  p r o v i d e d to enhance s e l f - c a r e  not a v a l i d p r e d i c t o r of  of compliance  t h a t compliance  compliant  s c o r e s with h e a l t h care was  i n f l u e n c e d by  other  factors. From g e n e r a l o b s e r v a t i o n s of the t o t a l  sample, i t appeared  t h a t s u b j e c t s ' d e f i n i t i o n s of h e a l t h v a r i e d and t h a t these d e f i n i t i o n s of h e a l t h i n f l u e n c e d compliant behaviour suggest  personal  or noncompliant  with the t h e r a p e u t i c regimen p r e s c r i b e d .  The f i n d i n g s  t h a t v a l i d a t i o n of p a t i e n t s ' d e f i n i t i o n s of h e a l t h be done  by h e a l t h care workers p r i o r to the implementation e d u c a t i o n on l i f e s t y l e  of p a t i e n t  changes to enhance communication and  to  e s t a b l i s h mutual g o a l s . S u b j e c t s i n t h i s study were m o t i v a t e d d i s e a s e and  i t s treatment  to l e a r n about  their  d u r i n g t h e i r r e c o v e r y on the c a r d i a c ward  f o l l o w i n g d i s c h a r g e from the coronary  care u n i t , and these f i n d i n g s  78 suggest t h a t p a t i e n t e d u c a t i o n  on a c a r d i a c ward i s an i d e a l time  for  both i n t e r v i e w s  l e a r n i n g to begin.  During  environment, s u b j e c t s asked numerous q u e s t i o n s t h e r a p e u t i c regimen perhaps s u g g e s t i n g resources  education  had h i g h e r  during the f i r s t  showed t h a t s u b j e c t s w i t h high  school  d i e t a r y recommendations  i n t e r v i e w than d i d s u b j e c t s with  college or  (.H = 5.95, d f = 2, p_ < .05).  Scores were  t o t h e K r u s k a l - W a l l i s rank-sum t e s t w i t h one-way a n a l y s i s  of v a r i a n c e .  These f i n d i n g s suggest t h a t s u b j e c t s with  e d u c a t i o n a l p r e p a r a t i o n have l e s s e x p e r i e n c e and  their  from h o s p i t a l .  compliance scores with  university preparation subjected  about  that additional learning  are required f o l l o w i n g discharge  Data from t h i s study  i n t h e home  comply more r e a d i l y with  with  by p r e v i o u s  decision-making  d i e t a r y recommendations than do  s u b j e c t s with higher educational p r e p a r a t i o n . not supported  lower  These r e s u l t s a r e  r e s e a r c h perhaps s u g g e s t i n g  s t u d i e s be conducted t o determine i f e d u c a t i o n  t h a t more  i s a significant  p r e d i c t o r of compliance. Simultaneous demands and the extent  of b e h a v i o u r a l  changes  expected by h e a l t h care workers of t h e s u b j e c t s appeared t o i n f l u e n c e compliance i n t h i s study.  Some s u b j e c t s were  requested  t o modify smoking h a b i t s and t h e i r consumption of h i g h  caloric  f o o d s ; however, s u b j e c t s had d i f f i c u l t y  both  recommendations.  Subjects  complying w i t h  f e l t t h a t smoking had more d e t r i m e n t a l  e f f e c t s on t h e i r h e a r t than o b e s i t y and decided  t o q u i t smoking and  modify but not e l i m i n a t e t h e i r consumption of h i g h c a l o r i c  foods.  79 All  subjects i n this  study who i d e n t i f i e d t h e i r o c c u p a t i o n  r e t i r e d were o l d e r than 65 y e a r s and had e x p e r i e n c e d m e d i c a l problems.  and m e d i c a t i o n recommendations  compliance.  F i n d i n g s suggest t h a t  simultaneous  demands b e i n g made of the p a t i e n t  b e h a v i o u r a l changes t h a t differences  planning nursing  force. as  affect  and subsequent  nurses s h o u l d a s s e s s and the extent  effects  i n t o account when  were observed between p r o f e s s i o n a l  and  s u b j e c t s and t h e i r ease of t r a n s i t i o n  professionals,  resumed employment v i a p a r t - t i m e  t o resume f u l l - t i m e p o s i t i o n s subjects, part-time  of company p o l i c y .  i n t o the work  study who i d e n t i f i e d t h e i r  s u b j e c t s who i d e n t i f i e d t h e i r o c c u p a t i o n s  as  occupations  positions.  