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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 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f G r a d u a t e S t u d i e s ( S c h o o l o f N u r s i n g ) The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V6T 1W5 D a t e A u g u s t 31, 1985 r>v-C (9 / 7 c n i i 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 i i i 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 v i i CHAPTER 1 - INTRODUCTION . . 1 Statement of the Problem 1 Purpose of the Study 2 Definition of Terms 3 Assumptions and Limitations of the Study 5 CHAPTER 2 - REVIEW OF THE LITERATURE 7 Theoretical Background 7 Theoretical Frameworks 9 Orem's model for nursing 9 Dubos' theory of adaptation 11 Bandura's social learning theory . 12 Summary of theoretical frameworks 13 Compliance 14 Knowledge 18 Patient Education 21 Influence of the Significant Other 27 Summary . . . . . . . . . . . 30 CHAPTER 3 - METHODOLOGY 32 Research Design . . . . . . . 32 The Setting 33 Sample Selection 34 Criteria for selection of patients . 35 Rationale for criteria 35 Patient Education Program . . . 37 Program delivery on cardiac ward 39 Treatment 43 V Page CHAPTER 3 - METHODOLOGY (cont'd) Data Collection Instrument 45 Development of data collection instrument . . . . 46 Test of the interview guide 49 Administration of data collection instrument . . . 49 Ethics and Human Rights 52 CHAPTER 4 - PRESENTATION AND DISCUSSION OF FINDINGS . . . . 54 Characteristics of the Sample 54 Nonparametric Statistical Analyses of Compliance Scores 57 General Observations of the Sample 60 Self-care abilities 60 Self-care 67 Therapeutic demands 68 General Observations of Significant Others 72 Summary 73 CHAPTER 5 - SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 75 Overview of the Study . . . . . . . . . . . . . . . . . 75 Problem, design and implementation 75 Results 77 Conclusions 80 Implications 81 Nursing practice 81 Nursing research 82 Recommendations 83 REFERENCES 84 APPENDICES 89 Appendix A - Structured Patient Education Objectives . 89 Appendix B - Discharge Guidelines of Cardiac Teaching Unit 92 Appendix C - Data Collection Instrument 94 Appendix D - Demographic Data 99 Appendix E - Group 1 Introductory Letter 100 Appendix F - Group 2 Introductory Letter 101 Appendix G - Group 3 Introductory Letter 102 Appendix H - Patient Consent Form 103 Appendix I - Physician Consent Form 104 vi LIST OF TABLES Table Page 1 Summary of Two Methods of Program Delivery on Cardiac Ward 40 2 Number of Days Between Discharge and Interviews . . . 50 3 Characteristics of the Sample Groups 56 4 Summary of H Values for Compliance with Recommendations During Two Interviews 59 5 Raw Data, Number of Recommendations, and Scores for Compliance with Physical Activity Recommendations During First Interview 61 6 Raw Data, Number of Recommendations, and Scores for Compliance with Physical Activity Recommendations During Second Interview 62 7 Raw Data, Number of Recommendations, and Scores for Compliance with Dietary Recommendations During First Interview . . . 63 8 Raw Data, Number of Recommendations, and Scores for Compliance with Dietary Recommendations During Second Interview 64 9 Number of Recommendations and Scores for Compliance with Medication Recommendations During First and Second Interviews 65 v i i 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. All 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 killer 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 will 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 first 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 titled, "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 its 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. The medical regimen prescribed by the physician (Marston, 1970). 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 is 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 to promote e f f e c t i v e functioning of the heart (Barbarowicz et a l . , 1976). In order to promote appropriate behavioural changes, information concerning the recommendations must be given to the i n d i v i d u a l (Linde & Janz, 1979). The outcome of patient education i s , " . . . independence achieved through knowledge, and the assumption 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 " ( B e l l & Whiting, 1981, p. 28). Dietary 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 behavioural changes that begin within the h o s p i t a l environment and continue into the home environment where the i n d i v i d u a l and s i g n i f i c a n t other reside. Litman (1974) stat e s , "the family cons t i t u t e s perhaps the most important s o c i a l context within which i l l n e s s occurs and i s resolved" (p. 495). Therefore, the e f f e c t of a myocardial i n f a r c t i o n on an i n d i v i d u a l cannot be considered i n i s o l a t i o n as the event i s bound to have an impact on the s i g n i f i c a n t other which i n turn enhances or depresses the i n d i v i d u a l ' s r e h a b i l i t a t i o n (Davidson, 1979; Skelton & Dominian, 1973). Baden (1972) emphasizes the importance of family education on 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 myocardial i n f a r c t i o n by saying: An i n t e g r a l part of a patient's care and r e h a b i l i t a t i o n i s the education of h i s family so that they can be a help rather than a detriment to him. The family and friends of the patient can have a d i r e c t influence not only upon his acceptance and understanding of h i s heart condition, but also upon his adaptation to modifications i n h i s l i f e s t y l e , (p. 565) 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 is the individual's capability to engage in and perform the self-care actions. If an individual with a myocardial infarction is 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 is 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 skills 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 is 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 is 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 is 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. Individuals learn vicariously or by verbal persuasion of others. 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 will 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 field 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 is essential in the control and prevention of disease (Hogue, 1979). Difficulties with compliance have been well-documented in the literature. 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 first 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. Rudy (1980) reported that 76% changed dietary habits. Scalzi et al. (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 al. (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 reported a 93.3% compliance rate with dietary recommendations at one month post discharge and an 83.3% compliance rate at three months for coronary bypass subjects following an education program. Some studies have investigated compliance with medication recommendations. From a large study of the c h r o n i c a l l y i l l , Greene, Weinberger, J e r i n , and Mamlin (1982) found that 26% of the sample always complied with medication regimens, 46% complied most of the time, and 26% complied less than half of the time. From studies of i n d i v i d u a l s with myocardial i n f a r c t i o n s , Royle (1973) reported that 93% of the sample complied a l l of the time and only 7% disregarded some of the i n s t r u c t i o n s . S c a l z i et a l . (1980) reported near optimal compliance for subjects who received unstructured education with medication recommendations. From the preceding review, i t i s evident that studies i n v e s t i g a t i n g compliance are d i f f i c u l t to compare and none reported 100% compliance rates. Some studies suggested that compliance was more l i k e l y to occur with health care recommendations that require the l e a s t change. Taking o r a l medications appeared to be the l e a s t d i f f i c u l t behaviour to change whereas dietary changes appeared to be the most d i f f i c u l t (Gillum & Barsky, 1974; Oldridge et a l . , 1978). Important f a c t o r s i d e n t i f i e d to enhance compliance were pat i e n t education, family encouragement, support, and reinforcement (Davis, 1968; Gillum & Barsky, 1974; Oldridge et a l . , 1978). 18 Knowledge Numerous s tudies have i d e n t i f i e d lack of knowledge as a source of noncompliance. Royle (1973) interviewed 20 male subjects with myocardial i n f a r c t i o n s and s ix of the subjects ' wives fo l lowing discharge from h o s p i t a l . Most subjects demonstrated l i m i t e d knowledge of t h e i r therapeut ic regimen and complained of vague i n s t r u c t i o n s given by hea l th care workers. Subjects 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 ietary l i m i t a t i o n s as major sources of apprehension. Low anxiety l e v e l s were experienced by the subjects when s p e c i f i c i n s t r u c t i o n s about the regimen were rece ived and high anxiety l e v e l s r e s u l t e d from vague i n s t r u c t i o n s . Royle found that f a i l u r e to fo l low a therapeut ic regimen was the r e s u l t of lack of understanding of the regimen and l i m i t e d support from spouses. The i n a b i l i t y of the wives to provide support was a t t r i b u t e d to lack of in format ion . A s i m i l a r study found that four out of seven subjects demonstrated needs for information during the ear ly recovery per iod at home ( P f i s t e r e r , 1975). From interviews with myocardial i n f a r c t i o n pat ient s and t h e i r spouses or s i g n i f i c a n t o thers , Rudy (1980) found the f o l l o w i n g : When pa t ient s resumed everyday a c t i v i t i e s , pa t i ent s and spouses became aware that dec i s ions confronted them and that they lacked re levant informat ion. Wives frequently expressed the fact that they had not been inc luded i n p a t i e n t education sessions and i n discharge planning to a s i g n i f i c a n t degree. Inc lus ion of spouses i n discharge p lanning was usua l ly l i m i t e d to d i e t and medication 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 voca t iona l d i s a b i l i t i e s fo l lowing a myocardial i n f a r c t i o n to fear and to vague i n s t r u c t i o n s 19 about employment resumption. Vague i n s t r u c t i o n s created knowledge d e f i c i t s r e s u l t i n g i n minimum exert ion by pa t ient s which retarded t h e i r voca t iona l a b i l i t i e s . The majority of pa t ient s with voca t iona l d i s a b i l i t i e s f e l l w i t h i n the u n s k i l l e d , s e m i - s k i l l e d , and s k i l l e d t rades . Crawshaw a l so blamed lack of knowledge as the prime reason for the i n a b i l i t y of the wives to provide support during recovery and suggested that education be given to the couple to promote recovery. S i m i l a r f indings were reported by Segev and Schles inger (1981). Recent ly , severa l researchers have explored the area of sexual a c t i v i t y a f t e r myocardial i n f a r c t i o n s . Sexual r e l a t i o n s are na tura l a c t i v i t i e s wi th in a mar i t a l or common-law dyad yet research i n d i c a t e d that frequency and pleasure assoc ia ted with in tercourse diminished a f ter one member suffered a myocardial i n f a r c t i o n . The reason for mar i t a l d i scord was the equation of sexual behaviour with strenuous a c t i v i t y imposing the associated r i s k of sudden death. The cause of t h i s misconception was lack of information which created fear i n both the pa t i ent and partner (Cole, L e v i n , Whit ley , & Young, 1979; Mims, 1980; Puksta, 1977; S c a l z i S Dracup, 1978). Henrick (1979) reported that when male subjects received i n s t r u c t i o n regarding sexual a c t i v i t y without the i n c l u s i o n of t h e i r par tners , t h e i r r e h a b i l i t a t i o n was severely hampered as a r e s u l t of lack of support and knowledge from the pa r tner . Several s tudies found that the emotional trauma associated with a myocardial i n f a r c t i o n during the acute phase r e s u l t e d i n 20 pa t i ent s f o r g e t t i n g , m i s i n t e r p r e t i n g , and r e l a y i n g i n c o r r e c t informat ion to f ami l i e s despite the fact that verba l i n s t r u c t i o n s were given to the pa t i en t by hea l th care workers. Without re levant in format ion , pa t ient s and f ami l i e s encountered d i f f i c u l t i e s with t h e i r attempts to follow a therapeut ic regimen (Baden, 1972; Rahe et a l . , 1975; S c a l z i et a l . , 1980; Toth & Toth , 1977). When re levant information about a therapeut ic regimen was not provided by hea l th care workers, pa t i ent s with myocardial i n f a r c t i o n s and t h e i r spouses tended to seek advice from f r i e n d s , r e l a t i v e s , and co-workers. Misconceptions about heart disease, expected behaviours , l i f e expectancy, and demands to make of others fur ther hindered the p a t i e n t s ' a b i l i t i e s to fol low a therapeut ic regimen and l i m i t e d the a b i l i t i e s of the s i g n i f i c a n t others to provide support during r e h a b i l i t a t i o n (Crawshaw, 1974; L a r t e r , 1976; Royle , 1973; Segev & Schles inger , 1981). As a group, the s tudies suggested that i n d i v i d u a l s with myocardial i n f a r c t i o n s encountered d i f f i c u l t i e s with a c t i v i t y , d i e t a r y , and medication recommendations fo l lowing discharge from h o s p i t a l and that f a i l u r e to fol low a therapeut ic regimen was a r e s u l t of lack of knowledge, vague i n s t r u c t i o n s by hea l th care workers, and l i m i t e d support from the s i g n i f i c a n t others because o f t h e i r l i m i t e d knowledge. However, many pat ient s and t h e i r s i g n i f i c a n t others wanted and expected to rece ive in format ion , during h o s p i t a l i z a t i o n , about heart disease and i t s e f fect s on t h e i r future (Baden, 1972; Royle, 1973). Recently , hea l th care 21 workers have explored the area of patient education and i t s r e l a t i o n s h i p to r e h a b i l i t a t i o n . Patient Education From the l i t e r a t u r e , two types of patient education were defined and investigated: structured and unstructured. Structured patient education tended to be defined as an organized and sequential d e l i v e r y of information. Numerous approaches have been discussed i n the l i t e r a t u r e . The programs were directed by behavioural objectives and imparted to the i n d i v i d u a l , family, or group. The purpose of the program was to induce health enhancing behaviours to achieve optimal health following 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 about a therapeutic regimen. Content of a structured program f o r myocardial i n f a r c t i o n p a tients addressed anatomy and physiology of the heart, the healing process, drug therapy, emotional f a c t o r s , and r i s k factors such as d i e t , obesity, a c t i v i t y , smoking, and s t r e s s . Teaching format consisted of lec t u r e s , discussions, s l i d e s , audiotapes, videotapes, and/or films and was supplemented with manuals or pamphlets for home use. Instructors were l i m i t e d to one nurse or a selected group of health care workers with s p e c i a l i z e d educational t r a i n i n g who provided some form of i n d i v i d u a l discussion and follow-up a f t e r presentation of content ( B i l l e , 1977; Bracken, Bracken, & Landry, 1977; Linde & Janz, 1979; Milazzo, 1980; S c a l z i et a l . , 1980; Sivarajan et a l . , 1983). 