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Uncertainty over time and its relationship to life satisfaction for biological valve patients Ford, Jo-Ann Elizabeth 1989

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UNCERTAINTY OVER TIME AND ITS RELATIONSHIP TO LIFE SATISFACTION FOR BIOLOGICAL VALVE PATIENTS By JO-ANN ELIZABETH FORD B.Sc.N., The University of Western Ontario, 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 October 1989 © Jo-Ann Elizabeth Ford, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Nursing The University of British Columbia Vancouver, Canada DE-6 (2/88) i i Abst ract T h i s descr ip t ive corre lat ional study was des igned to determine the perce ived l eve l o f uncertainty o f ind iv idua ls w h o have had a b i o l og i ca l card iac va lve imp lan ted . T h e study invest igated the re lat ionship between uncertainty and factors that might in f luence this uncertainty such as t ime since implant , age at in i t ia l imp lant , and the re lat ionships between uncertainty and qual i ty o f l i fe ind icators , such as pat ients ' percept ions o f their l i fe sat isfact ion. T h e L a z a r u s and F o l k m a n (1984) cogn i t i ve theory o f psycho log i ca l stress and c o p i n g gu ided this study. A conven ience sample o f 121 subjects w h o had their f i rst b io log i ca l va l ve imp lan ted at least 12 months pr io r comple ted the Uncer ta in ty Stress Sca le ( U S S ) , the M i s h e l Uncer ta in ty i n I l lness Sca le C o m m u n i t y V e r s i o n ( M U I S C V ) , the Can t r i l S e l f - A n c h o r i n g Sca le , and a patient in fo rmat ion sheet. T h e subjects were ma i l ed the quest ionnaires. O v e r a l l , the b io log i ca l va l ve patients perce ived moderate ly l o w levels o f uncertainty. The nature o f the uncertainty exper ienced appears to be p r imar i l y generated by the patient not be ing able to forete l l the future and by unpredic tab i l i ty i n their s i tuat ion. There was a s igni f icant d i f ference in uncertainty depend ing on the t ime s ince imp lan t for subjects grouped accord ing to year o f implant . Subjects whose va lves were imp lan ted between 1976 and 1978, w h o had their va lves i i i imp lan ted fo r approx imate ly 11 to 13 years, exper ienced the lowest l eve l o f uncertainty. T h e highest leve l o f uncertainty was exper ienced by subjects imp lan ted between 1979 and 1981. Subjects implanted between 1982 and 1984 exper ienced the second highest l eve l o f uncertainty and the second lowest l eve l o f uncertainty was exper ienced by subjects implanted between 1985 and 1987. A s ign i f icant re lat ionship was not found between uncertainty and the age o f a patient at implant . Qua l i t y o f l i fe indicators o f b i o log i ca l va lve patients may be adversely in f l uenced by uncertainty. H i g h e r levels o f uncertainty are appraised as stressful o r threatening and contr ibute to a poorer past, present, and future l i fe sat isfact ion and health status. A s ign i f icant pos i t ive re lat ionship was demonstrated between uncertainty and stress. T h e h igher the leve l o f uncertainty, the h igher the subjects ' overa l l percept ions o f stress. T h e f ind ings o f this study were d iscussed i n re lat ion to other research studies, the theoret ical f ramework , and methodo log ica l p rob lems inherent to the study. Impl icat ions fo r nurs ing pract ice, theory, and educat ion, and recommendat ions for future research were ident i f ied. Tab le o f Contents i v Abst rac t i i Tab le o f Contents i v L i s t o f T ab le v i i L i s t o f F igu res v i i i Acknow ledgemen ts i x C H A P T E R O N E : Introduct ion B a c k g r o u n d to the P r o b l e m 1 P r o b l e m Statement 5 Purpose 6 Theore t ica l F r a m e w o r k 6 Cogn i t i ve App ra i sa l 6 C o p i n g Strategies 9 Adapta t iona l Outcomes 9 Reappra isa l 10 S u m m a r y 10 Research Quest ions 11 S ign i f i cance o f the Research 11 D e f i n i t i o n o f terms 12 Assumpt ions 13 L im i ta t i ons 14 Organ iza t i on o f the Thes is 14 C H A P T E R T W O : R e v i e w o f the L i terature Introduct ion 15 Uncer ta in ty 15 Q u a l i t y o f L i f e 22 T e m p o r a l Factors That M a y B e Assoc ia ted W i t h Ou tcomes 25 T i m e S ince Implant 25 A g e at In i t ia l Implant 28 S u m m a r y o f L i terature R e v i e w 30 C H A P T E R T H R E E : M e t h o d o l o g y Int roduct ion 33 Research D e s i g n 33 Samp le 33 D a t a C o l l e c t i o n Procedure 34 Instruments fo r D a t a Co l l ec t i on 35 Uncer ta in ty Stress Sca le ( U S S ) 35 M i s h e l Uncer ta in ty i n I l lness Sca le ( C o m m u n i t y Ve rs ion ) M U I S C V 38 Can t r i l S e l f - A n c h o r i n g Sca le 4 2 Pat ient In format ion Sheet 43 E th i cs and H u m a n R igh ts 43 D a t a A n a l y s i s 45 C H A P T E R F O U R : Presentat ion and D i s c u s s i o n o f Resul ts Int roduct ion 47 Character is t ics o f the Samp le 47 Demograph i c Character ist ics o f the Samp le 47 Hea l th Character ist ics o f the Samp le 49 V a l v e Implant H i s to ry 50 F ind ings 52 Research Ques t ion 1: W h a t is the perce ived l eve l o f uncertainty o f patients w i th b io log i ca l va lves? 52 Research Ques t ion 2: W h a t is the perce ived l eve l o f past, present, and future l i fe sat isfact ion o f b io log i ca l va l ve patients? 55 Research Ques t ion 3: W h a t is the re lat ionship between uncertainty and the t ime since imp lant o f the b io log i ca l va l ve? 57 Research Ques t ion 4 : W h a t is the re lat ionship between uncertainty and past, present, and future l i fe sat isfact ion for patients w i th a b io log i ca l va lve implant? 59 Research Ques t ion 5: W h a t is the re lat ionship between age at in i t ia l va lve imp lant and leve l o f uncertainty for b io log i ca l va lve patients? 59 A n c i l l a r y F ind ings 60 Uncer ta in ty and the Stress o f Uncer ta in ty 60 Uncer ta in ty and Threat 62 Uncer ta in ty and Oppor tun i ty 63 Uncer ta in ty and Hea l th Status 63 Uncer ta in ty and Gender 64 Advantages and Prob lems o f the B i o l o g i c a l V a l v e 66 D i s c u s s i o n o f the Resul ts 68 Character is t ics o f the Samp le 68 Uncer ta in ty 7 0 T i m e S ince Implant 75 Stress o f Uncer ta in ty 79 A g e at Implant 79 Percept ions o f L i f e Sat is fact ion 80 S u m m a r y 84 C H A P T E R F I V E : S u m m a r y , Conc lus i ons , Impl icat ions, and Recommendat ions Int roduct ion 87 S u m m a r y 87 Conc lus ions 92 Impl ica t ions for N u r s i n g Pract ice and Theory 93 Recommenda t ions for Future Research 97 References 100 Append i ces A p p e n d i x A : T a b l e A - l , N e w Y o r k Hear t Assoc ia t i on Func t iona l C lass i f i ca t ion 107 A p p e n d i x B : Introductory Let ter 109 A p p e n d i x C : R e m i n d e r Let ter 112 A p p e n d i x D :Uncer ta in t y Stress Sca le ( U S S ) 114 A p p e n d i x E : M i s h e l Uncer ta in ty i n I l lness Sca le C o m m u n i t y V e r s i o n ( M U I S C V ) 117 A p p e n d i x F : Can t r i l S e l f - A n c h o r i n g Scales 121 A p p e n d i x G:Pa t ien t In format ion Sheet 124 A p p e n d i x H : T a b l e H - l , F requency o f Hear t V a l v e Operat ions in Canada 1982-1983 127 A p p e n d i x I: Tab le 1-1 M U I S C V I tem M e a n s for B i o l o g i c a l V a l v e Patients and P r i m a r y and Reoperat ion C A B G Patients 129 v i i L i s t o f Tab les Tab le I A g e D is t r i bu t ion F o r Samp le 48 II Occupa t i on o f B i o l o g i c a l V a l v e Subjects 49 III E d u c a t i o n L e v e l F o r Samp le 49 I V A g e at In i t ia l Implant F o r Samp le 51 V T i m e S ince Implant o f the Samp le 51 V I T o t a l Uncer ta in ty Score F o r B i o l o g i c a l V a l v e Patients w i th the Uncer ta in ty Stress Sca le 53 V I I To ta l Uncer ta in ty Score F o r B i o l o g i c a l V a l v e Patients w i th the M i s h e l Uncer ta in ty Sca le 53 V I I I Uncer ta in ty Stress Sca le I tem and Fac tor M e a n s and Standard Dev ia t ions 54 I X M i s h e l Uncer ta in ty Stress I tem and Fac tor M e a n s and Standard Dev ia t i ons 55 X Past , Present, Future and A v e r a g e L i f e Sat is fact ion 56 X I Uncer ta in ty Scores ( U S S ) by Y e a r o f Implant 58 X I I Unce r ta iny Scores ( M U I S C V ) by Y e a r o f Implant 58 X I I I To ta l Uncer ta in ty Stress Score F o r B i o l o g i c a l V a l v e Pat ients U s i n g the U S S 61 X I V Stress o f Uncer ta in ty Scores ( U S S ) F o r Implant G r o u p s 62 X V Present and Future Hea l th Status F o r