i n order t o m a i n t a i n t h e i r  For  part  infarctions These  i n d i v i d u a l s who perform n o n p r o f e s s i o n a l  encounter more d i f f i c u l t i e s  had  jobs.  employment was not c o n s i d e r e d  Fear of r e c u r r e n t m y o c a r d i a l  suggest t h a t  All  nonprofessionals  i n d u c e d by heavy labour was expressed by these s u b j e c t s . findings  of  each i n d i v i d u a l , and take t h e s e  and p o t e n t i a l  A l l subjects i n t h i s  the l a t t e r  changes  care.  Differences nonprofessional  previous  These s u b j e c t s encountered few l i f e s t y l e  with dietary  individual  as  tasks  w i t h resumption of employment than do  p a t i e n t s who perform p r o f e s s i o n a l  tasks,  and t h a t  early  i d e n t i f i c a t i o n of these f a c t o r s by h e a l t h c a r e workers might h e l p t o ease the p a t i e n t ' s t r a n s i t i o n back i n t o the work From o b s e r v a t i o n s actively  of n i n e s i g n i f i c a n t  i n v o l v e d with p h y s i c a l a c t i v i t y ,  others, dietary,  force. all  were  and m e d i c a t i o n  80 recommendations t h a t were p r e s c r i b e d f o r t h e i r mates. f i n d i n g s suggest  These  t h a t knowledge about the t h e r a p e u t i c regimen be  g i v e n t o s i g n i f i c a n t o t h e r s by h e a l t h care workers to enable women to p r o v i d e support  and  reinforcement  these  to t h e i r p a r t n e r s d u r i n g  t h e i r r e c o v e r y a t home.  Conclusions T h i s study  i n v e s t i g a t e d the e f f e c t s of s t r u c t u r e d e d u c a t i o n  f o r the p a t i e n t , and the s i g n i f i c a n t o t h e r , on compliance  with  h e a l t h care recommendations f o r p a t i e n t s r e c o v e r i n g from a myocardial  i n f a r c t i o n a f t e r d i s c h a r g e from h o s p i t a l .  Significant  d i f f e r e n c e s were not found p o s s i b l y as a r e s u l t of the s m a l l sample s i z e and between group d i f f e r e n c e s of the two  demographic v a r i a b l e s  o f age  not found  and  employment.  P a t i e n t e d u c a t i o n was  v a l i d p r e d i c t o r of compliant  to be a  behaviour.  From g e n e r a l o b s e r v a t i o n s of the t o t a l sample, numerous f a c t o r s were i d e n t i f i e d t h a t i n f l u e n c e d compliance. were p e r s o n a l d e f i n i t i o n s of h e a l t h , simultaneous  These f a c t o r s  demands and  the  e x t e n t of b e h a v i o u r a l changes r e q u i r e d , and the demographic v a r i a b l e s of e d u c a t i o n and  employment.  Findings also  t h a t the s i g n i f i c a n t o t h e r s of p a t i e n t s were a c t i v e l y the t h e r a p e u t i c regimen p r e s c r i b e d f o r t h e i r mates.  suggested i n v o l v e d with  81 Implications Nursing p r a c t i c e . p r o f e s s i o n a l s who  Nurses are the primary h e a l t h care  teach p a t i e n t s with m y o c a r d i a l  t h e i r d i s e a s e and treatment. i n enhancing  The  p a t i e n t compliance  infarctions  nurse can perform  about  a critical  role  with h e a l t h c a r e recommendations.  T h i s study, t h e r e f o r e , h o l d s some important  implications for  nursing p r a c t i c e : 1.  A c a r d i a c ward f o l l o w i n g d i s c h a r g e from a coronary  care  u n i t and the home environment are s u i t a b l e s e t t i n g s f o r p a t i e n t education.  During these stages of t h e i r r e c o v e r y , p a t i e n t s are  m o t i v a t e d t o l e a r n about the d i s e a s e p r o c e s s and i t s management. 2.  S i n c e d e f i n i t i o n s of h e a l t h v a r i e d among s u b j e c t s i n t h i s  study, nurses c o u l d i n v e s t i g a t e p a t i e n t d e f i n i t i o n s t o enhance communication and v a l i d a t e g o a l s . 3.  S i n c e s u b j e c t s with n o n p r o f e s s i o n a l o c c u p a t i o n s  encountered nurses  difficulties  with t h e i r resumption  of employment,  s h o u l d a s s e s s t h e i r p a t i e n t ' s o c c u p a t i o n and a s s i s t h i s  t r a n s i t i o n back i n t o the work f o r c e . 4. of  N u r s i n g assessment of p a t i e n t s s h o u l d i n c l u d e the  b e h a v i o u r a l changes and simultaneous  demands expected  p a t i e n t , and s h o u l d take these i n d i v i d u a l d i f f e r e n c e s and  extent  of the potential  e f f e c t s i n t o account when p l a n n i n g n u r s i n g c a r e . 