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 al. 1980; Bille, 1977). Patient education was part of a routine nursing assignment, performed at the nurse's convenience, and eliminated if 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 al., 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 that subjects had greater knowledge l e v e l s about t h e i r i l l n e s s following structured education than unstructured education. Milazzo did not r e l a t e knowledge scores to compliance. i n a s i m i l a r study, B i l l e (1977) found that knowledge l e v e l s of i n d i v i d u a l s with myocardial i n f a r c t i o n s were s i m i l a r with or without the use of a structured teaching format. He also reported that compliance with a therapeutic regimen prescribed by the physician was not s i g n i f i c a n t l y r e l a t e d to knowledge lev e l s or to the educational format. B i l l e used an i n t e r e s t i n g compliance questionnaire to determine the physician's recommendation, compliance rate, and d i f f i c u l t i e s associated with noncompliance; however, he did not break the recommendations into f i n e r categories, reported only group mean compliance rates, and did not discuss d i f f i c u l t i e s encountered by noncompliant i n d i v i d u a l s . In t h i s study, no attempts were made to validate subjects' perceptions of t h e i r i n s t r u c t i o n s with the physician and the investigator did not p a r t i c i p a t e i n educational sessions. In a s i m i l a r study of i n d i v i d u a l s with myocardial i n f a r c t i o n s that covered a two year time span, S c a l z i et a l . (1980) also found i n s i g n i f i c a n t differences between knowledge levels and structured and unstructured teaching methods, and a t t r i b u t e d negative f i n d i n g s to l i m i t e d knowledge retention of the subjects during h o s p i t a l i z a t i o n . However, subjects who received structured education demonstrated better compliance with medication 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 differences were not obtained for dietary recommendations. Subjects who received structured education co n s i s t e n t l y had higher compliance scores with a l l three recommendations; however, the lev e l s tended to decline by three months post discharge. The investigators suggested that be t t e r compliance i n the structured teaching group was the r e s u l t of continued i n s t r u c t i o n during follow-up v i s i t s by the researcher. S c a l z i et a l . found that the d i s t r i b u t i o n of printed material f o r home use provided convenient reference material a f t e r discharge. Sivarajan et a l . (1983) concluded that a structured education program on r i s k factors i n s t i t u t e d a f t e r discharge from h o s p i t a l demonstrated l i m i t e d effectiveness on behavioural changes with dietary recommendations following a myocardial i n f a r c t i o n . However, a l l subjects had p a r t i c i p a t e d i n education programs during h o s p i t a l i z a t i o n that varied from information provided i n booklets and cassettes to d e t a i l e d teaching sessions with pre and post t e s t i n g . The inve s t i g a t o r s made no attempt to compare the type of teaching during h o s p i t a l i z a t i o n to study r e s u l t s obtained from the c o n t r o l and experimental groups. They measured behavioural changes from p r e h o s p i t a l i z a t i o n to postdischarge without considering whether or not the subjects were s p e c i f i c a l l y i n s t r u c t e d by health care workers to change p a r t i c u l a r behaviours. Similar studies using coronary artery bypass subjects were reviewed because of the semblance of the therapeutic regimen. Barbarowicz et a l . (1980) found that knowledge scores were twice as 25 great for subjects who received structured education (p_<.001) and remained s i g n i f i c a n t l y higher f o r three months when compared to scores of subjects who received unstructured education. When knowledge scores were r e l a t e d to health enhancing behaviours, there were no s i g n i f i c a n t differences between the groups. Linde and Janz (1979) reported s i m i l a r findings for knowledge l e v e l s but also found that structured education enhanced compliance. Li m i t i n g e f f e c t s of the study were that no control group was used and compliance rates were compared to 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. One problem encountered by the researchers was the d i f f i c u l t y i n assessing whether the higher compliance rates were a r e s u l t of the structured education program and/or the continuity of care provided by the i n v e s t i g a t o r s . Other researchers have reported p o s i t i v e associations between structured patient education and compliance for patients with noncardiovascular disorders. Bowen et a l . (1961) studied patients with diabetes m e l l i t u s and discovered that patients who received structured education demonstrated a s i g n i f i c a n t l y greater gain i n knowledge about t h e i r disease and increased s k i l l performance with t h e i r treatment than patients who received unstructured patient education. Hecht (1974) randomly divided patients with a diagnosis of tuberculosis i n t o four groups. The experimental groups received staggered l e v e l s of structured education and the con t r o l group 26 rece ived no s p e c i a l t eaching . Results showed that pa t ient s i n the experimental group made fewer drug errors than those pa t ient s i n the c o n t r o l group. Compliance was measured by p i l l count where ser ious er ror s were reduced from 53% i n the c o n t r o l group to 17% i n the group that rece ived the most in tens ive t each ing . From the l i t e r a t u r e review on pa t ient educat ion, evidence suggested that s t ruc tured pa t i en t education r e s u l t e d i n higher knowledge l e v e l s about cardiac i l l n e s s than unstructured teaching methods (Barbarowicz et a l . , 1980; Linde & Janz, 1979; M i l a z z o , 1980). C o n f l i c t i n g r e s u l t s were reported for the e f f i cacy of s t ructured pa t i en t education on compliance. Some s tudies found p o s i t i v e r e l a t i o n s h i p s (Linde & Janz, 1979; S c a l z i et a l . , 1980; Bowen et a l . , 1961), whereas other s tudies found no r e l a t i o n s h i p s (Barbarowicz et a l . , 1980; B i l l e , 1977; S ivara jan et a l . , 1983). The l i t e r a t u r e suggests that increased hea l th knowledge was f requent ly i n s u f f i c i e n t i n enhancing compliance with health care recommendations but was shown to be an i n f l u e n t i a l f ac tor i n increa s ing readiness to undertake recommended hea l th behaviours (Barbarowicz et a l . , 1980; Hogue, 1979; M i l a z z o , 1980). Further documentation of the e f f i c acy of s t ructured pa t i en t education i n reaching p o s i t i v e treatment outcomes i s required (Lee & Garvey, 1977). I t was i n t e r e s t i n g to note that from the research on pa t i en t educat ion, severa l s tudies neglected to mention the i n c l u s i o n of the s i g n i f i c a n t other i n educat ional sessions ( B i l l e , 1977; Bowen et a l . , 1961; Milazzo, 1980). Other studies encouraged the s i g n i f i c a n t other to attend educational sessions; however, p a r t i c i p a t i o n or attendance was not enforced (Barbarowicz et a l . , 1980; Bracken et a l . , 1977; Linde & Janz, 1979; S c a l z i et a l . , 1980; Sivarajan et a l . , 1983). Influence of the S i g n i f i c a n t Other Several researchers have suggested that the l i m i t e d knowledge of a s i g n i f i c a n t other about the therapeutic regimen was a pertinent f a c t o r 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 to comply with the regimen (Crawshaw, 1974; Royle, 1973; Rudy, 1980; Segev & Schlesinger, 1983). Few studies have examined the e f f e c t of the s i g n i f i c a n t others l e v e l of knowledge on the health-related behaviours of t h e i r partner. Tyzenhouse (1973) interviewed male subjects with myocardial 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 that wives with the most knowledge did not have husbands who showed a corresponding improvement i n health. None of the wives stated that she influenced the a c t i v i t i e s of her husband. Tyzenhouse concluded that a wife needs to understand the therapeutic regimen and i t s importance but may serve the husband's recovery best through supportive rather than d i r e c t i v e a c t i v i t i e s . Tyzenhouse estimated knowledge and health improvement and did not r e l a t e her findings to any type of patient education. 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 al. (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 al. 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 al. 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 in 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 its 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 if provided with knowledge about the therapeutic regimen (Adsett & Bruhn, 1968; Becker & Green, 1975; Mayou et al. 1978). Significant others were physically and psychologically healthier than their partners (Ruskin et al., 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 others are included i n patient education. 32 CHAPTER 3 Methodology Descr ipt ions of the research des ign, s e t t i n g and sample begin t h i s chapter, fol lowed by a d e s c r i p t i o n of the education program i n progress at the h o s p i t a l under study. This lays the groundwork to descr ibe the manipulation of the independent v a r i a b l e s . The data c o l l e c t i o n instrument i s then descr ibed as we l l as the development and admini s t ra t ion of the instrument. A d e s c r i p t i o n of e t h i c a l cons iderat ions concludes t h i s chapter . 5 Research Design Th i s study employed an explanatory experimental design to accept or r e j e c t the s tated hypotheses. Explanatory designs are used to p r e d i c t and expla in the i n t e r a c t i o n of va r i ab le s when s u f f i c i e n t data about the var i ab le s are known. The i n t e r a c t i o n of the var i ab le s must be guided by a conceptual or t h e o r e t i c a l framework. Explanatory designs provide s t r a teg ie s for examining evidence to accept or r e j e c t hypotheses (Brink & Wood, 1978). Experimental designs are used when the inves t i ga tor has c o n t r o l of subject assignment to d i f f e ren t experimental condi t ions and can manipulate the independent v a r i a b l e s . Use of c o n t r o l groups can l i m i t the in ter ference of other v a r i a b l e s . By random assignment of subjects to e i t h e r a c o n t r o l or experimental group, two equivalent groups at the s t a r t of the study are p o s s i b l e . By 33 sub ject ing one of the groups to the experimental v a r i a b l e , i t i s p o s s i b l e to a t t r i b u t e changes that occur i n the experimental group and not i n the c o n t r o l group to the e f fec t of the independent v a r i a b l e (Brink & Wood, 1978). Previous study f indings presented i n the second chapter, descr ibed the p o t e n t i a l e f fec t s of the independent var iab le s of s t ructured pa t i en t education and the s i g n i f i c a n t other on the dependent var i ab le of compliance with hea l th care recommendations. The s e l e c t i o n of independent var i ab le s was guided by a combination of Orem's model for nurs ing , Dubos' theory of adaptat ion, and Bandura's s o c i a l l earn ing theory. Extraneous va r i ab le s such as age, occupation, education and previous myocardial i n f a r c t i o n s could not be f u l l y c o n t r o l l e d w i t h i n the confines of t h i s study even though random assignment was » used as a r e s u l t of the small sample s i z e . Demographic va r i ab le s w i l l be addressed i n Chapter 4. The S e t t i n g The s e t t i n g for t h i s study was one cardiac ward of a large metropol i tan teaching h o s p i t a l . The h o s p i t a l served i n d i v i d u a l s who res ided or worked i n the downtown core or surrounding areas. The h o s p i t a l provided h ighly s k i l l e d s t a f f and modern equipment to perform cardiac monitor ing , a wide range of d iagnost ic t e s t s , pacemaker i n s e r t i o n s , and open-heart surgery for i n d i v i d u a l s who experienced cardiac compl icat ions . The h o s p i t a l was a major 34 r e f e r r a l centre for cardiac patients from smaller, regional i n s t i t u t i o n s . Individuals with suspected myocardial i n f a r c t i o n s were ro u t i n e l y admitted to the coronary care unit where electrocardiograms and serum enzyme tes t s were performed to confirm the diagnosis. Approximately 250 i n d i v i d u a l s with confirmed myocardial i n f a r c t i o n s were entered into the census of the coronary care unit over the preceding years. When t h e i r condition became more stable, i n d i v i d u a l s were tran s f e r r e d to private or semi-private rooms on a 35-bed cardiac ward u n t i l discharged by the attending c a r d i o l o g i s t . Individuals with cardiac problems other than myocardial i n f a r c t i o n , as well as pre and postopen heart s u r g i c a l patients, were admitted to the cardiac ward. Sample Se l e c t i o n The target population for t h i s study included male patients between the ages of 30 and 70, with s i g n i f i c a n t others, who sustained a myocardial i n f a r c t i o n and were admitted to the cardiac ward of one h o s p i t a l during the time period for patient s e l e c t i o n i n t o the study. The time period was from January 1, 1983 to February 29, 1984. Although the h o s p i t a l admitted large numbers of confirmed myocardial i n f a r c t i o n s during the time frame of the study, the hospital's census was down and few i n d i v i d u a l s met the c r i t e r i a established f o r t h i s study. The researcher a n t i c i p a t e d obtaining a sample of 15 pat i e n t s ; however, lack of subjects meeting s p e c i f i e d c r i t e r i a resulted i n a sample of 12 pati 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 planned, eight c r i t e r i a were established for patient s e l e c t i o n into the study. C r i t e r i a for study i n c l u s i o n were: 1. The patient was male between the ages of 30 and 70. 