Samp le 64 X V I Uncer ta in ty and Stress M e a n and Standard Dev ia t i on Scores B y Gende r 65 X V I I Pe rce i ved Advantages o f B i o l o g i c a l V a l v e s G i v e n B y Subjects 66 X V U I P rob lems That V a l v e Subjects Fo resaw W i t h The i r B i o l o g i c a l V a l v e 67 I X X C o m p a r i s o n o f M e a n L i f e Rat ings 81 v i i i L i s t o f F igu res F igu res 1 Theore t i ca l F r a m e w o r k for Uncer ta in ty and Qua l i t y o f L i f e 7 ix A C K N O W L E D G E M E N T S I w o u l d l i ke to thank the members o f m y thesis cornmit tee, D r . A n n H i l t o n (chairperson) and M a r i l y n D e w i s fo r shar ing their expert ise, know ledge , and cont inued support. I w o u l d l i ke to thank the ind iv idua ls w h o so w i l l i n g l y took the t ime to part ic ipate i n m y study. W i thou t their par t ic ipat ion, this study w o u l d not have been poss ib le . I w i s h to extend a very spec ia l thanks to m y parents for their l ove , endless support , and encouragement. Thank you for " b e i n g t h e r e " . M y appreciat ion is extended to the surgeons fo r i nc lus ion o f their patients i n m y study, i nc lud ing D r . W . R . E . Jamieson , D i rec to r o f Research for Ca rd iovascu la r Surgery . I a m also grateful to E v a G e r m a n n , D r . T o d d Rogers , M r . K e n M a c K e n z i e , and fr iends for their t ime, expert ise, support, and contr ibut ions to the comp le t ion o f m y thesis. 1 C H A P T E R O N E Introduct ion B a c k g r o u n d to the P r o b l e m T h e cho ice o f prosthet ic heart va lve replacement fo r the patient w i th va lvu la r disease rests between a mechan ica l or b io log i ca l prosthesis. It is est imated i n Canada that the f requency o f u t i l i zat ion o f b io log i ca l and mechan ica l prostheses is essent ia l ly equal (Ba rw insky , personal commun ica t i on , 1988). H o w e v e r , i n B r i t i s h C o l u m b i a ' s two major tertiary hospi ta ls , b i o log i ca l va lves have been the prosthesis o f cho ice i n approx imate ly 9 3 % o f patients undergo ing va lve rep lacement over the past 12 years (Jamieson et a l , 1988). Pat ients requ i r ing card iac va lve substitutes are concerned w i th their qual i ty o f l i fe and their expectat ion o f su rv iva l . B i o l o g i c a l prostheses are used to op t im ize the qual i ty o f l i fe for patients by p rov id ing a l ower rate o f overa l l va l ve related compl ica t ions than the mechan ica l va lve . T h e advantage o f extended durab i l i ty w i th most mechan ica l prostheses is tempered by the need for long- te rm ant icoagulat ion and its associated r isks . A c c o r d i n g to Jamieson (1986), the qua l i ty o f l i f e o f patients w i th b io log ica l va lves is d is t inct ly super ior to mechan ica l va lves due to the quietness o f the prosthesis, m i n i m a l chron ic care, and non-catastrophic fa i lure. T h e major concern w i th these b io l og i ca l prostheses has been related to their durab i l i ty because there is a tendency for them to degenerate progress ive ly and/or ca l c i f y resul t ing in va lve fa i lure. T w e n t y percent 2 o f patients require elect ive or urgent reoperat ion to replace the b io log i ca l va l ve w i th in 10 years o f the in i t ia l imp lant due to structural va l ve deter iorat ion (Jamieson et a l , 1988; C o h n et a l , 1984). Structural va l ve deter iorat ion has been documented as the most prominent comp l i ca t ion o f b io log i ca l va lves (Ga l l o , A r t i nano & N i s t a l , 1985; Jamieson , 1984; Bor to lo t t i et a l , 1985). A l t h o u g h general predict ions o f va lve deter iorat ion are avai lab le fo r those w h o have had va lve replacements, the i nd i v i dua l does not k n o w i f and w h e n his par t icu lar va lve may need replacement. W i t h the passage o f t ime, the l i ke l i hood o f requ i r ing a substitute becomes greater since there is more t ime for structural deter iorat ion to take p lace (Jamieson et a l , 1988). Th i s unpredic tabi l i ty i n the pat ient 's si tuat ion is l i ke l y to g ive r ise to the percept ion o f uncertainty. A c c o r d i n g to B l a c h e r (1987), no other body organ is v i e w e d as more centra l to l i fe than the heart. Th i s percept ion arises f r o m a h is tor ica l v i e w that the heart is endowed w i th specia l myst ique and sentiment. T h e awareness o f the patient that their heart w i l l be stopped and later restarted dur ing an open heart operat ion may conjure up images o f death (B lacher , 1987). C o h n (1982) states that heart surgery is subject ive ly regarded as a l i fe- threatening si tuat ion for the patient w i th an uncertain outcome. H o w e v e r , patients w h o have had their nat ive card iac va lve rep laced may exper ience less uncertainty because they have been through heart surgery and have surv ived the event. Uncer ta in ty arises f r o m a 3 var iety o f sources and not on l y f r o m the unpredictabi l i ty o f their va l ve . M i s h e l (1988) p roposed that uncertainty may arise f r o m ambigu i ty , comp lex i t y , lack o f in fo rmat ion and unpredic tabi l i ty o f the si tuat ion. A c c o r d i n g to M i s h e l (1981), uncertainty may affect the person 's abi l i ty to appraise situations, w h i c h i n turn m a y l im i t the e f f i c iency o f cop ing w i th them. T h i s uncertainty m a y disrupt the no rma l pattern o f func t ion ing o f the i nd i v i dua l and his f am i l y . Interest ingly enough, structural va lve deter iorat ion is dependent on the durat ion o f implanta t ion as w e l l as the age o f the i nd i v i dua l at the t ime o f the in i t ia l imp lan t ( G a l l u c c i et a l , 1984, Jamieson et a l , 1988). T h e longer the i nd i v i dua l has the va lve the greater the chance o f structural va lve deter iorat ion. A s w e l l , the younger the person at the t ime o f implanta t ion, the greater the chance o f structural va l ve deter iorat ion ( G a l l u c c i et a l , 1984, Jamieson et a l , 1988). T h i s m a y g ive rise to more uncertainty i n the younger age group, because o f the expec ted l i fe o f the va lve . T h e f reedom f r o m structural va lve deter iorat ion s ign i f i cant ly increases w i th the age o f the patient at the t ime o f the in i t ia l implant . There are more patients i n the age group 30-59 years w h o have structural va l ve deter iorat ion than the age group 60 years and o lder (Jamieson et a l , 1988). N o t on l y is there a di f ference in structural va lve deter iorat ion as one gets o lder , but d i f ferences ex is t between the deve lopmenta l tasks o f the young adult, m idd le adult, and o lder adult (Neugarten, 1985) that may affect responses. 4 U n i q u e character ist ics and behaviours have been ascr ibed to each age group (Neugar ten, 1985). D i f fe rences have been found to exist among the three per iods i n the w a y a person perceives a l i fe threatening event ( M c C r a e , 1982). H o w e v e r , is the d i f ference a lso seen in their percept ion o f uncertainty? In add i t ion , it is not k n o w n i f uncertainty is a factor that affects the qual i ty o f l i fe o f a patient w i th a b i o l og i ca l va lve . Qua l i t y o f l i fe s igni f ies " a w ide range o f capabi l i t ies , l imi ta t ions, and percept ions that may affect a pat ient 's per formance o f f u n c t i o n " (Wenger , 1984a, p.3). A c c o r d i n g to Ferrans and Powers (1985), l i fe sat isfact ion is the one d imens ion that is the most important ind icator o f qual i ty o f l i fe . C a m p b e l l and col leagues (1976) def ine l i fe sat isfact ion as the perce ived d iscrepancy between an i nd i v i dua l ' s aspirat ions i n l i fe and his/her achievements i n l i fe ( C a m p b e l l et a l , 1976). L i f e sat isfact ion has been ca l l ed the barometer o f qual i ty o f l i fe (Laborde & P o w e r s , 1980). L i f e sat isfact ion is af fected by the w a y people evaluate and cope w i th the stressors o f phys i ca l i l lness (Lazarus & F o l k m a n , 1984). B y l im i t i ng appra isa l o f a si tuat ion and i m m o b i l i z i n g cop ing responses, uncertainty m a y in f luence l i fe sat isfact ion. A c c o r d i n g to Laza rus and F o l k m a n (1984), there has been l i t t le study o f uncertainty and h o w people cope w i t h it. A better understanding o f the uncertainty exper ienced by b io log i ca l va lve patients w i l l assist nurses i n he lp ing these ind iv idua ls more ef fect ive ly . 