5.  S i n c e s i g n i f i c a n t o t h e r s were a c t i v e l y i n v o l v e d with  t h e i r mates' t h e r a p e u t i c regimen, p a t i e n t e d u c a t i o n i n the areas of  82 p h y s i c a l a c t i v i t y , d i e t , and  medication-taking  should be  given  to  s i g n i f i c a n t o t h e r s by h e a l t h care p r o f e s s i o n a l s . Nursing explanatory  research.  As p r e v i o u s l y s t a t e d , t h i s was  experimental  study  s m a l l convenience sample.  conducted i n one  Insignificant  an  s e t t i n g with  a  f i n d i n g s were p o s s i b l y t h e  r e s u l t of the s m a l l sample s i z e and between group d i f f e r e n c e s of the v a r i a b l e s of age  and  employment.  F i n d i n g s cannot  g e n e r a l i z e d beyond the study p o p u l a t i o n . research 1.  Implications for nursing  include: Further  i n v e s t i g a t i o n of the independent v a r i a b l e s of  method of p a t i e n t e d u c a t i o n  and  i n f l u e n c e of the s i g n i f i c a n t  on compliance u s i n g a l a r g e r sample p o p u l a t i o n .  Using  t o measure knowledge l e v e l s of the p a t i e n t s and t h e i r others  u s i n g instruments accurate  to measure b e h a v i o u r a l  compliant  behaviours  changes may  with h e a l t h c a r e  other  instruments significant  a t v a r i o u s i n t e r v a l s d u r i n g the r e c o v e r y p r o c e s s  t o determine the e f f e c t i v e n e s s of p a t i e n t e d u c a t i o n .  2.  be  might h e l p  Similarly, r e f l e c t more  recommendations.  F u r t h e r i n v e s t i g a t i o n of the p o s s i b l e r e l a t i o n s h i p of  educational preparation to decision-making  r e l a t i v e to d i e t a r y  compliance. 3.  I n v e s t i g a t i o n of resumption of employment between  p r o f e s s i o n a l and  nonprofessional  occupations  t h i s study  suggested t h a t i n d i v i d u a l s w i t h  occupations  encountered more d i f f i c u l t i e s  resumption than d i d s u b j e c t s who  s i n c e f i n d i n g s from nonprofessional  with  employment  performed p r o f e s s i o n a l t a s k s .  83 Recommendations On the b a s i s of the f i n d i n g s and i m p l i c a t i o n s of t h i s it  study,  i s recommended t h a t : 1.  Nursing  assessment i n c l u d e the p a t i e n t ' s d e f i n i t i o n of  h e a l t h , o c c u p a t i o n , simultaneous  demands b e i n g made of the p a t i e n t ,  and the e x t e n t of b e h a v i o u r a l changes expected communication, c l a r i f y  t o enhance  g o a l s , and t o i n d i v i d u a l i z e p a t i e n t  education. 2.  S i g n i f i c a n t o t h e r s of p a t i e n t s w i t h m y o c a r d i a l  be p r o v i d e d with knowledge and m e d i c a t i o n - t a k i n g  3.  i n the areas of p h y s i c a l a c t i v i t y ,  so t h a t they may  mates d u r i n g the r e c o v e r y  infarctions  be a b l e t o a s s i s t  diet,  their  process.  Nurses enhance c o l l a b o r a t i v e e f f o r t s w i t h p h y s i c i a n s t o  determine d i e t a r y and m e d i c a t i o n to discharge. would p e r m i t  h e a l t h care recommendations  E a r l y i d e n t i f i c a t i o n of these d i s c h a r g e  prior  instructions  the nurse t o d i s c u s s t e n t a t i v e p l a n s with the p a t i e n t  and h e l p t a i l o r the care p l a n to r e f l e c t p a t i e n t needs. 4.  Future s t u d i e s i n v e s t i g a t i n g p a t i e n t e d u c a t i o n and  compliance employ t o o l s t o measure knowledge changes a t v a r i o u s stages of the r e c o v e r y 5.  l e v e l s and b e h a v i o u r a l  process.  The demographic v a r i a b l e s of e d u c a t i o n a l p r e p a r a t i o n and  o c c u p a t i o n be i n v e s t i g a t e d f u r t h e r t o determine i f these v a r i a b l e s a r e v a l i d p r e d i c t o r s of compliant  behaviour.  84 References A d s e t t , C . A . , & Bruhn, J . G . (1968). S h o r t - t e r m group psychotherapy f o r p o s t - m y o c a r d i a l i n f a r c t i o n p a t i e n t s and t h e i r wives. Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , 99 (12), 577-584. Aho, W. R. (1977). R e l a t i o n s h i p of w i v e s ' p r e v e n t i v e h e a l t h o r i e n t a t i o n t o t h e i r b e l i e f s about h e a r t d i s e a s e i n husbands. 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F a c t o r s i n f l u e n c i n g p a t i e n t noncompliance: t h e o r e t i c a l approach. N u r s i n g R e s e a r c h , 20, ( 6 ) , 509-516.  A  W r i g h t , R. L . D. (1976). U n d e r s t a n d i n g s t a t i s t i c s an i n f o r m a l i n t r o d u c t i o n f o r the b e h a v i o u r a l s c i e n c e s . New York: Harcourt Brace J o v a n o v i c h .  89 Appendix A Structured Patient Education  Objectives  The purpose of the t e a c h i n g s e s s i o n s i s t o review and t o i n d i v i d u a l i z e s l i d e / t a p e content. The o b j e c t i v e s were developed by the i n v e s t i g a t o r based on content from the program e n t i t l e d "An a c t i v e p a r t n e r s h i p f o r the h e a l t h of your h e a r t ( a f t e r your h e a r t a t t a c k ) " and produced by the American Heart A s s o c i a t i o n . Tape 1: 1.  To know the cause, e f f e c t s , a) b) c) d) e) f) g)  h) Tape 2: 1.  Your H e a r t A t t a c k and Your and  Future r i s k f a c t o r s of a h e a r t  attack.  t o i d e n t i f y the f u n c t i o n of the h e a r t . t o i d e n t i f y the f u n c t i o n of the coronary a r t e r i e s . t o d e s c r i b e the damage done t o the h e a r t d u r i n g a h e a r t attack. to d e s c r i b e the r e c o v e r y p r o c e s s of the h e a r t a f t e r a h e a r t attack. t o i d e n t i f y time parameters a s s o c i a t e d w i t h the h e a r t ' s recovery post-attack. t o i d e n t i f y the cause of a h e a r t a t t a c k . t o l i s t f o u r r i s k f a c t o r s t h a t i n f l u e n c e coronary a r t e r y disease. to i d e n t i f y r i s k f a c t o r s t h a t a f f e c t t h i s  individual.  Move I n t o A c t i o n  To know s p e c i f i c f a c t s about the e f f e c t of p h y s i c a l a c t i v i t y on the h e a r t a f t e r a h e a r t a t t a c k . a) b) c) d) e) f)  g) h)  i) j)  t o i d e n t i f y the purpose of c o l l a t e r a l c i r c u l a t i o n . to e x p l a i n the r a t i o n a l e f o r a gradual i n c r e a s e i n a c t i v i t i e s as i t a f f e c t s the h e a r t . t o l i s t 5 a c t i v i t i e s t h a t can be performed d u r i n g the f i r s t 3 weeks a t home. t o l i s t 4 a c t i v i t i e s t h a t s h o u l d be avoided d u r i n g the f i r s t 3 weeks a t home. t o i d e n t i f y c u r r e n t a c t i v i t i e s enjoyed. to compare a c t i v i t i e s c u r r e n t l y enjoyed t o the l i s t o f a c t i v i t i e s to do and not to do t h a t a f f e c t an i n d i v i d u a l r e c o v e r i n g from a h e a r t a t t a c k . to d i s c u s s methods to adhere to the l i s t of p h y s i c a l a c t i v i t i e s t o do and not t o do d u r i n g r e c o v e r y . t o i d e n t i f y the time p e r i o d a s s o c i a t e d w i t h r e s t r i c t e d d r i v i n g f o l l o w i n g a h e a r t a t t a c k a c c o r d i n g to the laws o f B.C. t o i d e n t i f y o t h e r sources of t r a n s p o r t a t i o n allowed d u r i n g the d r i v i n g r e s t r i c t i o n . to i d e n t i f y a c t i v i t y expenditure involved i n sexual intercourse.  90 k) 1) m)  Tape 3; 1.  e) f) g) h) i) j)  to define cholesterol. to define saturated f a t . to define polyunsaturated f a t . t o d e f i n e the c o l l e c t i v e e f f e c t s of c h o l e s t e r o l / f a t on t h e a r t e r i e s of the body. t o i d e n t i f y the r a t i o n a l e f o r a v o i d i n g foods h i g h i n cholesterol/fat. t o l i s t 6 f o o d items t o e a t when on a low c h o l e s t e r o l / f a t diet. t o l i s t 6 f o o d items t o a v o i d when on a low c h o l e s t e r o l / f a t diet. t o i d e n t i f y f o o d items h i g h i n c h o l e s t e r o l / f a t consumed with c u r r e n t d i e t . t o i d e n t i f y s a t i s f a c t o r y f o o d items t h a t can be s u b s t i t u t e d f o r those items h i g h i n c h o l e s t e r o l / f a t . t o d i s c u s s t h e r e l e v a n c e of low c h o l e s t e r o l / f a t food items to t h e i n d i v i d u a l who p r o c u r e s and prepares meals i n t h e home.  