2. The patient had not suffered a previous myocardial i n f a r c t i o n within the l a s t f i v e years. 3. The patient was attended to by a c a r d i o l o g i s t . 4. The patient resided with a s i g n i f i c a n t other. 5. The patient was l i t e r a t e and spoke the English language. 6. The patient was oriented. 7. The patient resided within the Greater Vancouver area. 8. The patient was w i l l i n g to p a r t i c i p a t e i n the study. Rationale f o r C r i t e r i a . A v a r i e t y of reasons prompted the investi g a t o r to se l e c t s p e c i f i c c r i t e r i a for study i n c l u s i o n . Male subjects were selected because the l i t e r a t u r e suggested that more men that women experienced myocardial i n f a r c t i o n s (Barbarowicz et a l . , 1976; Mc D i l l , 1975). Studies i n v e s t i g a t i n g both sexes with myocardial i n f a r c t i o n s supported the above f i n d i n g s . Sivarajan et a l . (1983) studied 219 men and 39 women. Rahe et a l . (1975) had a study sample of 19 men and 5 women. Bracken et a l . (1977) investigated a sample group of 31 patients with 74.2% being men. R e s t r i c t i n g the target population to males c o n t r o l l e d f o r the inf l u e n c i n g factor of sex, and p o t e n t i a l 36 benefits derived from the study might be generalized to the larger group of patients with myocardial i n f a r c t i o n s . The primary reason for age l i m i t a t i o n s was the in v e s t i g a t o r ' s i n t e r e s t i n studying men who were currently employed or recently r e t i r e d . The inve s t i g a t o r assumed that a myocardial i n f a r c t i o n would have a major impact on men and t h e i r s i g n i f i c a n t others within the s p e c i f i e d age group. Lack of subjects meeting the selected c r i t e r i a resulted i n an increase of the age l i m i t to 80 years midway through the study. Only one subject met the r e v i s e d c r i t e r i a . Patients experiencing a f i r s t myocardial i n f a r c t i o n were, selected to control for the variable of knowledge. Patients who had suffered a myocardial i n f a r c t i o n more than f i v e years ago were included i n the study as t h e i r r e c a l l of information and the p a t i e n t education program i f applicable, was probably l i m i t e d . This p a r t i c u l a r c r i t e r i o n eliminated numerous subjects from po s s i b l e study i n c l u s i o n . A large number of patients admitted to the cardiac ward were experiencing second and t h i r d myocardial i n f a r c t i o n s within a shorter time span than f i v e years which further 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 patient education to enhance compliance, prevent reoccurrence, and reduce mortality f i g u r e s . Subjects required an attending c a r d i o l o g i s t who was deemed an expert at diagnosing and t r e a t i n g myocardial i n f a r c t i o n s . A l l c a r d i o l o g i s t s on s t a f f at the h o s p i t a l supported patient p a r t i c i p a t i o n i n the education program and wrote discharge i n s t r u c t i o n s as previously described for the patients to take home. The documented health care recommendations were used as a reference by the i n v e s t i g a t o r for providing f a c t u a l data. The subjects required a s i g n i f i c a n t other. From the l i t e r a t u r e review, the s i g n i f i c a n t other appeared to have the most e f f e c t on the recovery process and the patient's compliance with health care recommendations. Only the s i g n i f i c a n t others of subjects who were to p a r t i c i p a t e i n the educational session were approached by the i n v e s t i g a t o r for consent to p a r t i c i p a t e i n the study. Subjects were required to be l i t e r a t e , oriented, and speak the English language i n order to p a r t i c i p a t e i n the audiovisual patient education program, to r e f e r to the patient manual, and to communicate with the i n v e s t i g a t o r . Geographical r e s t r i c t i o n s were necessary to permit follow-up v i s i t s i n the subjects' homes. Patient Education Program The program i n progress at the h o s p i t a l consisted of seven slide-tapes and a take-home patient manual. The tapes and manual were 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 a t t a c k ) " . The slide-tapes imparted information to the patients about anatomy and physiology of the heart as r e l a t e d to coronary 38 artery disease, angina and myocardial i n f a r c t i o n s , r i s k f a c t ors 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 treatment, such as the ingestion of medication. Because the outcome of the study measured compliance with dietary, a c t i v i t y , and medication health care recommendations, and because knowledge of the anatomy and physiology of the heart was e s s e n t i a l for preparing the patient to understand the recommendations, discussion i n the structured education sessions and follow-up interviews was l i m i t e d to these four tapes. The duration of each tape was 20 to 25 minutes. Content of the f i r s t tape included an explanation of the anatomy and physiology of the heart, defined a myocardial i n f a r c t i o n , described the healing process of the heart a f t e r a myocardial i n f a r c t i o n , described the cause of myocardial i n f a r c t i o n s i n the terms of coronary artery disease, and introduced the r i s k factors associated with heart disease. The topi c of the second tape was p h y s i c a l a c t i v i t y and content consisted of the r a t i o n a l e and d i r e c t i o n s for a gradual resumption of a c t i v i t i e s . Information concerning a c t i v i t i e s to do and not to do during the f i r s t three weeks at home were l i s t e d . Restricted a c t i v i t i e s such as sexual intercourse, d r i v i n g a car, returning to a job, hobbies, and sports were addressed. Chest pains associated with exertion were also described with accompanying d i r e c t i o n s f or treatment. The intended message of the tape was to l i m i t p h y s i c a l a c t i v i t i e s during recovery with a gradual return to a s i m i l a r 39 or better p h y s i c a l c a p a b i l i t y than experienced by the i n d i v i d u a l p r i o r to the myocardial i n f a r c t i o n . The t h i r d tape introduced the patient to proper dietary h a b i t s . Diets 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 discussed. Foods to eat and foods to avoid were l i s t e d for each d i e t as well as general t i p s to a s s i s t the patient to follow each d i e t . The tape stressed moderation for p a r t i c u l a r food consumption rather than t o t a l elimination. The t o p i c of the fourth tape was medication. No s p e c i f i c drugs were described, however, the tape discussed general t i p s about the "do's" and "don'ts" of medication ingestion. The tape in s t r u c t e d the patient to question the name, purpose, method, frequency, dosage, and side e f f e c t s for each medication prescribed. A manual for home use was given to each patient. Content included the pertinent f a c t s from the tapes and l i s t s of dietary and a c t i v i t y r e s t r i c t i o n s . Program Delivery on the Cardiac Ward. Within the time parameters of t h i s study, two methods of program del i v e r y were implemented by nursing s t a f f . The delivery of the program by nursing s t a f f was defined for the purpose of t h i s study, as unstructured education by the in v e s t i g a t o r . The usual method was i n d i v i d u a l d e l i v e r y ; however, a group del i v e r y method was put i n t o p r a c t i c e for two months midway through the study. The methods of program del i v e r y and the deli v e r y variables are shown i n Table One. 4 0 Table 1 Summary of Two Methods of Program Delivery on Cardiac Ward Delivery Methods  Program Variables Individual Group Content Manuals S i g n i f i c a n t other S t a f f involvement Discussion Learning Objectives Location Time of day Frequency Sequenced Add i t i o n a l learning sources Physician's written regimen 1-7 tapes given i f present more than 1 nurse possibly none h o s p i t a l room usually day s h i f t 1-7 tapes shown over several days or a l l at once possibly possibly d i e t i t i a n and medication cards at discharge 7 tapes given i n v i t e d nursing assistant more than 1 nurse possibly none patients' lounge afternoon and evening 1-2 per day sequenced from Monday to Friday possibly d i e t i t i a n and medication cards at discharge 41 Several problems were i d e n t i f i e d with both methods from observat ion and comments from s t a f f and pa t ient s who were involved with the unstructured teaching methods. Problems encountered with 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 shortages and more than one nurse be ing respons ib le for the program. The presentat ion of the tapes usua l ly occurred at the convenience of the nurse, r e s u l t i n g i n the p a t i e n t viewing a l l of the tapes during one sess ion, more often than not. The tapes were u sua l ly shown during the day s h i f t when more nurs ing s t a f f were present ; however, the s i g n i f i c a n t others were frequently absent. The tapes were u sua l ly out of sequence and i n d i v i d u a l d i scuss ions were ra re . Problems encountered with the group method were poor attendance as a r e s u l t of d i s i n t e r e s t or c o n f l i c t with te s t s and v i s i t o r s , discharge before the e n t i r e program was presented, and lack of sequence to tapes i f t r ans fe r to the cardiac ward occurred midweek. Pat ient s complained that s t a f f seldom a r r i v e d to turn on the equipment and that d i scuss ions with the nurse fo l lowing the tapes were r a re . P r i o r to discharge, pa t i ent s rece ived medication cards de sc r ib ing each of t h e i r prescr ibed drugs. Content of the cards inc luded the name, the purpose, t i p s for inge s t ion , and side e f f e c t s . Some pat ient s rece ived the cards , some pat ient s rece ived the cards with a d i scus s ion with the nurse, and some pat ient s d id not rece ive the cards . Patients with dietary r e s t r i c t i o n s received a v i s i t from the d i e t i t i a n p r i o r to discharge. The d i e t i t i a n d i s t r i b u t e d l i s t s of "do's" and "don'ts" for each diet prescribed. If time permitted, the d i e t i t i o n discussed the diets with patients and s i g n i f i c a n t others, i f the s i g n i f i c a n t others were present during the v i s i t . If the d i e t i t i o n was busy, the patient was handed the l i s t s of foods for each d i e t . If the l a t t e r s i t u a t i o n occurred and the physician had prescribed more than one d i e t for the i n d i v i d u a l , the patient was responsible for eliminating c o n f l i c t i n g foods that occurred between dietary overlaps. At discharge, the patients were given a standard form by the c a r d i o l o g i s t which l i s t e d the dietary r e s t r i c t i o n s , a c t i v i t y r e s t r i c t i o n s with dates s p e c i f y i n g when to resume a c t i v i t i e s , a l i s t of medications, and recommended times for follow-up appointments with the physician. The c a r d i o l o g i s t attempted to discuss the form with both the patient and s i g n i f i c a n t other. Although the content and format of the program met the c r i t e r i a for structured education, the unorganized and random de l i v e r y of the program constituted unstructured education. The end r e s u l t was that some patients received the t o t a l program whereas other patients received parts or none of the services o f f e r e d by the h o s p i t a l . 43 Treatment Variables to be manipulated were the method of patient education and the involvement of the s i g n i f i c a n t other to determine t h e i r e f f e c t s on compliance rates. Patients who met the sample c r i t e r i a were randomly assigned to one of three groups. P r i o r to the i n i t i a t i o n of the study, twenty subject numbers were drawn from a hat and repeatedly assigned sequentially to the control group (1), the f i r s t experimental group (2), or to the second experimental group (3) u n t i l the subject numbers were eliminated. In other words, the f i r s t subject number drawn was assigned to group 1, the second to group 2, the t h i r d to group 3, the fourth to group 1, and so f o r t h . Twenty subject numbers were drawn to cover possible a t t r i t i o n from the sample. Within the groups, the i n v e s t i g a t o r introduced the following v a r i a b l e s : 1. The c o n t r o l group received unstructured patient education as p r a c t i c e d by the nursing s t a f f on the cardiac ward and described i n the preceding section. The patient and possibly the s i g n i f i c a n t other may have seen the slide-tape presentation, may have received discussions by nursing s t a f f , may have discussed the prescribed d i e t with the d i e t i t i a n , may have received the medication cards, may have received the manual, and may have watched the tapes on one day or over several days. 2. In the f i r s t experimental group, patients received structured education from the i n v e s t i g a t o r . A l l subjects, without 44 t h e i r s i g n i f i c a n t others i n attendance, viewed four s l ide- tape pre senta t ions . The inves t i ga tor may have been present for the f i r s t tape and was d e f i n i t e l y present for the second, t h i r d and four th tapes. The sequence of tapes was anatomy and physiology of the hear t , p h y s i c a l a c t i v i t y , d i e t , and medicat ion. Fol lowing each tape, the conte'nt and i t s r e l a t i o n s h i p to l i f e s t y l e were discussed with the inve s t i ga to r guiding the d i scuss ion from s t ruc tured teaching ob ject ives (see Appendix A ) . The pa t i ent manual was given to each subject p r i o r to the f i r s t tape and was re fe r red t o , by both subject and i n v e s t i g a t o r , a f ter each tape. Program times were arranged with the pa t i en t at h i s convenience, with the program being shown i n the pr ivacy of the p a t i e n t ' s room. The door to the room was c losed to reduce d i s t r a c t i o n s . A maximum of two tapes were viewed each day as d i c t a t ed by the p a t i e n t ' s c o n d i t i o n . The primary purpose for l i m i t i n g the tapes to one or two per day was to prevent the pa t i ent from becoming o v e r t i r e d and c louding hi s a b i l i t y to l e a r n . 