5 P r o b l e m Statement Pat ients w h o have heart va lve disease may require a va lve replacement to restore adequate card iac funct ion. U n d e r l y i n g the cho ice o f b io log i ca l versus mechan ica l va lve replacement is the impress ion that a b io log i ca l va lve w i l l p romote a better qual i ty o f l i fe p rov i d i ng a l owe r rate o f overa l l va l ve re lated compl i ca t ions . H o w e v e r , even though advantages exist w i th the implanta t ion o f b i o l og i ca l va lves , structural va lve deter iorat ion has been w e l l documented, w i th one i n f i ve patients requ i r ing reoperat ion o f the b io log i ca l va l ve by ten years (Cohn et a l , 1984, Jamieson et a l , 1988). Pat ients do not k n o w i f and when their b i o l og i ca l va l ve m a y need replacement. W i t h the passage o f t ime since the in i t ia l rep lacement , the l i ke l i hood o f requ i r ing a substitute va lve becomes greater s ince there is more t ime for the deter iorat ion to have taken p lace. T h e unpredic tabi l i ty o f the si tuat ion m a y g ive r ise to uncertainty about the si tuat ion. A s w e l l , structural va l ve deter iorat ion s ign i f icant ly decreases the o lder the patient is at in i t ia l implant . L i t t l e research has been done i n eva luat ing b io log i ca l va l ve patients and h o w they perce ive their s i tuat ion i n terms o f their qual i ty o f l i fe . N o research has been done i n eva luat ing h o w factors such as uncertainty about their b i o l og i ca l va l ve , age at in i t ia l imp lant , and t ime since implant might be associated w i th their v i ews o f l i fe . 6 Purpose T h e purpose o f this study was to invest igate h o w people w h o have had a b io log i ca l va lve imp lan ted v i e w the uncertaint ies and certainties i n their s i tuat ion together w i th their percept ion o f sat isfact ion w i th their l i fe . A s w e l l , the study invest igated the re lat ionship between uncertainty and factors that might in f luence this uncertainty such as t ime since implant , age at in i t ia l imp lant , and the re lat ionship o f that uncertainty to percept ion o f l i fe sat isfact ion. Theoret ica l F r a m e w o r k T h e theoret ical f ramework for this study is the cogn i t i ve theory o f psycho log i ca l stress and c o p i n g presented by Lazarus and F o l k m a n (1984) (see f igure 1). A c c o r d i n g to this m o d e l , cogn i t ive appraisal is the process o f ca tegor iz ing an encounter and its many facets w i th respect to its s ign i f i cance for we l l - be ing . Pe rson factors and si tuat ion factors are important determinants o f cogn i t i ve appra isa l . A s a result o f appraisal processes, c o p i n g strategies are u t i l i zed w h i c h in f luence outcomes. T h i s cop ing process is cont inuous ly media ted by cogn i t i ve reappraisals w h i c h f o l l o w and mod i f y ear l ier appraisals. C o g n i t i v e A p p r a i s a l Cogn i t i ve appraisal consists o f p r imary and secondary appraisal . In p r imary appra isa l , the person evaluates whether he or she has anyth ing at stake i n an encounter together w i th an evaluat ion o f whether the person-env i ronment re la t ionship is i r re levant, ben ign-pos i t ive , or stressful . In secondary appra isa l , the 7 Figure 1 - Theoretical Framework for Uncertainty and Quality of Life PERSON REAPPRAISAL ENVIRONMENT C O M M I T M E N T S B E L I E F S -about illness -about control UNCERTAINTY - about deterioration of tissue valve over time TEMPORAL FACTORS -time since implant -age at initial Implant COPING R E S O U R C E S COGNITIVE APPRAISAL Primary Appraisal (what is at stake) Secondary Appraisal (coping options) COPING STRATEGIES — (problem focused, emotion focused) COPING C O N S T R A I N T S OUTCOMES (social living, life st is fact ion, somatic health) * ADAPTED FROM Hilton, A. (1987). Coping with the uncertainties of breast cancer; Appraisal and coping strategies. University Microfilms International. (University Microfilms No. 87-00,205) Ann Arbor. 8 person evaluates what cop ing opt ions are avai lable. Person factors such as commi tments and bel iefs in f luence appraisal by de termin ing what is important fo r we l l -be ing i n a g i ven si tuat ion. T h e y shape the person 's understanding o f the event and as a result , the person 's cogn i t i ve appra isa l o f the event. Pe rson factors also p rov ide the basis fo r eva luat ing outcomes. T h e propert ies o f situations that make them potent ia l ly ha rmfu l or stressful are nove l ty , predic tab i l i ty , event uncertainty, the tempora l factors o f i m m i n e n c e , durat ion, and temporal uncertainty, and the t im ing o f an event i n terms o f the l i fe cyc le . I f a si tuat ion is comple te ly nove l and no aspect o f it has p rev ious ly been connected w i th harm, it w i l l not result i n an appraisal o f threat. Pred ic tab i l i t y is the l i ke l i hood o f an advance observat ion that m a y conta in a type o f wa rn ing that someth ing pa in fu l or ha rmfu l w i l l happen. Even t uncertainty incorporates the no t ion o f probabi l i ty . Subject ive probabi l i ty estimates can often vary f r o m the object ive probab i l i t y o f occurrence. A n uncertain si tuat ion that i nvo lves a h igh l y s igni f icant aspect o f l i fe is evaluated as a threat re lated to an inab i l i t y to obta in a c lear concept ion o f what is go ing to happen. O n the other hand , uncertainty may reduce threat by p rov id ing an alternative to the mean ing o f the s i tuat ion. T h e f ina l factor, the tempora l factor o f i m m i n e n c e , refers to how m u c h t ime there is before an event occurs. Du ra t i on is the length o f t ime dur ing w h i c h an event occurs . Tempora l uncertainty is not k n o w i n g w h e n an event w i l l 9 occu r and is stressful w h e n a threatening cue indicates that the event is go ing to happen. T h e t im ing o f events i n terms o f the l i fe cyc le can also affect appraisal because ind iv idua ls deve lop a concept o f the no rma l expectable l i fe cyc le that certain l i f e events w i l l occu r at certain t imes. C o p i n g Strategies C o p i n g is de f ined " a s constant ly chang ing cogni t ive and behav ioura l efforts to manage spec i f ic external and/or internal demands that are appraised as tax ing o r exceed ing the resources o f the p e r s o n " (Lazarus & F o l k m a n , 1984, p. 141). C o p i n g is a sh i f t ing process in w h i c h a person must re ly on one f o r m o f cop ing at a certain t ime, and at other t imes re ly on other strategies as the status o f the person-env i ronment re lat ionship changes. C o p i n g m a y be prob lem- focussed or emot ion focussed. C o p i n g depends upon ava i lab le resources and the constraints that inh ib i t use o f these resources. Resources are someth ing one draws upon and resources help to mediate stress. In add i t ion , the l eve l o f threat that a person exper iences in f luences the extent to w h i c h resources can be used for cop ing . Adapta t iona l Ou tcomes Laza rus and F o l k m a n (1984) state, " t h e p r ime impor tance o f appraisal and c o p i n g processes is that they affect adaptat ional o u t c o m e s " (p. 181). Three bas ic k inds o f outcomes are func t ion ing i n wo rk and soc ia l l i v i n g , mora le or l i fe sat is fact ion, and somat ic health. S o c i a l func t ion ing refers to the manner i n w h i c h a person fu l f i l l s his var ious roles and inc ludes sat isfact ion w i th interpersonal re lat ionships. M o r a l e o r l i fe sat isfact ion refers to how people fee l about themselves and inc ludes happiness, sat isfact ion, and subject ive we l l -be ing . Somat i c health refers to menta l and phys ica l health. Reappra isa l A shift i n the person-envi ronment re lat ionship w i l l lead to reappraisa l o f what is happen ing , the s ign i f icance o f the event, and what can be done. Cho i ces among c o p i n g alternatives are made and then cop ing strategies are u t i l i zed f o l l o w e d by adaptat ional outcomes. Reappra isa l is an ongo ing process, becoming the basis fo r further cop ing . In summary , reappraisal is a change i n the o r ig ina l appraisal that is a result o f chang ing condi t ions i n the person and/or si tuat ion. S u m m a r y A c c o r d i n g to Lazarus and F o l k m a n (1984) cogn i t i ve appraisal is i n f l uenced by si tuat ional uncertainty. In turn, appraisal in f luences the cop ing strategies w h i c h are u t i l i zed to manage the si tuat ion w h i c h in f luence outcomes such as l i fe sat isfact ion. S ince cop ing is a process, it w o u l d be expected that for ind iv idua ls w i th b io log i ca l heart va lves , tempora l factors such as t ime since the imp lan t and age at in i t ia l implant w o u l d also in f luence appraisal and, thereby, outcomes. Th i s study exp lo red the re lat ionship between the si tuat ional factors o f uncerta inty, t ime since implant , age at in i t ia l implant , and the adaptat ional ou tcome o f l i fe sat isfact ion for persons w i th b io log i ca l va lves . 