To know s p e c i f i c f a c t s a) b) c) d) e) f)  3.  You A r e What You E a t  To know s p e c i f i c f a c t s about a low c h o l e s t e r o l / l o w f a t d i e t . a) b) c) d)  2.  t o i d e n t i f y p e r s o n a l g u i d e l i n e s when resuming s e x u a l intercourse. t o l i s t 3 warning s i g n s i n d i c a t i n g t o stop a c t i v i t y and rest. to i d e n t i f y p h y s i c a l a c t i v i t y limitations affecting current occupation.  about a low sodium  diet.  t o i d e n t i f y t h e e f f e c t of s o d i u m / s a l t on t h e body. t o i d e n t i f y the e f f e c t o f s o d i u m / s a l t on t h e h e a r t a f t e r a heart attack. t o l i s t 6 f o o d items h i g h i n sodium c o n t e n t . t o i d e n t i f y food items i n the c u r r e n t d i e t t h a t a r e h i g h i n sodium c o n t e n t . t o i d e n t i f y s a t i s f a c t o r y f o o d items t h a t can be s u b s t i t u t e d f o r those items h i g h i n sodium c o n t e n t . t o d i s c u s s t h e r e l e v a n c e of low sodium f o o d items t o the i n d i v i d u a l who p r o c u r e s and prepares meals i n the home.  To know methods t o l o s e weight. a)  t o i d e n t i f y two methods t o l o s e weight.  91 Tape 4: 1.  Your P r e s c r i p t i o n f o r H e a l t h  To know s p e c i f i c f a c t s about the t a k i n g home. a) b) c) d) e) f) g)  of m e d i c a t i o n s  i n the  t o i d e n t i f y f a c t o r s t h a t w i l l promote a s a t i s f a c t o r y r o u t i n e t o take medications i n the home. t o i d e n t i f y d e t r i m e n t a l f a c t o r s a f f e c t i n g the t a k i n g of m e d i c a t i o n s i n the home. t o i d e n t i f y the r a t i o n a l e f o r knowing the name of t h e medication. t o i d e n t i f y the r a t i o n a l e f o r knowing the purpose of the medication. t o i d e n t i f y the r a t i o n a l e f o r knowing the dosage and frequency of m e d i c a t i o n . t o i d e n t i f y the r a t i o n a l e f o r knowing the s i d e e f f e c t s of medication. t o l i s t the name, and purpose of c u r r e n t m e d i c a t i o n .  92 Appendix B Discharge Guidelines of Cardiac Teaching U n i t ( G u i d e l i n e s from t h e i n s t i t u t i o n under study with t h e i r  approval)  Diet Type: Alcohol  Restrictions:  Activities: Your s t r e n g t h and energy w i l l g r a d u a l l y r e t u r n but may take up t o 3 months. A u s e f u l g u i d e l i n e t o a s s i s t you i n r e t u r n i n g t o your normal a c t i v i t i e s would be: Week 1 - Stay i n d o o r s - c a r r y on t h e same l e v e l of a c t i v i t y reached in hospital. I f t h e weather i s a g r e e a b l e , you may s i t out o f doors i n t h e garden or on t h e p a t i o . R i s e a t your u s u a l time i n t h e morning, dress and be up most o f t h e day. L i e down h a l f an hour a f t e r each meal and when you are t i r e d . T r y t o do a l i t t l e more each day. I f you e x p e r i e n c e c h e s t p a i n , l i e down u n t i l t h e p a i n d i s a p p e a r s . S t a i r Climbing:  Yes  No  Restrictions: Week 2 - Begin Day Day Day  outdoor  walking.  Walk one c i t y b l o c k and back. Walk two c i t y b l o c k s and back. Walk t h r e e c i t y b l o c k s and back.  Increase a c i t y b l o c k d a i l y u n t i l you a r e walking e i g h t c i t y b l o c k s and back. T h e r e a f t e r , walk one m i l e o r more d a i l y , a t whatever pace s u i t s you. You may walk up h i l l s and s l o p e s . C a l l your d o c t o r , o r go t o your l o c a l Emergency Department i f you develop chest p a i n and i t i s not r e l i e v e d a f t e r t a k i n g 3 o r 4 n i t r o g l y c e r i n e t a b l e t s (one every 5 m i n u t e s ) , o r , i f t h e p a i n does not go away with r e s t w i t h i n 20 minutes. Home A c t i v i t y  Suggestions: Weeks  1.  Fix light  lunches  2.  Be alone d u r i n g t h e day  1 2  3  4  93 Weeks 3.  Be a passenger i n a c a r  4.  Resume s e x u a l  5.  Take a h o l i d a y - d r i v i n g - flying  6.  