3. , The second experimental group cons i s ted of the pa t i ent and h i s s i g n i f i c a n t o ther . The couple rece ived s t ructured education from the i n v e s t i g a t o r and the inve s t i ga to r was present for a l l four tapes . The treatment was i d e n t i c a l to that of group 2, with the only d i f ference being 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 other . L imi ta t ions were as soc ia ted with the t iming of the s t ructured p a t i e n t education program. The program was conducted p r i o r to discharge with f i n a l discharge i n s t r u c t i o n s being unknown. As a 45 r e s u l t , a l l diets were discussed as per learning objectives (see Appendix A), with a p a r t i c u l a r emphasis on the diet that the patient was being served during h o s p i t a l i z a t i o n . Current medications were discussed with r e l a t i o n to name and purpose of the drug. Patients were encouraged to question the physician or nurse about prescribed medication and to ask for medication cards on the day of discharge. Patients i n the experimental groups a l s o received v i s i t s from the d i e t i t i a n i f required and a discussion with the c a r d i o l o g i s t p r i o r to discharge as described for the co n t r o l group. This explanatory experimental study was designed to measure compliance rates of patients i n the control group (group 1) who received unstructured patient education, patients i n group 2 who received structured patient education, and patients i n group 3 who received structured patient education with t h e i r s i g n i f i c a n t other, to determine the e f f e c t s of patient education methods and the e f f e c t s of the s i g n i f i c a n t other on compliance. Data C o l l e c t i o n Instrument An interview schedule was chosen for t h i s explanatory experimental study. P o l i t and Hungler (1978) recommended interviews to obtain s e l f - r e p o r t information from subjects i n face-to-face s i t u a t i o n s f o r the research design used i n t h i s study. 46 The interview schedule contained some closed-ended questions which permitted subjects 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 questions to permit the respondents to reply to questions i n t h e i r own words. The closed-ended questions measured the dependent variable of compliance rates and the open-ended questions encouraged the subjects to i d e n t i f y health care recommendations and to i d e n t i f y problems encountered and leading to noncompliance with the recommendations. Development of the Data C o l l e c t i o n Instrument. The dependent v a r i a b l e to be measured was defined as compliance rates with a c t i v i t y , dietary, and medication health care recommendations. Therefore, three general content areas of a c t i v i t y , d i e t , and medication were developed to measure the dependent v a r i a b l e . S p e c i f i c content of each general content area was derived from the slide-tape presentations used i n the education program. The data c o l l e c t i o n instrument i s presented i n Appendix C. As previously discussed, the tape on a c t i v i t y suggested l i m i t i n g p h y s i c a l a c t i v i t i e s f o r s t a i r climbing, walking outdoors, l i f t i n g objects, sexual a c t i v i t y , return to work, hobbies or sports, t r a v e l l i n g , and d r i v i n g a car. The a c t i v i t y recommendations from the tapes also corresponded to a c t i v i t y categories on the discharge i n s t r u c t i o n form given to the patient by the c a r d i o l o g i s t . The dependent v a r i a b l e was measured by a multiple choice question with an o r d i n a l scale. Subjects were asked i f they 47 followed the a c t i v i t y recommendations a l l of the time, half the time, some of the time, or never. Numerical values were assigned to each answer choice. Since the desired behaviour was a l l of the time, t h i s answer merited three points, the maximum points achievable. None of the time merited zero points. The use of t h i s s c a le a s s i s t e d the inve s t i g a t o r to provide numerical data about compliance rates. Two "other" categories i n the s p e c i f i c content area were included i n the event that the physician prescribed a d d i t i o n a l l i m i t a t i o n s other than those defined. The closed-ended question using o r d i n a l s c a l i n g permitted the summation of t o t a l compliance scores and comparison of the scores among subjects and groups using a percentage a n a l y s i s . The slide-tape on diet suggested foods to eat and avoid on d i e t s 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 to s a l t free diets and reducing alcohol consumption. Compliance rates were measured using the same format as described for a c t i v i t y recommendations with the best response being a l l of the time and being awarded three points. Two "other" categories were included i n the event that the physician prescribed a d d i t i o n a l dietary l i m i t a t i o n s other than those defined. The slide-tape on medication did not r e f e r to s p e c i f i c drugs except for n i t r o g l y c e r i n . The tape encouraged patients to question health care workers about the name, purpose, method, frequency, dosage, and side e f f e c t s f o r each medication prescribed. Commonly prescribed drugs such as n i t r o g l y c e r i n , digoxin, furosemide, and 48 potassium ch lor ide were incorporated in to categories with f i v e "o ther " categories a l l o c a t e d to cover a d d i t i o n a l prescr ibed medicat ions . Subjects were asked to estimate i f they had been able to fo l low d i r e c t i o n s for each of the medications prescr ibed and responses were measured us ing the same format as descr ibed for a c t i v i t y recommendations. The best response of a l l of the time was awarded three p o i n t s . In order to measure compliance ra tes , subjects were asked open-ended questions to i d e n t i f y hea l th care recommendations. A c t i v i t y recommendations were determined by asking the subject i f the doctor had suggested l i m i t i n g a c t i v i t i e s i n any way. Die tary recommendations were i d e n t i f i e d by asking the subject i f the doctor had suggested r e s t r i c t i n g the d ie t i n any way. Medicat ion recommendations were determined by asking the subject i f the doctor ordered any medication to take at home. In order to obtain data about causes for noncompliance, subjects were asked i f any d i f f i c u l t i e s were encountered with f o l l o w i n g the doc tor ' s recommendations and to describe the d i f f i c u l t y . The open-ended quest ion was asked for each a c t i v i t y , d i e t , and medication p r e s c r i b e d . In a d d i t i o n , subjects were asked demographic data r e l a t e d to m a r i t a l s ta tus , occupat ion, educat ion, and prevous myocardial i n f a r c t i o n (see Appendix D ) . B i l l e (1977) used a s i m i l a r instrument to assess pa t i en t compliance i n h i s study. Although he was able to draw conclus ions 49 from assessments using the scale, no information was offered 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 Guide. Content v a l i d i t y was accepted for the education program produced by the American Heart Association and t i t l e d , "An active partnership f o r the health of your heart (after your heart attack)". The f i r s t d r a f t of the interview guide was c r i t i c a l l y discussed with experts i n the areas of research and cardiovascular disorders r e s u l t i n g i n minor changes being made to the guide. The instrument was pre-tested on one i n d i v i d u a l who received unstructured teaching with compliance being measured at one and three months following discharge from h o s p i t a l . These checks supported the b e l i e f that the interview guide had content v a l i d i t y and was i n a form that permitted responses from the subject. Administration of Data C o l l e c t i o n Instrument. The instrument was used for two interviews i n the subjects' homes at one and at three to four months postdischarge (see Table 2). The instrument was completed by the invest i g a t o r as directed by the subjects being interviewed. A l l responses were b r i e f and were noted on the instrument. The subject was the focus of the interview. If the s i g n i f i c a n t other was present, questions were directed to the subject and, i f applicable, the subject would ask the s i g n i f i c a n t other to respond. One week p r i o r to the scheduled interview time, the inve s t i g a t o r telephoned the subject to arrange a convenient hour 50 Table 2 Number of Days between Discharge and Interviews Number of Days Subject F i r s t Interview Second Interview 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 for the interview. Holidays, appointments, previous commitments, and deaths within the family created discrepancies i n the timing of the interviews. General conversation between the investigator and subject and the s i g n i f i c a n t other, i f present, preceded data c o l l e c t i o n . The i n v e s t i g a t o r always inquired about the general condition of the subject and the general value of the patient education program. At the f i r s t interview, demographic data was obtained from the subject. The subject was asked to show the physician's 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 a l l subjects complied with t h i s request. Subjects were reminded that a l l information would be 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 the purpose of t h i s study was reintroduced. The interview followed the sequence as outlined by the data c o l l e c t i o n instrument. Questions were asked about a c t i v i t y , d i e t and medication. A f t e r the health care recommendations were i d e n t i f i e d , the i n v e s t i g a t o r prompted a discussion concerning the content of each slide-tape and patient manual with regard to the p a r t i c u l a r health care recommendation. The purpose of the discussion was to remind the subject about content from the patient education program. Following the discussion, the i n v e s t i g a t o r asked the closed-ended question concerning compliance with each subject choosing a response that best suited t h e i r compliance rate. The subject was then asked i f any d i f f i c u l t i e s were encountered with following the recommendation and to describe the d i f f i c u l t i e s . Each health care recommendation was pursued i n t h i s manner u n t i l data was c o l l e c t e d for each general content area. During the second interview, reference was made to health care recommendations i d e n t i f i e d during the f i r s t interview. The subject was asked i f the recommendations continued to be reinforced by the physician, i f the recommendations had changed, or i f new recommendations were prescribed. E t h i c s and Human Rights Following acceptance of the research proposal by the Unive r s i t y of B r i t i s h Columbia screening committee for research and other studies in v o l v i n g human subjects and by the research committee of the i n s t i t u t i o n where the study was to be conducted, the inve s t i g a t o r approached the head nurses of the coronary care u n i t and cardiac ward. The inv e s t i g a t o r was permitted access to the kardex and charting system to locate p o t e n t i a l subjects with myocardial i n f a r c t i o n s meeting s p e c i f i c c r i t e r i a , and to obtain pertinent data about the subjects under study. Subjects were approached by the invest i g a t o r one to three days post tran s f e r from the coronary care unit, with the assumption that the patient was i n a stable condition. Following an introduction by the invest i g a t o r and a statement of the general purpose of the v i s i t , subjects were given an introductory l e t t e r explaining the purpose and a c t i v i t y of the study (see Appendices E, F, G). 53 Subjects were given f i f t e e n minutes to read the l e t t e r without the in v e s t i g a t o r i n attendance. Subjects who agreed to p a r t i c i p a t e were asked to read and sign a consent form (see Appendix H). Written consent was received from subjects i n groups 1 and 2. Written consent was obtained from subjects and t h e i r s i g n i f i c a n t others i n group 3. A t o t a l of three subjects refused to p a r t i c i p a t e i n the study. A consent form was also signed by the attending c a r d i o l o g i s t as part of the research protocol established by the 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 maintained by assigning each subject a number. The invest i g a t o r had access to name, address and telephone number of the subjects to permit two home v i s i t s . 