11 Research Questions This study was designed to answer the following research questions for patients who have had a biological valve implanted: 1. What is the perceived level of uncertainty? 2. What is the perceived level of past, present, and future life satisfaction? 3. What is the relationship between uncertainty and the time since implant? 4. What is the relationship between uncertainty and past, present, and future life satisfaction? 5. What is the relationship between age at initial implant and level of uncertainty? Significance of the Research The significance of this research for the nursing profession is that the findings will provide a better understanding of the degree of uncertainty experienced by the patient with a biological heart valve. This knowledge is important in understanding patients' responses to having a biological valve and will assist nurses as to how best to help patients cope more effectively in the preoperative, postoperative and follow-up period. Nurses need to be aware of the degree and nature of uncertainty in biological valve patients in order to identify nursing interventions that might alter uncertainty. Studies which measure uncertainty and l i fe sat isfact ion may prov ide usefu l in fo rmat ion that can be u t i l i zed by health care professionals to p lan and imp lement educat ional and support ive programs and prov ide counse l l i ng that meets the spec i f i c needs o f these patients. G a i n i n g know ledge o f uncertainty w i th these patients w i l l faci l i tate commun ica t i on between the nurse and patient. A s w e l l , the researcher is interested i n exp lo r ing this area in order to add to the body o f nurs ing know ledge concern ing uncertainty and qual i ty o f l i fe . T o date, no nurs ing research has been reported w h i c h addresses the uncertainty exper ienced by the patient w i th a b io log i ca l va lve . De f i n i t i on o f Te rms B i o l o g i c a l V a l v e (B ioprosthes is , t issue va lve) - a cardiac va lve substitute w h i c h is compr i sed o f porc ine (pig) t issue. M e c h a n i c a l V a l v e - a card iac va lve substitute constructed w i th a py ro ly t i c carbon d isc . Structural va l ve deter iorat ion (pr imary tissue fa i lure) - an abnormal i ty o f the prosthesis w h i c h inc ludes leaflet per forat ion, d isrupt ion, and/or ca lc i f i ca t ion o f the bioprosthet ic va lve . V a l v e replacement - in i t ia l surgery to replace a card iac (native) va lve w i th a b io log i ca l prosthesis. Reopera t ion ( R E O P ) - addi t ional surgery to replace a prosthesis for structural va lve deter iorat ion. Uncer ta in ty - a cogn i t i ve state that occurs i n a si tuat ion when the person (dec is ion-maker) is unable to assign def in i te values to objects and events and/or unable to accurately predict outcomes ( M c i n t o s h , 1974). Uncer ta in ty w i l l be measured by the Uncer ta in ty Stress Sca le ( U S S ) deve loped by H i l t o n and the M i s h e l Uncer ta in ty i n I l lness Sca le C o m m u n i t y V e r s i o n ( M U I S C V ) . Qua l i t y o f l i fe - s ign i f ies " a w ide range o f capabi l i t ies , l imi ta t ions, and percept ions that m a y affect a pat ient 's per formance or funct ion i n a var ie ty o f soc ia l ro les and considers the leve l o f personal sat isfact ion that results f r o m that per formance or f u n c t i o n " (Wenger , 1 9 8 4 A , p. 3). Qua l i t y o f l i fe w i l l be measured by the ind icator o f l i fe sat isfact ion. L i f e Sat is fact ion - the perce ived d iscrepancy between an i nd i v i dua l ' s aspirat ions i n l i fe and h is /her achievements i n l i fe w h i c h range f r om the percept ion o f fu l f i l lmen t to that o f depr ivat ion (Campbe l l et a l , 1976). L i f e sat isfact ion w i l l be measured by the Can t r i l se l f -anchor ing scale. Assumpt ions F o r the purposes o f this study the f o l l o w i n g assumpt ions were made: 1. Subjects w i l l respond honest ly to the scales and quest ionnaires used. 2. Percept ions o f l i fe sat isfact ion is a v a l i d ind icator o f qual i ty o f l i fe . L im i ta t i ons T h i s study has the f o l l o w i n g l imi tat ions: 1. A conven ience sample was used, and therefore, the sample m a y not be representat ive o f the populat ion o f b io log i ca l va l ve patients. 2 . T h e f ind ings o f this study are not general izable to other patient groups. 3. M a i l e d quest ionnaires may have a poor return rate. Organ iza t ion o f the Thes is T h i s thesis is compr i sed o f f i ve chapters. In Chapter O n e , the background to the p r o b l e m , p rob lem statement, purpose, theoret ical f ramework , research quest ions, s ign i f i cance o f the research, def in i t ions, assumpt ions, and l imi ta t ions have been presented. In Chapter T w o , a rev iew o f selected l i terature pert inent to the ident i f ied research p rob lem is presented. Chapter Three addresses the research methodo logy i nc lud ing a descr ip t ion o f the research des ign , samp l ing procedure, data co l lec t ion instruments and procedure, ethics and human r ights, and data ana lys is . In Chapter Fou r , the descr ip t ion o f the sample, f i nd ings , and a d iscuss ion o f the results w i l l be presented. T h e summary , conc lus ions , imp l i ca t ions for nurs ing pract ice, and recommendat ions for future research are presented i n Chapter F i v e . C H A P T E R T W O R e v i e w o f the L i terature Introduct ion T h e purpose o f this chapter is to present an exp lora t ion and analys is o f selected l i terature under the three headings w h i c h have emerged f r o m the theoret ical f ramework . T h e f irst sect ion prov ides an ove rv iew o f l i terature w h i c h pertains to a person 's percept ion o f s i tuat ional uncertainty. T h e second sect ion prov ides an ove rv i ew o f l i terature that addresses adaptat ional outcomes o f l i fe sat isfact ion. T h e f ina l sect ion deals w i th tempora l factors that c o u l d in f luence uncerta inty, such as t ime since imp lant and age o f the person at in i t i a l implant . Uncer ta in ty Uncer ta in ty is de f ined as a cogn i t i ve state that occurs i n a si tuat ion when the dec is ion -maker is unable to assign def in i te values to objects and events and/or is unable to accurately predict outcomes ( M c i n t o s h , 1974). S a d o w s k y (1982) descr ibes uncertainty as " t h e gap between what is k n o w n and what needs to be k n o w n in order to make correct d e c i s i o n s " (p.342). Laza rus and F o l k m a n (1984) c lear ly di f ferent iate between ambigu i ty or l ack o f s i tuat ional c lar i ty , and uncerta inty, w h i c h is the person 's lack o f understanding about the mean ing o f the env i ronmenta l conf igura t ion. A c c o r d i n g to Budne r (1962), a s i tuat ion is uncerta in w h e n it cannot be adequately structured because a number o f cues are l a c k i n g . M i s h e l (1984) reports that uncertainty events are character ized as ambiguous , vague, unpredictable, unclear, and l ack ing in format ion . A cogn i t i ve structure is not f o rmed when suff ic ient cues are l ack ing or when s t imu l i are perce ived as uncertain. W h e n c lear appraisal o f the si tuat ion by the person is not poss ib le it l im i ts a person 's abi l i ty to choose appropriate act ions or cop ing processes ( M i s h e l , 1984). A rev iew o f the l i terature has found uncertainty to be associated w i th i l lness and disease (Lazarus & F o l k m a n , 1984; M i s h e l , 1984; M i s h e l & B raden , 1987; W e e k s , 1980). M i s h e l (1988a) suggests that events surrounding i l lness rare ly meet the necessary cr i ter ia to f o r m a cogn i t i ve structure. A cogn i t i ve structure is the pat ient 's subject ive evaluat ion o f the i l lness and treatment. T h e pat ient 's symptoms are general ly ambiguous and nove l . Of ten patients rece ive incomple te in fo rmat ion f r o m health care professionals about their cond i t ion or patients rece ive in format