Resume l i g h t housework ( d u s t i n g , c o o k i n g , washing d i s h e s )  7.  Resume heavy housework laundry, f l o o r s )  1  2  3  4  relationships  (vacuuming,  Driving: The B.C. Motor V e h i c l e A c t p r o h i b i t s you from d r i v i n g your c a r f o r 6 weeks a f t e r a h e a r t a t t a c k . Approximate r e t u r n t o work:  '  weeks.  Follow-up V i s i t s : Family Doctor: Cardiologist: Other: Medications:  List  below  Restrictions: D e f i n i t e l y NO CIGARETTE SMOKING. disease.  I t i n c r e a s e s t h e r i s k of h e a r t  ATTACH MEDICATION TEACHING CARDS BELOW:  94 Appendix C Data C o l l e c t i o n Instrument P t . Number Date interview Physical a)  Activity  D i d your d o c t o r suggest t h a t you l i m i t your a c t i v i t y i n any way, i . e . : Climbing s t a i r s Walking outdoors L i f t i n g objects Resumption of s e x u a l Return to work Hobbies or s p o r t s D r i v i n g a car Other Other '  b)  activity  '  Would you e s t i m a t e t h a t you have been a b l e t o f o l l o w t h e s e suggestions: Climbing (3) (2) (1) (0)  Stairs Walking Outdoors a l l the time ' ' ' " (3) a l l the' time about h a l f the time (2) about h a l f the time some of the time (1) some of the time never ' (0) never  Resumption o f Sexual A c t i v i t y L i f t i n g Objects ' (3) a l 1 the time (3) a l l the time ' (2) about h a l f the time (2) about h a l f the time (1) some of the time (1) some of the time (0) never (0) never Return to (3) (2) (1) (0) Travel  (3) (2) (1) (0)  Work Hobbies o r s p o r t s a l l the time (3) a l l the time about h a l f the time (2) about h a l f the time some of the time (1) some of the time never (0) never  a l l the time about h a l f the time some of the time never  Driving a (3) (2) (1) (0)  car a l l the time about h a l f the time some of the time never  95 Other  —  Other (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  I f you have had d i f f i c u l t y f o l l o w i n g the d o c t o r ' s s u g g e s t i o n s , can you g i v e a reason? Why? Climbing s t a i r s : Walking o u t d o o r s : L i f t i n g objects: Resumption of s e x u a l Return t o Work: Hobbies or s p o r t s : Travel: Driving a car: Other: Other:  activity:  Score  /100%  96 B.  Diet a)  D i d the d o c t o r suggest t h a t you r e s t r i c t way, i . e . : Reducing d i e t t o l o s e Salt free Low sodium Low f a t / c h o l e s t e r o l Alcohol Other ' Other  b)  weight  Would you e s t i m a t e t h a t suggestions:  '  '  you have been a b l e t o f o l l o w  Reducing D i e t Salt free (3) a l l the time _____ (3) (2) about h a l f t h e time (2) (1) some of the time ' (1) (0) never (0) Low sodium Low (3) a l l the time (2) about h a l f the time (1) some of t h e time (0) never Alcohol (3) (2) _____ (1) (0)  your d i e t i n any  these  a l l the time about h a l f t h e time some of the time never  fat/cholesterol (3) a l l the time (2) about h a l f t h e time (1) some of the time (0) never  Other a l l the time about h a l f t h e time some of the time never  (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  Other (3) (2) (1) (0) c)  a l l t h e time about h a l f the time some of the time never  I f you have had d i f f i c u l t y f o l l o w i n g s u g g e s t i o n s , can you give a reason?  the d o c t o r ' s Why?  Reducing d i e t : Salt free Low sodium: Low f a t / c h o l e s t e r o l : Alcohol: Other: Other: Score  /100%  97 C.  Medication a)  D i d your d o c t o r o r d e r any m e d i c a t i o n f o r you t o take a t home? i . e . : Nitroglycerine Digoxin • Furosemide ' Potassium C h l o r i d e Other Other Other Other Other  b)  How How How How How How How How How  often often often often often often often often often  Would you e s t i m a t e t h a t you have been able t o f o l l o w t h e s e directions: Digoxin Nitroglycerine (3) (3) a l l the time (2) about h a l f t h e time (2) (1) some of the time (1) (0) never (0)  a l l the time about h a l f t h e time some of the time never  Potassium C h l o r i d e Furosemide (3) a l l t h e time (3) a l l the time (2) about h a l f the time (2) about h a l f the time (1) some of t h e time (1) some o f t h e time (0) never (0) never Other  Other (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  (3) (2) (1) (0)  a l l t h e time about h a l f the time some of the time never  (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  Other  (3) (2) (1) (0)  a l l the time about h a l f the time some of the time never  (3) (2) (1) (0)  a l l t h e time about h a l f the time some of the time never  Other  Other  98 c)  I f you have had d i f f i c u l t y f o l l o w i n g the d o c t o r ' s s u g g e s t i o n s , can you g i v e a reason? Why? Nitroglycerine: Digoxin: Furosemide: Potassium C h l o r i d e : Other: Other: Other: Other: Other: Score  Note.  /100%  Q u e s t i o n n a i r e t o be completed by the i n v e s t i g a t o r .  Appendix D Demographic  Data  S u b j e c t Number: Address: Phone Number: Age: Marital  Status:  Occupation: Education: Previous  myocardial  infarctions:  Presence of spouse d u r i n g s l i d e - t a p e Activity Diet Medication Group  Designation:  presentations  100 Appendix E Group 1 I n t r o d u c t o r y L e t t e r  Dear T h i s l e t t e r i s t o ask you t o p a r t i c i p a t e i n a study which I am d o i n g as a student a t t h e U n i v e r s i t y of B r i t i s h Columbia, t a k i n g my Masters i n N u r s i n g . Although n u r s i n g and m e d i c a l s t a f f have h e l p e d me t o c o n t a c t you, I do not work on t h i s n u r s i n g u n i t . I am i n t e r e s t e d i n the format of h e a l t h t e a c h i n g given t o c l i e n t s such as y o u r s e l f and your response t o the t e a c h i n g method a f t e r d i s c h a r g e from h o s p i t a l . D u r i n g your h o s p i t a l i z a t i o n , n u r s i n g s t a f f w i l l share s l i d e - t a p e p r e s e n t a t i o n s with you about r e c o v e r i n g from a h e a r t attack. I f you are w i l l i n g t o p a r t i c i p a t e i n the study, I would l i k e t o meet with you twice a t your r e s i d e n c e , the f i r s t time b e i n g one month a f t e r d i s c h a r g e from h o s p i t a l and a g a i n t h r e e months a f t e r d i s c h a r g e . I n t e r v i e w time a t your r e s i d e n c e w i l l take a p p r o x i m a t e l y 30 minutes of your time. You are f r e e t o withdraw from the study a t any time. not be i d e n t i f i e d by name i n the study.  You  will  If you are w i l l i n g t o p a r t i c i p a t e i n the study, I w i l l meet w i t h you p r i o r t o d i s c h a r g e t o i n t r o d u c e myself and t o answer any q u e s t i o n s t h a t you may have about the study a t t h a t time. After d i s c h a r g e , I w i l l c o n t a c t you by phone, t h r e e weeks l a t e r t o arrange an i n t e r v i e w time. I f you d e c i d e not t o p a r t i c i p a t e , your d e c i s i o n w i l l not a f f e c t your c o n t a c t or care with the h o s p i t a l s t a f f i n any way. you d e c i d e t o p a r t i c i p a t e , you w i l l be informed of the f i n a l r e s u l t s of the study i f d e s i r e d . Sincerely  yours,  Rhonda K i r k  If  101 Appendix F Group 2 I n t r o d u c t o r y L e t t e r  Dear T h i s l e t t e r i s t o ask you t o p a r t i c i p a t e i n a study which I am d o i n g as a student a t t h e U n i v e r s i t y of B r i t i s h Columbia, t a k i n g my Masters i n N u r s i n g . Although n u r s i n g and m e d i c a l s t a f f have h e l p e d me t o c o n t a c t you, I do not work on t h i s n u r s i n g u n i t . I am i n t e r e s t e d i n the format o f h e a l t h t e a c h i n g given t o c l i e n t s such as y o u r s e l f and your response t o the t e a c h i n g method a f t e r d i s c h a r g e from h o s p i t a l . I f you a r e w i l l i n g t o p a r t i c i p a t e i n the study, I w i l l watch and d i s c u s s t h r e e s l i d e - t a p e p r e s e n t a t i o n s about r e c o v e r i n g from a h e a r t a t t a c k w i t h you d u r i n g your h o s p i t a l i z a t i o n . I would l i k e t o meet with you twice a t your r e s i d e n c e , the f i r s t time b e i n g one month a f t e r d i s c h a r g e from h o s p i t a l and a g a i n t h r e e months a f t e r discharge. I n t e r v i e w time a t your r e s i d e n c e w i l l take a p p r o x i m a t e l y 30 minutes of your time. You a r e f r e e t o withdraw from t h e study a t any time. not be i d e n t i f i e d by name i n the study.  