54 CHAPTER 4 Presentation and Discussion of Findings The presentation and discussion of findings i s presented i n f i v e sections beginning with a d e s c r i p t i o n of sample c h a r a c t e r i s t i c s . Nonparametric s t a t i s t i c a l analyses of compliance scores w i l l be presented next, followed by general observations of the t o t a l sample and by general observations regarding the r o l e of the s i g n i f i c a n t others. A summary w i l l conclude the chapter. C h a r a c t e r i s t i c s of the Sample The sample consisted of 12 subjects who were randomly assigned to one of three methods of predischarge education — unstructured, structured, and structured with the s i g n i f i c a n t other present. Content of the patient education sessions included anatomy and physiology of the heart, suggestions for medication-taking, and methods for management of r i s k factors r e l a t e d to diet and p h y s i c a l a c t i v i t y . Sample c h a r a c t e r i s t i c s are presented on the basis of age, employment, education, and h i s t o r y of previous myocardial i n f a r c t i o n s (see Table 3). Random assignment to groups was done as the optimum way to equalize groups on c h a r a c t e r i s t i c s that might influence compliance, independent of whether or not subjects received structured teaching. Because of the small group s i z e , however, Table 3 suggests that groups were markedly unequal on the two demographic variables of age and employment. 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 al., 1980; Bracken et al., 1977; Scalzi et al., 1980). Similar studies using three-way-designs 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 al., 1983). All 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 al., 1980; Bille, 1977; Scalzi et al., 1980). Bracken et al. (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 C h a r a c t e r i s t i c s of the Sample Groups Group Subject Age Employment Education Previous I n f a r c t i o n 1 2 3 5 40 52 61 51 employed employed employed employed u n i v e r s i t y u n i v e r s i t y u n i v e r s i t y high school 2 2 2 2 6 8 11 12 67 r e t i r e d high school 1 70 r e t i r e d trade school 1 68 r e t i r e d college 0 74 r e t i r e d high school 0 4 7 9 10 56 employed high school 0 70 r e t i r e d high school 2 52 employed u n i v e r s i t y 0 36 employed u n i v e r s i t y 0 57 sample c h a r a c t e r i s t i c s are s i m i l a r to c h a r a c t e r i s t i c s from other studies (Barbarowicz et a l . , 1980; Bracken et a l . , 1977; S c a l z i et a l . , 1980). Three subjects i n the sample had myocardial i n f a r c t i o n s more than f i v e years p r i o r to the study. Two of these subjects were randomly assigned to group 2 and one was assigned to group 3. A l l other subjects were experiencing t h e i r f i r s t myocardial i n f a r c t i o n s at the time the study was conducted. Similar studies that investigated cardiac problems used subjects who were experiencing t h e i r f i r s t myocardial i n f a r c t i o n . Subjects with previous i n f a r c t i o n s were eliminated from sample s e l e c t i o n (Milazzo, 1980; S c a l z i et a l . , 1980; Sivarajan et a l . , 1983). Despite random a l l o c a t i o n , sample c h a r a c t e r i s t i c s of the three groups were unequal on the two demographic variables of age and employment which may have confounded findings of the study. Nonparametric S t a t i s t i c a l Analyses of Compliance Scores To assess group differences, compliance scores with health care 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 subjected to the Kruskal-Wallis rank-sum t e s t , a one-way an a l y s i s of variance t e s t , f or nonparametric data (Siegel, 1956; Wright, 1976). The l e v e l of s t a t i s t i c a l s i g n i f i c a n c e was set at p_<.05. A summary of values using the Kruskal-Wallis rank-sum t e s t with one-way analysis of variance on compliance scores i s presented i n Table 4. Compliance with ph y s i c a l a c t i v i t y , dietary, and medication recommendations during both interviews were not s t a t i s t i c a l l y s i g n i f i c a n t and the following hypotheses were rej e c t e d : 1. Myocardial i n f a r c t i o n patients receiving structured education with the s i g n i f i c a n t other w i l l have higher rates of compliance with health care recommendations than myocardial i n f a r c t i o n patients r e c e i v i n g structured education without t h e i r s i g n i f i c a n t other. 2. Myocardial i n f a r c t i o n patients receiving structured education with t h e i r s i g n i f i c a n t other w i l l have higher rates of compliance with health care recommendations than myocardial i n f a r c t i o n patients r e c e i v i n g unstructured education. 3. Myocardial i n f a r c t i o n patients receiving structured education w i l l have higher rates of compliance than myocardial i n f a r c t i o n patients r e c e i v i n g unstructured education. I n s i g n i f i c a n t findings from t h i s study are s i m i l a r to the r e s u l t s obtained from other studies that investigated patient education formats for myocardial i n f a r c t i o n patients and compliance with a therapeutic regimen ( B i l l e , 1977; S c a l z i et a l . , 1980; S i l v a r a j a n et a l . , 1983). Although S c a l z i et a l . (1980) reported s t a t i s t i c a l l y s i g n i f i c a n t differences (p_<.05) f o r knowledge and compliance with medication and p h y s i c a l a c t i v i t y recommendations, trends over time were not found to be s i g n i f i c a n t . 59 Table 4 Summary of H. Values for Compliance with Recommendations during two Interviews Recommendations Interview Schedule H Values Si g n i f i c a n c e A c t i v i t y 1 2.67 NS A c t i v i t y 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 to two decimal points. 60 The i n s i g n i f i c a n t findings of t h i s study need to be in t e r p r e t e d with caution because of the small sample size and between group dif f e r e n c e s . General Observations of the Sample Numerous observations were made of the t o t a l sample which suggested that compliance was r e l a t e d to i n d i v i d u a l differences. Raw data, number of recommendations, and compliance scores f o r p h y s i c a l a c t i v i t y recommendations during both interviews are presented i n Tables 5 and 6, data r e l a t e d to dietary recommendations are presented i n Tables 7 and 8, and data r e l a t e d to medication recommendations are presented i n Table 9. The v a r i a b i l i t y of compliance scores among i n d i v i d u a l s despite some form of patient education suggests that compliance was influenced by other f a c t o r s . These factors w i l l be discussed according to s e l f - c a r e a b i l i t i e s , s e l f - c a r e , and therapeutic demands as directed by the t h e o r e t i c a l frameworks chosen to guide t h i s study. S e l f - c a r e a b i l i t i e s . Bandura's (1977b) s o c i a l learning theory suggested that i n d i v i d u a l s were motivated to learn as a r e s u l t of t h e i r p h y s i o l o g i c a l state. Subjects i n t h i s study had a l t e r e d p h y s i o l o g i c a l states caused by the myocardial i n f a r c t i o n . Of the eight subjects who were approached to p a r t i c i p a t e i n structured p a t i e n t education, f i v e subjects were eager to learn about the disease and i t s treatment. One subject delayed discharge for a few hours u n t i l the l a s t tape had been presented. The other three Table 5 Raw Data, No. of Recommendations, and Scores for Compliance with Phys ica l A c t i v i t y Recommendations during f i r s t interv iew Recommendations Scores w 3 TS 0 1 CD 3 ft W W r i-9 O H c rt p- >-! 0 o- DJ i-h 01 c p- ft < < !-! p. (D 0 0) 3 P - 3 rt iQ >-3 to 0 0 if i - 1 CT rt DJ •x cr DJ 0 p- p- P - rt 3 CD p-0) > onal 1 1 - 2 3 3 2 2 2 6 14/18 58 1 2 - 2 - 2 0 1 1 5 6/15 40 1 3 - 3 - 3 2 2 1 5 11/15 73 1 5 — 3 — 3 3 3 3 5 15/15 100 2 6 3 3 3 3 _ 3 3 6 18/18 100 2 8 3 3 3 3 - 2 - 5 14/15 93 2 11 - 3 - 2 - 3 - 3 8/9 89 2 12 3 ~ 3 1 — 3 7/9 78 3 4 _ 3 3 3 3 _ 4 12/12 100 3 7 2 - 3 3 - 3 - 4 11/12 92 3 9 - 3 3 3 3 2 - 5 14/15 93 3 10 3 2 - - 3 3 3 3 6 17/18 94 NOTE: A l l recommendation scores have a denominator of 3. A=no. of a c t i v i t y recommendations. a percentage scores rounded to nearest whole number. Table 6 Raw Data, No. of Recommendations, and Scores for Compliance with Phys i ca l A c t i v i t y Recommendations during second interv iew Recommendations Scores 0) w r1 O S tc i-3 >-! c rt p- 3 0 0 *! 0 0) H i P - "0 1—1 cr rt DJ c P - rt < < 1—' QJ 0 xs CD P - CD 0 P - w. P - rt o tn 3 1—' 3 •< 3 (D iQ 3 CO > 0 C6 3 3 Cu 1 1 - 2 - 3 1 2 - 3 - 3 1 3 - 3 - 3 1 5 - 3 - 3 2 6 3 3 - 3 2 8 3 3 - 3 2 11 - 3 - 3 2 12 3 - - 3 3 4 - 3 - 3 3 7 3 - - 3 3 9 - 3 - 3 3 10 3 3 - 3 2 2 2 5 11/15 73 3 3 2 5 14/15 93 3 3 2 5 14/15 93 0 3 3 5 12/15 80 _ 3 3 5 15/15 100 - 2 - 4 1 1/12 92 - 3 - 3 9/9 100 — 1 3 7/9 78 3 3 4 12/12 100 - 2 - 3 8/9 89 2 3 - 4 1 1/12 92 3 3 3 6 18/18 100 NOTE: A l l recommendation scores have a denominator of 3. a c t i v i t y recommendations. a percentage scores rounded to nearest whole number. A=no. of Table 7 Raw Data, No. of Recommendations, and Scores for Compliance with Dietary Recommendations during f i r s t interview  Recommendations w c 0 cr a c c n <t> 0 n p-rt ng O 3" w 0 r > o 3^ OJ y-' 0 P - rt 0 H 1 CD K o 3" rt 0i rt to 0 (t> Ol n rt H i 3" p, rt H i CD CD . 0 p -t-! rt 0 (t> 0 \ 3 CD M 0) Scores 1 1 - 2 - 1 2 - 3 5/9 56 1 2 - 2 - 2 0 - 3 4/9 44 1 3 - 1 - 3 - - 2 4/6 67 1 5 3 — 3 3 — 3 9/9 100 2 6 _ _ _ 3 3 2 6/6 100 2 a - - 3 2 - - 2 5/6 83 2 11 - 3 - 3 3 3 4 12/12 100 2 12 * * 3 — — 2 2 5/6 83 3 4 3 3 3 2 _ 4 11/12 92 3 7 - 3 - 2 3 - 3 8/9 89 3 9 1 - - 2 - - 2 3/6 50 3 10 3 - - 2 3 - 3 8/9 89 NOTE: A l l recommendation scores have a denominator of 3. R=no. of dietary recommendations. a percentage scores rounded to nearest whole number. 64 v u c <0 •H rH a, e o o 0 to CD ^ o o to c <B tn c - -H 01 M c 3 0 tJ •P 01 rcj c T3 0 C •H CJ •P 10 05 T3 C 0 C 0 o V -rH ai 4-> 05 (0 0 T3 0 C 0 « | 0 0 z M o (0 CO •P <0 a) CO .p •H (0 Q CD Q r—1 X! A 3 •P lO <a •H E-i F r a c t i o n a l T o t a l R O t h e r A l c o h o l Low f a t / C h o l e s t e r o l S a l t f r e e Low sodium R e d u c i n g S u b j e c t Group •£> CM O O in o o CN 0> r- <Tt 10 \ \ \ \ m in cn ID ro <3" ro CN I I I I CN O I I i - « - ro ro l i l t CN CN ro I I CN ro ro T- CN ro in o ro O cn o o o ro O 00 O CO o o in 00 T— * — t — • ro ID 0> cn cn ID ID ro CD \ \ W W ro in cn co cn ID ro in <u e 0 c u 0 a> » - CN ro ro ro CN CN CN •P i-H (0 0 c jC 0 •p i i ro ro 1 1 1 1 c 01 CD T3 rj • (0 <0 ai ai c c i i 1 1 1 1 1 l 0 > -H o JJ 4J ,C rd TJ TS 0) C CD ro CN ro ro ro ro CN ro CD CD -0 u s a 0 § 3 0 o 0 CO o n CD l ro 1 1 1 1 1 1 a M 01 o 0) •H >i u -P U 0 (0 as o -a 4J 01 1 1 ro CN ro ro 1 1 c CO •H 0) T) cn g 10 0 -P o o c l l 1 | ro | « - CN CD • 0 0 u rH C CD r-l II ft < <X> CO T— CN * h 01 O T— w E-i O CN CN CN CM ro ro ro ro 2 Table 9 No. of Recommendations and Scores for Compliance with Medication Recommendations during f i r s t and second interviews CD o c Xi cn c V CD 0 rt >-3 0 rt OJ OJ O n-o 3 0) i-3 0 ri-ai 0) o r t 0 D OJ 1 1 5 14/15 93 5 14/15 93 1 2 4 10/12 83 4 11/12 92 1 3 3 9/9 100 2 6/6 100 1 5 5 13/15 87 3 9/9 100 2 6 4 12/12 100 3 9/9 100 2 8 3 9/9 100 2 6/6 100 2 11 5 15/15 100 5 15/15 100 2 12 6 18/18 100 7 21/21 100 3 4 2 6/6 100 2 6/6 100 3 7 3 9/9 100 4 12/12 100 3 9 3 9/9 100 3 9/9 100 3 10 3 9/9 100 3 9/9 100 NOTE: M=no. of medication recommendations. apercentage scores rounded to nearest whole number. 66 subjects were interested i n the program, however, an eagerness to p a r t i c i p a t e was not as evident. These observations suggest that patients are motivated to learn during t h e i r recovery on a cardiac ward following trans f e r from a coronary care unit. These findings also support Baden's (1972) recommendations that patient education on a cardiac ward i s an i d e a l time f or patient learning. Although patient education was provided to enhance s e l f - c a r e a b i l i t i e s , education 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 education as a factor that influences an i n d i v i d u a l s ' s a b i l i t y to engage i n s e l f - c a r e . When compliance scores with dietary recommendations during the f i r s t interview (see Table 7) were compared with the demographic variable of education, s i g n i f i c a n t differences were obtained (H_ = 5.95, df = 2, p_<.05). Scores were subjected to the Kruskal-Wallis rank-sum t e s t with one-way analysis of variance (Siegel, 1956). The findings suggest that subjects with high school education had higher dietary compliance scores than did subjects with college and u n i v e r s i t y preparation. Dubos (1965) i d e n t i f i e d education as a personal f a c t o r i n defining one's state of health and Bandura (1977b) also recognized education as a personal stimulus for learning. Perhaps these findings suggest that i n d i v i d u a l s with lower educational preparation have less experience with decision-making and comply with recommendations more r e a d i l y than do i n d i v i d u a l s with greater education. These findings are not supported by previous research. 