ion that they cannot understand ( M i s h e l , 1988a). Pat ients may encounter many new situations i n the health care env i ronment w h i c h are not fami l ia r . Fur thermore, pat ients ' are of ten unclear about what they shou ld o r shou ld not do after d ischarge f r o m hospi ta l . T h i s lack o f object ive markers o f progress inh ib i ts the patients ab i l i ty to c lear ly gauge their recovery status ( M i s h e l , 1988a). M i s h e l (1988b) states that uncertainty i n the i l lness exper ience has four fo rms: " ( a ) ambigu i ty concern ing the state o f i l lness , (b) comp lex i t y regard ing treatment and system o f care, (c) l ack o f in format ion about the d iagnos is and seriousness o f the i l lness , and (d) unpredictabi l i ty o f the course o f the disease and p r o g n o s i s " (p. 225) . In a study by H i l t o n (1988b), w o m e n w i th breast cancer v i e w e d uncertainty as a state that exists on a con t inuum f r o m just less than certainty to a fee l ing o f vagueness w h i c h changes over time. F o r these w o m e n uncertainty arose f r o m many areas w h i c h inc luded : " n o t be ing able to forete l l the future, not fee l ing secure and safe f r o m danger, be ing in doubt, be ing undec ided, percept ions o f vagueness, and not be ing able to re ly or count on someone o r someth ing (H i l t on , 1988b, p. 217) . Laza rus (1974) noted that i n the cogn i t i ve structure o f uncertainty, events can be evaluated as threatening due to the inab i l i t y o f the patient to accurately predict the impact o f the si tuat ion. W h e n the exper ience is an un fami l i a r one i n v o l v i n g an important aspect o f l i fe such as su rv i va l , the impact o f uncertainty can be espec ia l l y s igni f icant . C o m a r o f f and M a g u i r e (1981) support L a z a r u s ' s f ind ings and state that certain i l lnesses and diseases that are ser ious, l i fe threatening, and d i f f i cu l t to cont ro l are replete w i th uncertainty. V a l v u l a r heart disease is one disease that ref lects these l i fe threatening character ist ics. In a study by M i s h e l (1983), card iovascu lar patients pe rce ived uncertainty as amb igu i ty about the severi ty o f their i l lness. T h i s uncertainty was related to 18 the l i fe- threatening nature o f card iac prob lems and ra ised fear o f i n va l i d i sm , con t inu ing damage to the heart, and death. Card iovascu la r patients were also f ound to perce ive uncertainty about the effect iveness o f treatment re lated to their inab i l i t y to c lear ly connect the treatment to spec i f ic outcomes. Duby ts (1988) found that uncertainty emerged as a central theme i n the exper ient ia l accounts o f patients w h o were wa i t ing for C A B G surgery. T h i s phenomeno log i ca l study ident i f ied three facets o f the total wa i t i ng exper ience: the i l lness , the prospect ive surgery, and the wa i t i ng per iod . Uncer ta in ty pervaded a l l three facets. In the i l lness facet, patients exper ienced uncertainty about the course o f i l lness and the poss ib i l i t y o f an i l lness-re lated comp l i ca t i on , such as death. W i t h the surgery facet, patients were uncertain about the actual exper ience o f surgery and the hosp i ta l iza t ion, and the short and l ong term outcomes o f surgery. F i n a l l y , w i th in the wai t facet there was uncertainty about whether one w o u l d surv ive the wa i t wi thout sustaining a myoca rd ia l in farc t ion o r dy i ng . S i m u r d a (1988) reported that both p r imary coronary artery bypass graft ( C A B G ) surgery patients and reoperat ion patients perce ived moderate ly l o w leve ls o f uncertainty overa l l . Th i s study ident i f ied the factor o f uncertainty i n patients undergo ing p r imary and reoperat ive C A B G surgery. It seems reasonable to assume that uncertainty w i l l be a factor i n patients w h o have undergone va lve surgery. M i s h e l (1988b) postulated that uncertainty can affect adaptation. " A d a p t a t i o n has been operat iona l ized as psychosoc ia l adjustment, recovery , stress, l i fe qua l i ty o r health ( M i s h e l , 1988b). There are a number o f studies reported i n the l i terature us ing di f ferent patient populat ions that address the in f luence o f uncertainty on adaptat ional outcomes. Suppor t exists fo r the re lat ionship between uncertainty and poor psycho log i ca l adjustment i n w o m e n d iagnosed w i th gyneco log i ca l cancer ( M i s h e l , 1988b). M i s h e l f ound that uncertainty was associated w i th a pess imis t ic out look and negat ive evaluat ion o f the future at d iagnosis and treatment fo r these w o m e n . In a study o f co l lege students, Su ls and M u l l e n (1981) found that uncertainty about cont ro l over aversive events was associated w i th poorer health. Other ev idence indicates that uncertainty is associated w i th poorer psycho log i ca l adjustment i n mu l t ip le sclerosis patients (Weeks , 1980). M i s h e l (1984) presented a structural m o d e l to exp la in the stress response i n hosp i ta l i zed patients for a med i ca l p rob lem. T h e perce ived uncertainty about symptoms, treatment, and outcome was examined as a major predic tor o f stress in these patients. Tes t ing o f this structural m o d e l ind icated support fo r the re la t ionship o f uncertainty to stress and the predic ted media t ing ro le o f uncertainty between seriousness o f i l lness and stress. A g e related s ign i f icant ly to stress but not to uncertainty. 20 Painter (1981) examined the re lat ionship between perce ived uncertainty, pe rce ived recovery , and resumpt ion o f l i fe act iv i t ies i n a group o f post myoca rd i a l in farc t ion (M I ) patients. The results ind icated a s igni f icant negat ive re lat ionship between perce ived uncertainty and perce ived recovery . H o w e v e r , the results d i d not p rov ide support fo r the hypothes ized negative re lat ionship between uncertainty and resumpt ion o f da i l y act iv i t ies. Painter suggested that i f a M I patient is unable to reso lve uncertainty, then it may affect the appra isa l o f his recovery . A c c o r d i n g to M i s h e l (1988b), uncertainty can be appraised as a danger or as an oppor tuni ty . Laza rus and F o l k m a n (1984) a lso have noted this dua l ro le o f uncertainty. Uncer ta in ty may be appraised as a threat related to an i nd i v i dua l ' s inab i l i t y to determine what is at stake. A l te rna t ive ly , uncertainty may be appraised as an opportuni ty , a l l o w i n g the i nd i v i dua l to formulate pos i t i ve interpretations o f the mean ing o f an event. M i s h e l (1984) suggests that uncertainty may have a pos i t ive in f luence on patients and may faci l i tate hope that their i l lness is not as severe as feared. In i l lnesses w i th a d o w n w a r d trajectory, uncertainty can be appraised as an opportuni ty. F o r example , i n a study o f adolescents w i th cyst ic f ibros is , it was found that patients w i th a h igher l eve l o f uncertainty had a longer future t ime perspect ive (Ya rchesk i , 1988). In a study o f spouses o f heart transplant patients, M i s h e l and M u r d a u g h (1987) found that 21 spouses v i e w e d the uncertainty i n wa i t i ng for a heart to become avai lab le as an opportuni ty compared to the certain death that w o u l d result i f a heart transplant was not poss ib le . H o w e v e r , spouses v i e w e d the uncertainty o f keep ing their husbands a l ive l o n g enough to rece ive a heart as a danger. Uncer ta in events w h i c h are appra ised as a danger i m p l y a negat ive ou tcome, and require cop ing strategies to reduce the uncertainty ( M i s h e l , 1988b). Uncer ta in events w h i c h are appra ised as an opportuni ty i m p l y a pos i t ive ou tcome, and require cop ing strategies to main ta in uncertainty. A c c o r d i n g to Laza rus and F o l k m a n (1984), c o p i n g is a statel ike process and c o p i n g strategies w i l l vary w i th every event. H i l t o n (1989) invest igated the re la t ionship a m o n g commi tments , uncertainty about the cancer s i tuat ion, threat o f recurrence, cont ro l o f the cancer s i tuat ion, and the set o f c o p i n g strategies appraised and used by w o m e n to cope w i th their breast cancer d iagnos is . She found that w o m e n w h o had a l o w commi tment , l o w cont ro l , h i gh uncertainty, and h igh threat o f recurrence used the cop ing strategy o f escape-avo idance, but d i d not accept respons ib i l i t y fo r their