You w i l l  If you are w i l l i n g t o p a r t i c i p a t e i n the study, I w i l l meet w i t h you t o review t h e s l i d e - t a p e p r e s e n t a t i o n and then w i l l c o n t a c t you by phone t h r e e weeks a f t e r d i s c h a r g e t o arrange an i n t e r v i e w time. I f you decide not t o p a r t i c i p a t e , your d e c i s i o n w i l l not a f f e c t your c o n t a c t or care with the h o s p i t a l s t a f f i n any way. you d e c i d e t o p a r t i c i p a t e , you w i l l be informed of the f i n a l r e s u l t s of the study i f d e s i r e d . Sincerely  yours,  Rhonda K i r k  If  102 Appendix G Group 3 I n t r o d u c t o r y L e t t e r  Dear T h i s l e t t e r i s t o ask you and your w i f e t o p a r t i c i p a t e i n a study which I am doing as a student a t t h e U n i v e r s i t y of B r i t i s h Columbia, t a k i n g my Masters i n N u r s i n g . Although n u r s i n g and m e d i c a l s t a f f have h e l p e d me t o c o n t a c t you, I do not work on t h i s nursing unit. I am i n t e r e s t e d i n the format o f h e a l t h t e a c h i n g given t o c l i e n t s such as y o u r s e l f and your response t o the t e a c h i n g method a f t e r d i s c h a r g e from h o s p i t a l . I f you a r e w i l l i n g t o p a r t i c i p a t e i n the study, I w i l l watch and d i s c u s s t h r e e s l i d e - t a p e p r e s e n t a t i o n s about r e c o v e r i n g from a h e a r t a t t a c k w i t h you and your w i f e d u r i n g your h o s p i t a l i z a t i o n . I would l i k e t o meet with you twice a t your r e s i d e n c e , t h e f i r s t time b e i n g one month a f t e r d i s c h a r g e from h o s p i t a l and a g a i n t h r e e months a f t e r d i s c h a r g e . I n t e r v i e w time a t your r e s i d e n c e w i l l take a p p r o x i m a t e l y 30 minutes of your time. You a r e f r e e t o withdraw from t h e study a t any time. not be i d e n t i f i e d by name i n the study.  You w i l l  If you and your w i f e a r e w i l l i n g t o p a r t i c i p a t e i n the s t u d y , I w i l l meet w i t h you t o arrange a convenient time t o review t h e s l i d e - t a p e p r e s e n t a t i o n s and then w i l l c o n t a c t you by phone t h r e e weeks a f t e r d i s c h a r g e t o arrange an i n t e r v i e w time. If you d e c i d e not t o p a r t i c i p a t e , your d e c i s i o n w i l l n o t a f f e c t your c o n t a c t o r c a r e w i t h t h e h o s p i t a l s t a f f i n any way. you decide t o p a r t i c i p a t e , you w i l l be informed of the f i n a l r e s u l t s of t h e study i f d e s i r e d . Sincerely  yours,  Rhonda K i r k  If  103 Appendix H P a t i e n t Consent  I,  Form  , do hereby  g i v e my  consent t o  p a r t i c i p a t e i n the study on c l i e n t responses t o t e a c h i n g format which i s b e i n g conducted by Rhonda K i r k , a graduate S c h o o l of N u r s i n g a t the U n i v e r s i t y of B r i t i s h  I understand a)  student i n the  Columbia.  t h a t p a r t i c i p a t i o n i n the study i n v o l v e s no  risks  or d i s c o m f o r t s . b)  t h a t my p a r t i c i p a t i o n i s v o l u n t a r y and t h a t I may withdraw a t any  c)  time.  t h a t r e f u s a l t o p a r t i c i p a t e i n the study or withdrawal  from the study w i l l  i n no way  interfere  w i t h the m e d i c a l or n u r s i n g c a r e which I w i l l receive, d)  and  t h a t any i n f o r m a t i o n p e r s o n a l l y i d e n t i f y i n g me a p a r t i c i p a n t i n t h i s study w i l l confidential.  S i g n a t u r e of C l i e n t  S i g n a t u r e of  Witness  S i g n a t u r e of  Other  Date  remain  as  strictly  104 Appendix I P h y s i c i a n Consent Form  I,  , do hereby give my  t o have  '  , a p a t i e n t under my  p a r t i c i p a t e i n the study on p a t i e n t response to the teaching  format which i s b e i n g  i n the Master of Science British  permission care,  cardiac  conducted by Rhonda K i r k , a  student  i n N u r s i n g program at the U n i v e r s i t y of  Columbia.  Signature  Date  of  Physician  

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