67 Marston (1970) concluded from a review of the l i t e r a t u r e that education was not an i n f l u e n c i n g fac tor of compliance. These f ind ings suggest that more research should be conducted to determine i f education i s a s i g n i f i c a n t p r e d i c t o r of compliant behaviour. S e l f - c a r e . Orem (1980) def ined s e l f - c a r e as, "the p r a c t i c e of a c t i v i t i e s that i n d i v i d u a l s i n i t i a t e and perform on t h e i r own behalf i n maintaining l i f e , hea l th , and we l l -be ing " (p. 35). Both Orem and Dubos (1965) supported the not ion that i n d i v i d u a l s define t h e i r own heal th s t a te . Observations from t h i s study supported the idea that hea l th d e f i n i t i o n s vary among i n d i v i d u a l s . For example, one subject , as a r e s u l t of extraneous circumstances, was motivated by fear of death to a t t a i n a state of improved hea l th and tended to comply with hea l th care recommendations. Fear has been found to be a prime motivator for compliant behaviour (Crawshaw, 1974; Marston, 1970). At the other end of the spectrum, another subject defined h i s hea l th s tate as happiness with l i v i n g . He pre ferred to die happy; consequently, he refused to comply with recommendations that a l t e r e d h i s l i f e s t y l e . From general observations of the sample, subjects defined t h e i r own state of h e a l t h , l i f e , and wel l -be ing and subsequent compliance. D e f i n i t i o n s of hea l th and improved hea l th , however, appeared to d i f f e r among hea l th care workers and subjects . Health care workers tended to prescr ibe recommendations to improve the p a t i e n t s ' hea l th and expected compliant behaviour from subjects 68 without a p r i o r consultation regarding health d e f i n i t i o n s . These observations suggest that personal d e f i n i t i o n s of health influence compliance and that health care workers should validate these d e f i n i t i o n s to enhance communication before implementing patient education on l i f e s t y l e changes. These findings also suggest that i n d i v i d u a l i z e d nursing care plans may benefit the patient during his recovery. Therapeutic demands. Orem (1980) i d e n t i f i e d therapeutic demands as personal needs that are a l t e r e d as a r e s u l t of the i n d i v i d u a l ' s state of health. Therapeutic demands for t h i s study were interpreted as the recommendations prescribed by health care workers i n the areas of p h y s i c a l a c t i v i t y , d i e t , and medication-taking for the purpose of s a t i s f y i n g the i n d i v i d u a l ' s a l t e r e d needs r e s u l t i n g from a myocardial i n f a r c t i o n . From observations of the sample, demands made of patients appeared to influence compliance. Previous research has suggested that the number of recommendations prescribed had a negative e f f e c t on compliance ( B a l l , 1974; Marston, 1970); however, findings from t h i s study found no r e l a t i o n s h i p between compliance and the number of recommendations prescribed. When the number of recommendations for each category of p h y s i c a l a c t i v i t y , d i e t , and medication-taking over two interviews were subjected to the Kruskal-Wallis rank-sum t e s t with one-way analysis of variance, s i g n i f i c a n t differences at the p_<.05 l e v e l were not obtained (Siegel, 1956). These findings 69 are possibly the r e s u l t of the extent of behavioural changes that subjects were expected to make rather than to the number. Individual behavioural changes were not measured i n t h i s study. Subjects who i d e n t i f i e d t h e i r occupation as r e t i r e d appeared to have few l i f e s t y l e changes to make with dietary and medication recommendations. Retired subjects i n t h i s study were older than 65 years and had experienced previous medical complications 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 cannot be ascertained. Three of f i v e r e t i r e d subjects had experienced previous myocardial i n f a r c t i o n s and were following low sodium and/or low f a t / c h o l e s t e r o l diets p r i o r to t h e i r current h o s p i t a l admission. Two of the other r e t i r e d subjects had h i s t o r i e s of renal disease or diabetes mellitus and appeared to have optimal compliance with s p e c i a l d i e t s . A l l subjects i n t h i s study who were older than 65 years, r e t i r e d , and had previous medical problems had developed d a i l y medication schedules as a r e s u l t of t h e i r conditions so few behavioural changes had to be implemented. B i l l e (1977) also found that r e t i r e d subjects had r e l a t i v e l y few factors i n t e r f e r i n g with compliance with health care recommendations. These findings suggest that older r e t i r e d subjects with previous medical problems had few behavioural changes to make with dietary and medication recommendations and that health care workers should assess the extent of changes that a f f e c t each i n d i v i d u a l and take t h i s into consideration when planning care. 70 In add i t ion to the extent of behavioural changes requ i red , simultaneous changes appeared to a f fec t d ie tary compliance scores . Six subjects were advised to fol low reducing d ie t s by the second interv iew (see Table 8 ) . Three of these subjects did not comply a l l of the time and ate foods that were high i n c a l o r i e s and cont ra ind ica ted i n t h e i r d i e t . The most frequent source of d i f f i c u l t y for noncompliance with reducing d ie t recommendations was a t t r i b u t e d to cessat ion of c i ga re t t e smoking. Two of the three subjects who d id not comply a l l of the time f e l t that smoking had more detr imental e f fec t s on t h e i r hearts than obesi ty and continued to eat foods that were high i n c a l o r i e s . These f indings suggest that when simultaneous demands are made of an i n d i v i d u a l , decision-making occurs and the predominant tendency i s to comply with one demand. These f indings are supported by s i m i l a r research r e s u l t s reported by Marston (1970). The event of a myocardial i n f a r c t i o n placed demands on a l l employed sub ject s . During the f i r s t in terv iew, subjects were advised to res t at home and avoid t h e i r place of employment. By the second interv iew, s ix of the seven employed subjects were advised to re turn to work v i a part- t ime employment; however, d i f ferences were noted for employment resumption between p r o f e s s i o n a l and nonprofess ional subjects . Four of the s ix subjects who i d e n t i f i e d t h e i r occupation as educators, engineers , and managers e a s i l y resumed employment v i a part-t ime p o s i t i o n s . Two subjects who performed s k i l l e d and u n s k i l l e d labour had to 71 resume f u l l - t i m e employment i n order to keep t h e i r jobs with t h e i r companies. Part-time employment was not company p o l i c y . Both subjects expressed fear during the f i r s t interview and f e l t that heavy labour would induce another myocardial i n f a r c t i o n . By the second interview, physicians had advised both of these subjects that they could resume f u l l - t i m e employment since part-time employment was not f e a s i b l e . One subject complied despite h i s fears; however, the other subject preferred not to resume employment and continued on sick leave. These findings support those reported by Crawshaw (1974) and Tyzenhouse (1973) who found that i n d i v i d u a l s who performed manual labour encountered more d i f f i c u l t i e s with resumption of employment than i n d i v i d u a l s who performed professional tasks. Eight subjects were advised by t h e i r physicians that they could resume sexual a c t i v i t y within two to three weeks following discharge from h o s p i t a l . The recommendation merely served as a guideline rather than a compliance item and provided information to subjects to a l l a y apprehension. Variables i n f l u e n c i n g the resumption of sexual a c t i v i t y were not investigated. Although data r e l a t e d to these recommendations were excluded from t o t a l scores, i t was i n t e r e s t i n g to note that one subject followed the guidelines and had resumed sexual a c t i v i t y , one subject resumed the a c t i v i t y on the day of discharge from the h o s p i t a l , and s i x subjects had not resumed the a c t i v i t y by the f i r s t interview. By the second interview, a l l subjects but two had resumed sexual a c t i v i t y . Fear 72 of a recurrent myocardial i n f a r c t i o n and medical complications were c i t e d as reasons for not resuming sexual a c t i v i t y . From general observations of the sample, i n d i v i d u a l d i f f e r e n c e s were noted that had an i n f l u e n c i n g e f f e c t on compliance. Individuals tended to define t h e i r own state of health which influenced whether or not they would comply with the therapeutic regimen. The extent of behavioural changes recommended, simultaneous recommendations prescribed, the v a r i a b l e of education, and demands for resumption of employment a f f e c t e d i n d i v i d u a l 1 s responses to therapeutic demands and influenced compliance. General Observations of S i g n i f i c a n t Others Bandura's (1977b) s o c i a l learning theory and Dubos' (1965) theory of adaptation recognized the s i g n i f i c a n t other as a stimulus for reinforcement and support to an i n d i v i d u a l recovering from a myocardial i n f a r c t i o n . Although only four s i g n i f i c a n t others were i n v i t e d to p a r t i c i p a t e i n patient education sessions, general observations were made of nine s i g n i f i c a n t others who p a r t i c i p a t e d i n both interviews i n t h e i r homes. With reference to 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 others assumed l i f t i n g and d r i v i n g chores when able, f i v e joined t h e i r mates for d a i l y walks, and three p a r t i c i p a t e d i n t h e i r mate's hobbies/sports. With reference to dietary recommendations, a l l nine 73 s i g n i f i c a n t others purchased and prepared food, a l l nine used the take-home manual as a dietary guide, and six used add i t i o n a l cooking resources. One s i g n i f i c a n t other had her mate's d i e t analyzed by computer to detect flaws with recommended food consumption and another marked meals on a calendar i n an e f f o r t to eliminate contraindicated foods from the prescribed d i e t . With reference to medication recommendations, f i v e s i g n i f i c a n t others reminded t h e i r mates to take medication and two of these f i v e s i g n i f i c a n t others placed d a i l y p i l l s i n a dish and checked the dish at bedtime to assure that medications were taken by t h e i r mates. Although s i g n i f i c a n t others' behaviours were not the focus of t h i s study, general observations of nine of the s i g n i f i c a n t others suggest that these women were a c t i v e l y involved with and supported and rein f o r c e d t h e i r mates' therapeutic regimens. These find i n g s support those reported by Mayou et a l . (1978) where half of the women i n the sample p a r t i c i p a t e d or encouraged t h e i r husbands to comply with health care recommendations. Summary Despite random a l l o c a t i o n of subjects to three d i f f e r e n t groups, the groups were markedly unequal on the two demographic v a r i a b l e s of age and employment. S t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s were not obtained for compliance between groups with p h y s i c a l a c t i v i t y , dietary, and medication recommendations and the 74 hypotheses of the study were rejected. I n s i g n i f i c a n t findings are p o s s i b l y the r e s u l t of a small sample size thus inferences drawn from the s t a t i s t i c a l analyses may be questionable. General observations of the t o t a l sample suggested that i n d i v i d u a l differences influence compliance. Health care workers should be aware of the patient's d e f i n i t i o n of health, the extent of and simultaneous behavioural changes a f f e c t i n g each patient, and the demographic variables of education and employment i n order to provide q u a l i t y of care to patients and enhance i n d i v i d u a l compliance; Findings also suggest that 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 to comply with a therapeutic regimen. 75 CHAPTER 5 Summary, Conclusions/ Implications, and Recommendations This study was designed to explore the independent variables of patient education and the s i g n i f i c a n t other on compliance. An overview of the study i s presented i n t h i s chapter followed by a conclusion. In addition, implications and recommendations f or nursing p r a c t i c e and nursing research are delineated. Overview of the Study A summary of the study w i l l be described i n r e l a t i o n to problem, design, implementation, and r e s u l t s . Problem, design, and implementation. An explanatory experimental study was conducted to investigate the e f f e c t s of structured education for the patient, and the s i g n i f i c a n t other, on compliance with health care recommendations for patients recovering from a myocardial i n f a r c t i o n a f t e r discharge from h o s p i t a l . The t h e o r e t i c a l framework of the study was a combination of Orem's.model for nursing, Dubos' theory of adaptation, and Bandura's s o c i a l learning theory. The framework predicted that subjects receiving structured education with t h e i r s i g n i f i c a n t others, would have higher compliance rates with health care recommendations than would subjects receiving structured education alone and unstructured education alone. The study was conducted with a convenience sample of twelve male patients who were admitted to a cardiac ward of one 76 metropolitan teaching h o s p i t a l . Subjects had a s i g n i f i c a n t other and had not experienced a myocardial i n f a r c t i o n within the previous f i v e years. Four s i g n i f i c a n t others p a r t i c i p a t e d i n the study. Agreement was obtained from the attending c a r d i o l o g i s t and consent was given by each subject, and the four s i g n i f i c a n t others, p r i o r to study p a r t i c i p a t i o n . The convenience sample was then randomly and equally a l l o c a t e d into three groups. Subjects i n group 1 served as the control group and received unstructured education as currently p r a c t i c e d by nursing s t a f f . Subjects i n group 2 received structured education by the in v e s t i g a t o r . Subjects i n group 3 received structured education by the invest i g a t o r with t h e i r s i g n i f i c a n t others i n attendance. Using a semi-structured interview guide with some open and some closed-ended questions, the investigator interviewed each subject twice i n t h e i r home at approximately one, and three to four months following discharge from h o s p i t a l . Each interview covered three content areas: p h y s i c a l a c t i v i t y , d i e t , and medications. Open-ended questions were used to e l i c i t data on the health care recommendations prescribed by the physician and to obtain data concerning d i f f i c u l t i e s with noncompliance. Closed-ended questions were used to estimate the subject's compliance using an ordinal scale. Responses were l a t e r tabulated and converted to numerical percentage scores. 