si tuat ion and d i d not use pos i t i ve appra isa l . H o w e v e r , w o m e n w i th a h igh threat o f recurrence and h igh cont ro l used the c o p i n g strategies o f p lan fu l p rob lem so lv ing , escape-avoidance, pos i t i ve reappra isa l , and se l f -cont ro l strategies. N o research has been done on what c o p i n g strategies b io log i ca l va lve patients use or on what c o p i n g strategies are most l i k e l y to support ef fect ive cop ing these patients. C o p i n g strategies are requ i red that address the nature o f the uncertainty exper ienced by the b i o l og i ca l va l ve patients. Q u a l i t y o f L i f e T h e concept o f qual i ty o f l i fe is an adaptat ional outcome o f par t icular interest w i t h b i o l og i ca l va lve patients. Qua l i t y o f l i fe is d i f f i cu l t to def ine and measure (Ferrans & Powers , 1985). A number o f authors have attempted to del ineate the components that shou ld be inc luded in the descr ip t ion and measurement o f qual i ty o f l i fe fo r card iac patients (Wenger , 1984b; L e v i n e & C r o o g , 1984). W e n g e r (1984b), ident i f ied qual i ty o f l i fe i n terms o f func t iona l capac i ty , symptoms and their consequences, percept ions o f health status and sat isfact ion w i th l i fe . She stated that subject ive evaluat ions o f the pat ient 's percept ion o f the impac t o f that event, funct ion, or capab i l i ty on l i fe style shou ld be i nc luded w i th object ive evaluat ions in the assessment o f qual i ty o f l i fe (Wenger , 1 9 8 4 A ) . It is the subject ive eva luat ion o f l i fe sat isfact ion that is cons idered o f great impor tance i n the measurement o f qual i ty o f l i fe ( C a m p b e l l et a l , 1976; W e n g e r 1984A) . L e v i n e & C r o o g (1984), i n addi t ion to l i fe sat is fact ion, ident i f ied the components o f qual i ty o f l i fe to be soc ia l ro les, phys io l og i ca l status, emot iona l state, and inte l lectual funct ion ing. T h e study o f l i fe sat isfact ion has been approached in a var iety o f ways 23 by invest igators. S o m e invest igators have examined overa l l l i fe sat isfact ion (Can t r i l , 1965) and others have examined l i fe sat isfact ion in a var iety o f domains o f l i fe such as heal th, emp loyment , and f am i l y l i fe ( C a m p b e l l et a l , 1976). L i f e sat isfact ion is the perce ived d iscrepancy between an i nd i v idua l ' s aspirat ions i n l i f e and his/her achievements i n l i fe w h i c h range f r o m the percept ion o f fu l f i l lmen t to that o f depr ivat ion (Campbe l l et a l , 1976). C a m p b e l l (1977) descr ibed l i fe sat isfact ion as i n v o l v i n g an act o f judgement or a cogn i t i ve exper ience and l a c k i n g the spontaneous qual i ty o f happiness or the exper ience o f fee l ing . Fur thermore, C a m p b e l l has argued that subject ive measures assess the exper ience o f l i fe d i rect ly , whereas object ive ones on l y measure mater ia l things that in f luence the exper ience. N o studies have been found by the researcher w h i c h examine the re lat ionship between uncertainty and l i fe sat isfact ion i n t issue va lve patients. H o w e v e r , a study was done by Pencko fe r and H o l m (1984) l o o k i n g at l i fe sat isfact ion i n coronary artery bypass surgery ( C A B G ) patients. In this study, two groups o f C A B G patients were compared in terms o f past, present, and future l i fe sat is fact ion, and sat isfact ion w i th f am i l y , sexua l , and soc ia l l i fe . T h e Can t r i l se l f -anchor ing scale was used to measure l i fe sat isfact ion in seventeen patients w h o were three to f i ve months postoperat ive and i n seventeen patients that were s ix to eight months postoperat ive. T h e results ind icated that the patients that were three to f i ve months postoperat ive perce ived their future l i fe sat isfact ion to be s ign i f icant ly better than their past l i fe sat isfact ion. O n the other hand , patients s ix to eight months postoperat ive perce ived both their present and future l i fe sat isfact ion to be s ign i f icant ly better than their past l i fe sat isfact ion. T h e invest igators postulated that the di f ference between the groups in the eva luat ion o f present l i f e sat isfact ion may have been related to the effects o f t ime on the recovery process, w h i c h w i l l be further d iscussed in the next sect ion. Patients i n the three to f i ve months postoperat ive group may have been affected by res idual i nc i s i ona l pa in . In both groups the patients attributed their d issat is fact ion w i th the past to fear o f the u n k n o w n and uncertainty about their future. The groups reported re l i e f and op t im i sm for the future f o l l o w i n g surgery. B o t h groups reported a s ign i f icant increase in f am i l y , sexua l , and soc ia l l i fe sat isfact ion postoperat ive ly . Trends i n the rat ings o f past, present, and future l i fe sat isfact ion suggested that C A B G surgery was associated w i th a h igher percept ion o f l i fe sat isfact ion and op t im i sm for the future i n p r imary C A B G patients and reoperat ion patients (S imurda , 1988). H o w e v e r , reoperat ion pat ients ' percept ions o f future l i fe sat isfact ion and health status were s ign i f icant ly l ower , suggest ing that the qual i ty o f l i fe f o l l o w i n g C A B G surgery is l owe r for the reoperat ion patients. A s w e l l , S i m u r d a (1988) reported that qual i ty o f l i fe o f C A B G patients m a y be adversely in f luenced by uncertainty. H i g h e r levels o f uncertainty were associated w i th poorer present and future l i fe sat isfact ion. T e m p o r a l Factors That M a y B e Assoc ia ted W i t h Outcomes  T i m e S ince Implant T h e t ime s ince implant is important to cons ider as appraisal takes p lace. Uncer ta in ty changes over t ime. M i s h e l (1980) hypothes ized that uncertainty w o u l d change over t ime in a group o f open heart surgery patients as they progressed through a con t i nuum o f events (preoperat ive, immedia te postoperat ive, intermediate postoperat ive and discharge stages) associated w i th the exper ience o f card iac surgery. M i s h e l (1980) p roposed an expected pattern o f uncertainty for each o f the stages. T h e areas o f uncertainty o f the preoperat ive stage were the unpredictable outcome o f surgery and potent ia l fo r death. T h e immedia te postoperat ive stage brought uncertainties about the comp lex treatment and env i ronment o f the cr i t i ca l care unit. Fee l ings o f insecur i ty and uncertainty f r o m the loss o f c lose care by health care professionals were concerns i n the intermediate postoperat ive stage. Concerns i n the d ischarge stage related to vagueness about what one shou ld and shou ld not do , and the unpredic tab i l i ty o f the return o f symptoms. In M i s h e l ' s study, patients w h o had undergone cardiac surgery were compared to a cont ro l group o f d ia lys is patients. T h e d ia lys is patients were chosen as a cont ro l group, as they exper ience a fa i r ly stable i l lness pattern and a consistent treatment reg imen. Uncer ta in ty scores were the same fo r the two groups and the scores for each group d i d not change s ign i f icant ly through the preoperat ive, immedia te postoperat ive, intermediate postoperat ive, and d ischarge stages. T h e results o f this compar ison were not consistent w i th M i s h e l ' s hypothesis that the nature and extent o f uncertainty w o u l d change as card iac patients progressed through the stages o f the surg ica l exper ience. M i s h e l p roposed that den ia l o f threatening events by card iac surgery patients m a y exp la in w h y they fa i l ed to show the expected changes in uncertainty. Ch r i s tman and col leagues (1988) studied the in f luence o f uncertainty and the use o f c o p i n g methods on emot iona l distress and recovery f o l l o w i n g myoca rd i a l in farc t ion . T h e patients were measured at three t ime per iods. T h e f i rst t ime was w i th in 72 hours o f hospi ta l d ischarge; the second t ime was one week after hospi ta l d ischarge; and the th i rd t ime was four weeks after hospi ta l d ischarge. T h e results o f the study ind icated that uncertainty and emot iona l distress were pos i t i ve ly and s ign i f icant ly related at a l l three t ime per iods. Pat ients w h o repor ted greater uncertainty a lso reported more emot iona l distress. In this study uncertainty has been found to have a negat ive in f luence on adaptat ional outcomes as related to stress and recovery . The highest mean uncertainty score o n the M i s h e l Uncer ta in ty I l lness Sca le ( M U I S ) was pr io r to hospi ta l d ischarge (79.2) w i th a s ign i f icant ly l ower mean uncertainty score one week after hospi ta l discharge (75.7). F o u r weeks after d ischarge f r o m hospi ta l , uncertainty increased s l igh t ly to a leve l not s ign i f icant ly di f ferent f r o m the uncertainty exper ienced p r io r to d ischarge (76.2). G a l l u c c i and col leagues (1984) have the longest documented exper ience w i t h the H a n c o c k porc ine b ioprosthesis, w h i c h is a type o f t issue va lve . In 1985 they reported that the f reedom f r o m structural va lve deter iorat ion at 12 years was 6 9 % fo r aort ic va lves and 6 1 % for mi t ra l va lves . T h e f reedom f r o m structural va lve deter iorat ion i n the Carpent ie r -Edwards t issue va lve was 7 7 % at ten years, 9 3 % at seven years, and 9 8 % at f i ve years (Jamieson, et a l , 1988). T h e porc ine bioprostheses ava i lab le for implanta t ion as card iac va lve substitutes are the prev ious and new generat ion porc ine va lves. T h e prev ious generat ion va lves , the H a n c o c k standard, Carpent ie r -Edwards standard, and the H a n c o c k m o d i f i e d are preserved by a high-pressure glutaraldehyde f i x e d process. T h e new generat ion bioprostheses are essent ia l ly preserved by a low-pressure g lutara ldehyde f i x e d process. The new generat ion porc ine va lves inc lude the f o l l o w i n g : Carpen t ie r -Edwards supra-annular, H a n c o c k II, W e s s e x , Z e n o m e d i c a , B i c o r , S t J u d e - B i o imp lan t , and Medtron ic- In tact (Jamieson et a l , 1989). T h e Carpen t ie r -Edwards supra-annular porc ine va l ve , in t roduced in 1981 , and the H a n c o c k U porc ine va lve , in t roduced in 1982 prov ide the most extensive porc ine va lve exper ience (Jamieson, et a l , 1989, W e i l a n d , 1983). Patients w i t h va lvu la r disease w i l l have their va lve status c lass i f i ed both preoperat ive ly and then postoperat ive ly accord ing to the N e w Y o r k Hear t A s s o c i a t i o n ( N Y H A ) Func t i ona l C lass i f i ca t ion (see A p p e n d i x 1). M a n y invest igators have demonstrated the s igni f icant improvement i n preoperat ive to postoperat ive N Y H A Func t i ona l C lass i f i ca t ion (Jamieson et a l , 1989a; L e v i n e et a l , 1981 ; N i s t a l et a l , 1986). In a study by Jamieson and col leagues (1989a) i n w h i c h 1183 patients were imp lan ted w i th b io log i ca l va lves between January 1975 and June 1976 (mean fo l l ow-up o f 6.5 years), 9 2 . 9 % o f the patients operated on were c lass in or I V accord ing to the N Y H A func t iona l c lass i f i ca t ion , whereas postoperat ive ly 9 2 . 3 % were i n N Y H A c lass I and II. A g e at In i t ia l Implant D i f fe rences i n the deve lopmenta l tasks o f the young , m idd le , and o lder adult have been recogn ized . Neugar ten (1985) postulated that people deve lop a concept o f the no rma l l i fe cyc le that inc ludes the expectat ion that cer ta in l i fe events w i l l occu r at certain t imes. Whe the r or not l i fe events produce cr ises depends on their t im ing . F o r example , death is usua l ly a no rma l and expected event fo r the o l d , but death can be tragic w h e n it occurs at too young an age. T h e p r imary deve lopmenta l tasks o f young adults (20-44 years) inc lude determin ing personal ident i ty, deve lop ing interpersonal re lat ionships, and bu i l d ing competency and achievement (Bradshaw, 1988). I f expectat ions for a product ive future are interrupted and threatened by i l lness , the young adul t 's ident i ty may be threatened (Steger, 1977). In m idd le adult l i fe (45-65 years) the occurrence o f i l lness threatens establ ished ro les. It increases one 's concerns about the t ime left, soc ioeconomic secur i ty , se l f -su f f i c iency , and the comple t ion o f important tasks or personal and career accompl ishments (Bradshaw, 1988). T h e o lder adult (over 65 years) faces many losses such as heal th, youth , f r iends, independence, wo rk , and economic status. M a n y o lder people be l ieve they have comp le ted the major part o f their l i fe w o r k and have l i v e d their l i ves w e l l . B y v i r tue o f their age, people at this stage o f l i fe have faced their mor ta l i ty and are prepar ing for their death (Brunner & Suddar th , 1988). A s w e l l , many o lder people w h o are threatened w i th i l lness are able to deal w i th i l lness w i th less anger than younger people. In a study conducted by M c C r a e (1982), m idd le -aged and o lder persons were less i nc l i ned than younger persons to re ly on host i le react ions, regardless o f type o f stress. A s w e l l , M c C r a e found that o lder people coped i n s im i la r ways to younger peop le , and where dif ferent cop ing strategies were used was a result o f the di f ferent types o f stress they faced. A c c o r d i n g to Jamieson and col leagues (1988), the f reedom f r o m structural va l ve deter iorat ion at 10 years i n the age group 30 through 59 years is 7 7 % compared w i th 8 3 % for 60 years and o lder . G a l l u c c i and Jamieson evaluated their patient populat ions o f two porc ine va lve manufacturers for age groups 25 years and less, 26 to 50 years and 51 years and over , and f ound s imi la r per formance character ist ics w i th regard to p r imary t issue fa i lure (Jamieson et a l , 1989). There fore , there are more patients i n the younger age group at implant w h o have structural va l ve deter iorat ion than the o lder age group. S u m m a r y o f the L i terature R e v i e w T h e rev iew o f the l i terature has ident i f ied a number o f areas requ i r ing further research. Uncer ta in ty is an important phenomenon associated w i th phys i ca l i l lness. Card iovascu la r disease w i th its l i fe- threatening nature and unpredic tab i l i ty is replete w i th uncertainty. Uncer ta in ty has emerged as a central theme i n the accounts o f card iovascu lar patients awai t ing C A B G surgery and has been noted both w i th patients w h o are recover ing f r om surgery, and w i th those recover ing f r o m myoca rd ia l in farc t ion. It seems reasonable to assume that uncertainty w i l l p l ay a ro le f o l l o w i n g open heart surgery. H o w e v e r , no studies have been done w h i c h examine the leve l o f uncertainty exper ienced by t issue va lve patients. Suppor t exists i n the l i terature for the re lat ionship between uncertainty and adaptat ional outcomes operat ional ized as psychosoc ia l adjustment, stress, recovery , and health. T h e in f luence o f uncertainty on the adaptat ional outcomes o f patients w i th b io log i ca l va lves has not been addressed. T h e adaptat ional outcome o f interest w i th va lve patients is the concept o f qua l i ty o f l i fe . There is a lack o f consensus regard ing w h i c h var iables are essent ia l to the analys is o f qual i ty o f l i f e ; however , l i fe sat isfact ion has been ident i f ied as one o f the most important indicators o f qual i ty o f l i fe . O n e invest igator f ound that h igher levels o f uncertainty w i th C A B G patients was associated w i th poorer present and future l i fe sat isfact ion. H o w e v e r , it is not k n o w n whether uncertainty w i l l be a factor i n patients w h o have undergone va lve surgery. It has been hypothes ized that the nature and extent o f uncertainty changes as open heart patients progress through the preoperat ive per iod to the d ischarge pe r i od o f the surg ica l exper ience. T h e results o f the M i s h e l (1980) study fa i l ed to support the hypothesis. It is k n o w n that there is a tendency for t issue va lve prostheses to degenerate progress ive ly over t ime. The longer the t ime s ince in i t ia l imp lan t , the greater the r isk that the tissue va lve may fa i l . There fore , further invest igat ion o f the re lat ionship between uncertainty and the t ime s ince imp lant o f the t issue va lve is needed. T h e l i terature indicates that bioprosthesis patients i n the younger age group at in i t i a l imp lant have s ign i f icant ly more structural va l ve deter iorat ion than the o lder age group. Y o u n g e r patients may exper ience more uncertainty than older patients due to the greater inc idence o f structural va lve deter iorat ion i n this group. A s w e l l , younger patients may exper