77 Results. Compliance scores with health care 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 subjected to the Kruskal-Wallis rank-sum te s t with one-way analysis of variance. Compliance scores during both interviews showed no between group s t a t i s t i c a l l y s i g n i f i c a n t differences (p_ < .05) and the hypotheses of the study were rejected. The i n s i g n i f i c a n t findings of t h i s study need to be interpreted with caution because of the small sample siz e and between group differences on the two demographic variables of age and employment. Although patient education was provided to enhance s e l f - c a r e a b i l i t i e s , education alone was not a v a l i d predictor of compliant behaviour. The v a r i a b i l i t y of compliance scores with health care recommendations suggested that compliance was influenced by other f a c t o r s . From general observations of the t o t a l sample, i t appeared that subjects' d e f i n i t i o n s of health varied and that these personal d e f i n i t i o n s of health influenced compliant or noncompliant behaviour with the therapeutic regimen prescribed. The f i n d i n g s suggest that v a l i d a t i o n of patients' d e f i n i t i o n s of health be done by health care workers p r i o r to the implementation of patient education on l i f e s t y l e changes to enhance communication and to e s t a b l i s h mutual goals. Subjects i n t h i s study were motivated to learn about t h e i r disease and i t s treatment during t h e i r recovery on the cardiac ward following discharge from the coronary care unit, and these findings 78 suggest that patient education on a cardiac ward i s an id e a l time f o r learning to begin. During both interviews i n the home environment, subjects asked numerous questions about t h e i r therapeutic regimen perhaps suggesting that a d d i t i o n a l learning resources are required following discharge from h o s p i t a l . Data from t h i s study showed that subjects with high school education had higher compliance scores with dietary recommendations during the f i r s t interview than did subjects with college or un i v e r s i t y preparation (.H = 5.95, df = 2, p_ < .05). Scores were subjected to the Kruskal-Wallis rank-sum t e s t with one-way analysis of variance. These findings suggest that subjects with lower educational preparation have less experience with decision-making and comply more r e a d i l y with dietary recommendations than do subjects with higher educational preparation. These r e s u l t s are not supported by previous research perhaps suggesting that more studies be conducted to determine i f education i s a s i g n i f i c a n t p redictor of compliance. Simultaneous demands and the extent of behavioural changes expected by health care workers of the subjects appeared to influence compliance i n t h i s study. Some subjects were requested to modify smoking habits and t h e i r consumption of high c a l o r i c foods; however, subjects had d i f f i c u l t y complying with both recommendations. Subjects f e l t that smoking had more detrimental e f f e c t s on t h e i r heart than obesity and decided to quit smoking and modify but not eliminate t h e i r consumption of high c a l o r i c foods. 79 A l l subjects i n t h i s study who i d e n t i f i e d t h e i r occupation as r e t i r e d were o lder than 65 years and had experienced previous medical problems. These subjects encountered few l i f e s t y l e changes wi th d ie tary and medication recommendations and subsequent compliance. Findings suggest that nurses should assess simultaneous demands being made of the pa t i ent and the extent of behavioura l changes that a f fect each i n d i v i d u a l , and take these i n d i v i d u a l d i f ferences and p o t e n t i a l e f fect s in to account when planning nurs ing care . Di f ferences were observed between pro fe s s iona l and nonprofess ional subjects and t h e i r ease of t r a n s i t i o n in to the work f o r c e . A l l subjects i n t h i s study who i d e n t i f i e d t h e i r occupations as p ro fe s s iona l s , resumed employment v i a part-t ime p o s i t i o n s . A l l subjects who i d e n t i f i e d t h e i r occupations as nonprofessionals had to resume f u l l - t i m e pos i t i ons i n order to maintain t h e i r jobs. For the l a t t e r subjects , part- t ime employment was not considered part of company p o l i c y . Fear of recurrent myocardial i n f a r c t i o n s induced by heavy labour was expressed by these subjects . These f indings suggest that i n d i v i d u a l s who perform nonprofess ional tasks encounter more d i f f i c u l t i e s with resumption of employment than do pa t ient s who perform pro fe s s iona l tasks , and that e a r l y i d e n t i f i c a t i o n of these factors by hea l th care workers might help to ease the p a t i e n t ' s t r a n s i t i o n back in to the work fo rce . From observations of nine s i g n i f i c a n t others , a l l were a c t i v e l y invo lved with p h y s i c a l a c t i v i t y , d i e t a ry , and medication 80 recommendations that were prescribed for t h e i r mates. These findings suggest that knowledge about the therapeutic regimen be given to s i g n i f i c a n t others by health care workers to enable these women to provide support and reinforcement to t h e i r partners during t h e i r recovery at home. Conclusions This study investigated the e f f e c t s of structured education for the patient, and the s i g n i f i c a n t other, on compliance with health care recommendations for patients recovering from a myocardial i n f a r c t i o n a f t e r discharge from h o s p i t a l . S i g n i f i c a n t d i f f e r e n c e s were not found possibly as a r e s u l t of the small sample si z e and between group differences of the two demographic variables of age and employment. Patient education was not found to be a v a l i d p redictor of compliant behaviour. From general observations of the t o t a l sample, numerous factors were i d e n t i f i e d that influenced compliance. These f a c t o r s were personal d e f i n i t i o n s of health, simultaneous demands and the extent of behavioural changes required, and the demographic va r i a b l e s of education and employment. Findings also suggested that the s i g n i f i c a n t others of patients were a c t i v e l y involved with the therapeutic regimen prescribed for t h e i r mates. 81 Implications Nursing p r a c t i c e . Nurses are the primary health care professionals who teach patients with myocardial i n f a r c t i o n s about t h e i r disease and treatment. The nurse can perform a c r i t i c a l r ole i n enhancing patient compliance with health care recommendations. This study, therefore, holds some important implications f or nursing p r a c t i c e : 1. A cardiac ward following discharge from a coronary care unit and the home environment are suitable settings for patient education. During these stages of t h e i r recovery, patients are motivated to learn about the disease process and i t s management. 2. Since d e f i n i t i o n s of health varied among subjects i n t h i s study, nurses could investigate patient d e f i n i t i o n s to enhance communication and v a l i d a t e goals. 3. Since subjects with nonprofessional occupations encountered d i f f i c u l t i e s with t h e i r resumption of employment, nurses should assess t h e i r patient's occupation and a s s i s t h i s t r a n s i t i o n back into the work force. 4. Nursing assessment of patients should include the extent of behavioural changes and simultaneous demands expected of the patient, and should take these i n d i v i d u a l differences and p o t e n t i a l e f f e c t s into account when planning nursing care. 5. Since s i g n i f i c a n t others were a c t i v e l y involved with t h e i r mates' therapeutic regimen, patient education 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 others by health care p r o f e s s i o n a l s . Nursing research. As previously stated, t h i s was an explanatory experimental study conducted i n one s e t t i n g with a small convenience sample. I n s i g n i f i c a n t findings were possibly the r e s u l t of the small sample size and between group differences of the variables of age and employment. Findings cannot be generalized beyond the study population. Implications for nursing research include: 1. Further i n v e s t i g a t i o n of the independent variables of method of patient education and influence of the s i g n i f i c a n t other on compliance using a larger sample population. Using instruments to measure knowledge l e v e l s of the patients and t h e i r s i g n i f i c a n t others at various i n t e r v a l s during the recovery process might help to determine the effectiveness of patient education. S i m i l a r l y , using instruments to measure behavioural changes may r e f l e c t more accurate compliant behaviours with health care recommendations. 2. Further i n v e s t i g a t i o n of the possible 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 dietary compliance. 3. Investigation of resumption of employment between pr o f e s s i o n a l and nonprofessional occupations since findings from t h i s study suggested that i n d i v i d u a l s with nonprofessional occupations encountered more d i f f i c u l t i e s with employment resumption than did subjects who performed professional tasks. 83 Recommendations On the basis of the findings and implications of t h i s study, i t i s recommended that: 1. Nursing assessment include the patient's d e f i n i t i o n of health, occupation, simultaneous demands being made of the p a t i e n t , and the extent of behavioural changes expected to enhance communication, c l a r i f y goals, and to 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 others of patients with myocardial i n f a r c t i o n s be provided with knowledge i n the areas of p h y s i c a l a c t i v i t y , d i e t , and medication-taking so that they may be able to a s s i s t t h e i r mates during the recovery process. 3. Nurses enhance c o l l a b o r a t i v e e f f o r t s with physicians to determine dietary and medication health care recommendations p r i o r to discharge. Early i d e n t i f i c a t i o n of these discharge i n s t r u c t i o n s would permit the nurse to discuss tentative plans with the p a t i e n t and help t a i l o r the care plan to r e f l e c t patient needs. 4. 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The reduct ion of card iovascular r i s k : An a p p l i c a t i o n of s o c i a l l ea rn ing per spec t ives . In A. J . Enelow, & J . B. Henderson (Eds . ) , Apply ing behavioural sc ience to  card iovascu lar r i s k , (pp. 133-146). Sea t t l e , WA: American Heart A s s o c i a t i o n . To th , A . , & Toth , S. (1977). Post-coronary pa t ient s receive group therapy. H o s p i t a l Progress , 58 (8) , 72-75. Toth , J . C. (1980). E f f ec t of s t ructured preparat ion for t rans fer on pa t i en t anxiety on leav ing coronary care u n i t . Nursing  Research, £ 9 ( 1 ) , 28-34. Tyzenhouse, P. S. (1973). Myocardial i n f a r c t i o n i t s e f fec t on the f ami ly . American Journa l of Nurs ing , 73 (6), 1012-1013. V i n c e n t , P. ,(1971). Factors i n f l u e n c i n g pa t i ent noncompliance: A t h e o r e t i c a l approach. Nurs ing Research, 20, (6), 509-516. Wright , R. L . D. (1976). Understanding s t a t i s t i c s an informal i n t r o d u c t i o n fo r the behavioura l sc iences . New York: Harcourt Brace Jovanovich. 89 Appendix A Structured Patient Education Objectives The purpose of the teaching sessions i s to review and to i n d i v i d u a l i z e slide/tape content. The objectives 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 partnership for the health of your heart (after your heart attack)" and produced by the American Heart Association. Tape 1: Your Heart Attack and Your Future 1. To know the cause, e f f e c t s , and r i s k factors of a heart attack. a) to i d e n t i f y the function of the heart. b) to i d e n t i f y the function of the coronary a r t e r i e s . c) to describe the damage done to the heart during a heart attack. d) to describe the recovery process of the heart a f t e r a heart attack. e) to i d e n t i f y time parameters associated with the heart's recovery post-attack. f) to i d e n t i f y the cause of a heart attack. g) to l i s t four r i s k factors that influence coronary a r t e r y disease. h) to i d e n t i f y r i s k factors that a f f e c t t h i s i n d i v i d u a l . Tape 2: Move Into Action 1. 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 heart a f t e r a heart attack. a) to 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 . b) to explain the r a t i o n a l e for a gradual increase i n a c t i v i t i e s as i t a f f e c t s the heart. c) to l i s t 5 a c t i v i t i e s that can be performed during the f i r s t 3 weeks at home. d) to l i s t 4 a c t i v i t i e s that should be avoided during the f i r s t 3 weeks at home. e) to i d e n t i f y current a c t i v i t i e s enjoyed. f) to compare a c t i v i t i e s currently enjoyed to the l i s t of a c t i v i t i e s to do and not to do that a f f e c t an i n d i v i d u a l recovering from a heart attack. g) to discuss 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 to do and not to do during recovery. h) to i d e n t i f y the time period associated with r e s t r i c t e d d r i v i n g following a heart attack according to the laws of B.C. i ) to i d e n t i f y other sources of transportation allowed during the d r i v i n g r e s t r i c t i o n . j) 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) to i d e n t i f y personal guidelines when resuming sexual intercourse. 1) to l i s t 3 warning signs i n d i c a t i n g to stop a c t i v i t y and r e s t . m) 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 l i m i t a t i o n s a f f e c t i n g current occupation. Tape 3; You Are What You Eat 1. To know s p e c i f i c f a c t s about a low cholesterol/low f a t d i e t . a) to define c h o l e s t e r o l . b) to define saturated f a t . c) to define polyunsaturated f a t . d) to define 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 the a r t e r i e s of the body. e) to i d e n t i f y the r a t i o n a l e f o r avoiding foods high i n c h o l e s t e r o l / f a t . f) to l i s t 6 food items to eat when on a low c h o l e s t e r o l / f a t d i e t . g) to l i s t 6 food items to avoid when on a low c h o l e s t e r o l / f a t d i e t . h) to i d e n t i f y food items high i n c h o l e s t e r o l / f a t consumed with current d i e t . i ) to i d e n t i f y s a t i s f a c t o r y food items that can be substituted for those items high i n c h o l e s t e r o l / f a t . j) to discuss the relevance of low c h o l e s t e r o l / f a t food items to the i n d i v i d u a l who procures and prepares meals i n the home. 2. To know s p e c i f i c facts about a low sodium d i e t . a) to i d e n t i f y the e f f e c t of sodium/salt on the body. b) to i d e n t i f y the e f f e c t of sodium/salt on the heart a f t e r a heart attack. c) to l i s t 6 food items high i n sodium content. d) to i d e n t i f y food items i n the current d i e t that are high i n sodium content. e) to i d e n t i f y s a t i s f a c t o r y food items that can be substituted for those items high i n sodium content. f) to discuss the relevance of low sodium food items to the i n d i v i d u a l who procures and prepares meals i n the home. 3. To know methods to lose weight. a) to i d e n t i f y two methods to lose weight. 91 Tape 4: Your P r e s c r i p t i o n f o r Health 1. To know s p e c i f i c facts about the taking of medications i n the home. a) to i d e n t i f y factors that w i l l promote a s a t i s f a c t o r y routine to take medications i n the home. b) to i d e n t i f y detrimental factors a f f e c t i n g the taking of medications i n the home. c) to i d e n t i f y the ra t i o n a l e f o r knowing the name of the medication. d) to i d e n t i f y the ra t i o n a l e f o r knowing the purpose of the medication. e) to i d e n t i f y the ra t i o n a l e f o r knowing the dosage and frequency of medication. f) to i d e n t i f y the ra t i o n a l e for knowing the side e f f e c t s of medication. g) to l i s t the name, and purpose of current medication. 92 Appendix B Discharge Guidelines of Cardiac Teaching Unit (Guidelines from the i n s t i t u t i o n under study with t h e i r approval) Diet Type: Alcohol R e s t r i c t i o n s : A c t i v i t i e s : Your strength and energy w i l l gradually return but may take up to 3 months. A useful guideline to a s s i s t you i n returning to your normal a c t i v i t i e s would be: Week 1 - Stay indoors - carry on the same l e v e l of a c t i v i t y reached i n h o s p i t a l . If the weather i s agreeable, you may s i t out of doors i n the garden or on the p a t i o . Rise at your usual time i n the morning, dress and be up most of the day. L i e down half an hour a f t e r each meal and when you are t i r e d . Try to do a l i t t l e more each day. If you experience chest pain, l i e down u n t i l the pain disappears. S t a i r Climbing: Yes No R e s t r i c t i o n s : Week 2 - Begin outdoor walking. Day Walk one c i t y block and back. Day Walk two c i t y blocks and back. Day Walk three c i t y blocks and back. Increase a c i t y block d a i l y u n t i l you are walking eight c i t y blocks and back. Thereafter, walk one mile or more d a i l y , at whatever pace s u i t s you. You may walk up h i l l s and slopes. C a l l your doctor, or go to your l o c a l Emergency Department i f you develop chest pain and i t i s not r e l i e v e d a f t e r taking 3 or 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 minutes), or, i f the pain does not go away with r e s t within 20 minutes. Home A c t i v i t y Suggestions: Weeks 1 2 3 4 1. Fix l i g h t lunches 2. Be alone during the day 93 Weeks 1 2 3 4 3. Be a passenger i n a car 4. Resume sexual r e l a t i o n s h i p s 5. Take a holiday - d r i v i n g - f l y i n g 6. Resume l i g h t housework (dusting, cooking, washing dishes) 7. Resume heavy housework (vacuuming, laundry, f l o o r s ) D r i v i n g : The B.C. Motor Vehicle Act p r o h i b i t s you from d r i v i n g your car for 6 weeks a f t e r a heart attack. Approximate return to work: ' weeks. Follow-up V i s i t s : Family Doctor: C a r d i o l o g i s t : Other: Medications: L i s t below R e s t r i c t i o n s : D e f i n i t e l y NO CIGARETTE SMOKING. I t increases the r i s k of heart disease. 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 Phys i ca l A c t i v i t y a) Did your doctor suggest that you l i m i t your a c t i v i t y i n any way, i . e . : Cl imbing s t a i r s Walking outdoors L i f t i n g objects Resumption of sexual a c t i v i t y '  Return to work Hobbies or sports D r i v i n g a car Other Other '  b) Would you estimate that you have been able to fol low these suggest ions: Cl imbing S t a i r s (3) a l l the time (2) about ha l f the time (1) some of the time (0) never Walking Outdoors  ' ' ' " (3) a l l the' time (2) about ha l f the time (1) some of the time ' (0) never L i f t i n g Objects (3) a l l the time (2) about ha l f the time (1) some of the time (0) never Resumption of Sexual A c t i v i t y  ' (3) a l1 the time ' (2) about ha l f the time (1) some of the time (0) never Return to Work Hobbies or sports (3) a l l the time (3) a l l the time (2) about ha l f the time (2) about ha l f the time (1) some of the time (1) some of the time (0) never (0) never T r a v e l (3) a l l the time (2) about h a l f the time (1) some of the time (0) never D r i v i n g a car (3) a l l the time (2) about ha l f the time (1) some of the time (0) never 95 Other Other (3) a l l the time (3) a l l the time (2) about half the time (2) about half the time — (1) some of the time (1) some of the time (0) never (0) never If you have had d i f f i c u l t y following the doctor's suggestions, can you give a reason? Why? Climbing s t a i r s : Walking outdoors: L i f t i n g objects: Resumption of sexual a c t i v i t y : Return to Work: Hobbies or sports: T r a v e l : Driving a car: Other: Other: Score /100% 96 B. Diet a) Did the doctor suggest that you r e s t r i c t your d i e t i n any way, i . e . : Reducing d i e t to lose weight Salt free Low sodium ' Low f a t / c h o l e s t e r o l Alcohol Other ' ' Other b) Would you estimate that you have been able to follow these suggestions: Reducing Diet S a l t free (3) a l l the time _____ (3) a l l the time (2) about ha l f the time (2) about half the time (1) some of the time ' (1) some of the time (0) never (0) never Low sodium Low f a t / c h o l e s t e r o l (3) a l l the time (3) a l l the time (2) about half the time (2) about half the time (1) some of the time (1) some of the time (0) never (0) never Alcohol (3) a l l the time (2) about half the time _____ (1) some of the time (0) never Other (3) a l l the time (2) about half the time (1) some of the time (0) never Other (3) a l l the time (2) about half the time (1) some of the time (0) never c) If you have had d i f f i c u l t y following the doctor's suggestions, can you give a reason? Why? Reducing d i e t : S a l t 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) Did your doctor order any medication f o r you to take at home? i . e . : Nit r o g l y c e r i n e How often Digoxin • How often Furosemide ' How often Potassium Chloride How often Other How often Other How often Other How often Other How often Other How often b) Would you estimate that you have been able to follow these d i r e c t i o n s : N i t r o g l y c e r i n e (3) a l l the time (2) about ha l f the time (1) some of the time (0) never Digoxin (3) a l l the time (2) about half the time (1) some of the time (0) never Furosemide (3) (2) (1) (0) Potassium Chloride a l l the time about half the time some of the time never (3) a l l the time (2) about half the time (1) some of the time (0) never Other Other (3) a l l the time (2) about half the time (1) some of the time (0) never (3) a l l the time (2) about half the time (1) some of the time (0) never Other Other (3) a l l the time (2) about half the time (1) some of the time (0) never (3) a l l the time (2) about half the time (1) some of the time (0) never Other (3) a l l the time (2) about half the time (1) some of the time (0) never 98 c) If you have had d i f f i c u l t y following the doctor's suggestions, can you give a reason? Why? Nit r o g l y c e r i n e : Digoxin: Furosemide: Potassium Chloride: Other: Other: Other: Other: Other: Score /100% Note. Questionnaire to be completed by the i n v e s t i g a t o r . Appendix D Demographic Data Subject Number: Address : Phone Number: Age: M a r i t a l Status : Occupation: Educat ion : Previous myocardial i n f a r c t i o n s : Presence of spouse during s l ide- tape presentat ions A c t i v i t y -Diet Medicat ion -Group Des ignat ion : 100 Appendix E Group 1 Introductory L e t t e r Dear This l e t t e r i s to ask you to p a r t i c i p a t e i n a study which I am doing as a student at the University of B r i t i s h Columbia, taking my Masters i n Nursing. Although nursing and medical s t a f f have helped me to contact you, I do not work on t h i s nursing u n i t . I am interested i n the format of health teaching given to c l i e n t s such as yourself and your response to the teaching method a f t e r discharge from h o s p i t a l . During your h o s p i t a l i z a t i o n , nursing s t a f f w i l l share slide-tape presentations with you about recovering from a heart attack. If you are w i l l i n g to p a r t i c i p a t e i n the study, I would l i k e to meet with you twice at your residence, the f i r s t time being one month a f t e r discharge from h o s p i t a l and again three months a f t e r discharge. Interview time at your residence w i l l take approximately 30 minutes of your time. You are free to withdraw from the study at any time. You w i l l not be i d e n t i f i e d by name i n the study. If you are w i l l i n g to p a r t i c i p a t e i n the study, I w i l l meet with you p r i o r to discharge to introduce myself and to answer any questions that you may have about the study at that time. A f t e r discharge, I w i l l contact you by phone, three weeks l a t e r to arrange an interview time. If you decide not to p a r t i c i p a t e , your decision w i l l not a f f e c t your contact or care with the h o s p i t a l s t a f f i n any way. If you decide to 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 desired. Sincerely yours, Rhonda Kirk 101 Appendix F Group 2 Introductory L e t t e r Dear This l e t t e r i s to ask you to p a r t i c i p a t e i n a study which I am doing as a student at the University of B r i t i s h Columbia, taking my Masters i n Nursing. Although nursing and medical s t a f f have helped me to contact you, I do not work on t h i s nursing u n i t . I am interested i n the format of health teaching given to c l i e n t s such as yourself and your response to the teaching method a f t e r discharge from h o s p i t a l . I f you are w i l l i n g to p a r t i c i p a t e i n the study, I w i l l watch and discuss three slide-tape presentations about recovering from a heart attack with you during your h o s p i t a l i z a t i o n . I would l i k e to meet with you twice at your residence, the f i r s t time being one month a f t e r discharge from h o s p i t a l and again three months a f t e r discharge. Interview time at your residence w i l l take approximately 30 minutes of your time. You are free to withdraw from the study at any time. You w i l l not be i d e n t i f i e d by name i n the study. If you are w i l l i n g to p a r t i c i p a t e i n the study, I w i l l meet with you to review the slide-tape presentation and then w i l l contact you by phone three weeks a f t e r discharge to arrange an interview time. If you decide not to p a r t i c i p a t e , your decision w i l l not a f f e c t your contact or care with the h o s p i t a l s t a f f i n any way. If you decide to 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 desired. Sincerely yours, Rhonda Kirk 102 Appendix G Group 3 Introductory L e t t e r Dear This l e t t e r i s to ask you and your wife to p a r t i c i p a t e i n a study which I am doing as a student at the University of B r i t i s h Columbia, taking my Masters i n Nursing. Although nursing and medical s t a f f have helped me to contact you, I do not work on t h i s nursing u n i t . I am interested i n the format of health teaching given to c l i e n t s such as yourself and your response to the teaching method a f t e r discharge from h o s p i t a l . If you are w i l l i n g to p a r t i c i p a t e i n the study, I w i l l watch and discuss three slide-tape presentations about recovering from a heart attack with you and your wife during your h o s p i t a l i z a t i o n . I would l i k e to meet with you twice at your residence, the f i r s t time being one month a f t e r discharge from h o s p i t a l and again three months a f t e r discharge. Interview time at your residence w i l l take approximately 30 minutes of your time. You are free to withdraw from the study at any time. You w i l l not be i d e n t i f i e d by name i n the study. If you and your wife are w i l l i n g to p a r t i c i p a t e i n the study, I w i l l meet with you to arrange a convenient time to review the slide-tape presentations and then w i l l contact you by phone three weeks a f t e r discharge to arrange an interview time. If you decide not to p a r t i c i p a t e , your decision w i l l not a f f e c t your contact or care with the h o s p i t a l s t a f f i n any way. If you decide to 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 desired. Sincerely yours, Rhonda Kirk 103 Appendix H Patient Consent Form I, , do hereby give my consent to p a r t i c i p a t e i n the study on c l i e n t responses to teaching format which i s being conducted by Rhonda Kir k , a graduate student i n the School of Nursing at the University of B r i t i s h Columbia. I understand a) that p a r t i c i p a t i o n i n the study involves no r i s k s or discomforts. b) that my p a r t i c i p a t i o n i s voluntary and that I may withdraw at any time. c) that r e f u s a l to 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 i n t e r f e r e with the medical or nursing care which I w i l l receive, and d) that any information personally i d e n t i f y i n g me as a p a r t i c i p a n t i n t h i s study w i l l remain s t r i c t l y c o n f i d e n t i a l . Signature of C l i e n t Date Signature of Witness Signature of Other 104 Appendix I Physician Consent Form I, , do hereby give my permission to have ' , a patient under my care, p a r t i c i p a t e i n the study on patient response to the cardiac teaching format which i s being conducted by Rhonda Kirk, a student i n the Master of Science i n Nursing program at the University of B r i t i s h Columbia. Signature of Physician Date 

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