ience more uncertainty as a resul t o f the deve lopmenta l stage they are exper ienc ing. O l d e r persons are of ten able to deal w i th i l lness w i th less anger than the younger adults, because many have faced their mor ta l i ty , or met their l i fe tasks. Peop le deve lop a concept o f the norma l l i fe cyc le that inc ludes the expectat ion that certain l i fe events w i l l occu r at certain t imes. Pat ients w i th bioprosthet ic va lves might exh ib i t di f ferent react ions at var ious points i n their l i fe cyc les because the event is perce ived as be ing " o n t i m e " or not i n terms o f l i fe deve lopment processes. H o w e v e r , no studies have related age at in i t ia l b ioprosthesis imp lant w i th uncertainty. C H A P T E R T H R E E M e t h o d o l o g y Introduct ion T h i s chapter descr ibes the research des ign, sample, data co l lec t ion procedure, instruments for data co l lec t ion , ethics and human r ights , and the stat ist ical procedures used i n data analys is . Research D e s i g n A descr ipt ive corre la t ional des ign was used i n this study. T h e corre la t ional component a l l owed the researcher to descr ibe funct iona l re lat ionships among var iables (Pol i t & Hung le r , 1983). Samp le T h e sample cons is ted o f 121 subjects selected through conven ience samp l ing . A sample o f 84 subjects was determined to be needed for this study by the Samp le C a l c p rog ram (Anderson , 1982). Th i s p rog ram determined the i dea l number o f subjects requi red to test the s ign i f icance o f a cor re la t ion o f R= .30 , based on a power o f 0.8, a m e d i u m size effect o f 0.30, and a con f idence in terva l o f .95. Subjects selected for i nc lus ion in the study met the f o l l o w i n g cr i ter ia: 1. T h e y had their f i rst b io log i ca l va lve imp lan ted at least 12 months pr ior . 2. The i r in i t i a l b i o l og i ca l va lve were imp lan ted after the age o f thirty years. 3. T h e y had single aort ic or mi t ra l va lve implants wi thout coronary artery disease. 4 . T h e y had not undergone reoperat ion fo r replacement o f their b io log i ca l va lve . 5. T h e y had their va lve surgery i n one o f the two tertiary centres i n V a n c o u v e r , B r i t i sh C o l u m b i a . 6. T h e y were able to read and understand E n g l i s h . Da ta Co l l ec t i on Procedure Part ic ipants i n this study were obta ined through seven l oca l card iovascu lar surgeons. A l l seven surgeons gave permiss ion for the staff o f the central va l ve registry o f the D i v i s i o n o f Card iovascu la r and Tho rac i c Surgery o f the Un i ve rs i t y o f B r i t i sh C o l u m b i a to ident i fy patients w h o met the cr i ter ia fo r the study. S tamped coded envelopes were de l ivered to the of f ice o f the centra l va l ve registry and ma i l ed f r o m there by their staff after l abe l l i ng each packet . A total o f 228 envelopes were ma i led . E a c h coded enve lope i nc luded an in t roductory letter (see A p p e n d i x B ) , the quest ionnaire, and a return stamped enve lope w i th the researcher 's address on it. Three weeks after the quest ionnaires were ma i l ed , the researcher i n fo rmed the staff o f the central va lve registry o f f i ce o f the coded envelopes st i l l outstanding, and de l i vered stamped envelopes conta in ing the reminder letters (see A p p e n d i x C ) fo r the o f f i ce staff to labe l and m a i l . Instruments for Da ta C o l l e c t i o n F o u r instruments for data co l lec t ion were u t i l i zed i n this study. T h e Uncer ta in ty Stress Sca le ( U S S ) (Append ix D ) deve loped by H i l t o n and the M i s h e l Uncer ta in ty i n I l lness Sca le ( M U I S ) ( C o m m u n i t y Ve rs ion ) (Append i x E ) were used to measure perce ived uncertainty. The Can t r i l S e l f - A n c h o r i n g Sca le (Append i x F ) was used to measure past, present, and future l i fe sat isfact ion and heal th status. F i n a l l y , a Pat ient In format ion Sheet (Append i x G ) was u t i l i zed to co l lec t demograph ic and health in format ion. Uncer ta in ty Stress Sca le ( U S S ) T h e Uncer ta in ty Stress Sca le (H i l t on , 1988a) consists o f three parts (see A p p e n d i x D ) . T h e f irst part contains 48 i tems and asks potent ia l part ic ipants fo r their perce ived agreement or d isagreement i n re lat ion to a number o f areas o f uncertainty/certainty. It uses a f i ve po in t L i k e r t scale. The second part asks potent ia l part ic ipants the degree o f stress that the uncertainty o r certainty e l ic i ts fo r each o f the 48 i tems. Th i s instrument is the on l y scale to date w h i c h measures the degree o f stress generated by uncertainty. T h e th i rd part is a g loba l assessment o f uncertainty about their heart cond i t ion , and the stress, threat, and opportuni ty generated f r o m the uncertainty i n their heart s i tuat ion w i t h the use o f v i sua l analogue scales. T h e deve lopment o f the U S S was based on H i l t o n ' s phenomeno log ica l research o f w o m e n cop ing w i th breast cancer (1988b). F r o m the phenomeno log i ca l study, uncertainty was ident i f ied as: not be ing able to forete l l the future; not fee l i ng secure and safe f r o m danger, be ing i n doubt; be ing undec ided ; hav ing a percept ion o f vagueness; and not be ing able to re ly o r count on someone o r something. T h e o r ig ina l U S S was a 55 i tem scale des igned for people w h o had a d iagnos is o f cancer. It cons is ted o f f i ve conceptual factors w h i c h were uncertainty re lated to: interpretation and understanding o f the s i tuat ion; m a k i n g dec is ions and manag ing /con t ro l l i ng the si tuat ion; not be ing able to forete l l the future i n terms o f the symptoms and outcomes; unre l iab i l i ty /undependabi l i ty o f tests and peop le ; and doubts about cho ices , be l ie fs , and people . Content va l ida t ion o f the i tems was done and rev is ions were made based on the comments o f experts, i nc lud ing sk i l l ed nurses and doctors, pat ients, and psychomet r ic ians . H i l t o n , us ing the U S S , conducted a p i lo t study o f 300 patients w h o had a d iagnos is o f cancer and w h o had stayed at the Canad ian Cance r Soc ie ty L o d g e i n V i c t o r i a , B r i t i sh C o l u m b i a . Fac to r analys is us ing M a x i m u m L i k e l i h o o d was done w i th a rotat ion o f c=.5. A n a l y s i s ident i f ied a n ine factor so lu t ion w i t h a goodness o f f i t - c h i square o f 0.99. A c c o r d i n g to P o l i t and H u n g l e r (1983) factor analys is is used to reduce a large set o f var iables into a smal le r , more manageable set o f measures. T h e n ine factors had internal cons is tency a lpha coef f ic ients w h i c h ranged f r o m 0.47 to 0.74. T h e results suggested that further ref inement was needed for some i tems and that i tems needed to be added to some subscales to g ive them a total o f ten each i n order to ensure better re l iab i l i ty . T o make the U S S appropriate for patients w i th other types o f d isorders, H i l t o n and her research assistants, i nc l ud ing this researcher, r ev iewed the l i terature re lated to uncertaint ies and concerns o f l i v i n g w i th card iovascu lar and k i dney d isorders. T h e y in te rv iewed ind iv idua ls w i th these disorders i n order to ident i fy uncertaint ies and certainties for them. T h e card iovascu lar group cons is ted o f patients w h o had coronary artery bypass surgery, va l ve surgery, heart d isease, arrhythmias, and aort ic aneurysm. A f t e r the card iovascu lar patients ind icated their areas o f uncertainty, they responded to a 55 i tem vers ion o f the U S S quest ionnaire o r ig ina l l y des igned for cancer patients and were asked to commen t on h o w the uncertainty too l c o u l d be mod i f i ed . T h e 55 i tem too l was rev i sed to a 48 i tem quest ionnaire w i th four factors. T h e four factors are: l ack o f c lar i ty i n interpretat ion and understanding o f the si tuat ion (12 i tems); not be ing able to foretel l the future i n terms o f the symptoms and outcomes (13 i tems) ; dependab i l i t y / re l i ab i l i t y (11 i tems); and be ing i nc l i ned to d isbel ie f , doubts about cho ices , treatments, strategies, and behaviours (12 i tems). T h e 48- i tem vers ion o f the U S S u t i l i zed i n this study has been tested w i t h 150 card iac and vascu lar patients, 100 k idney patients, and ove r 200 cancer patients. In this study the internal cons is tency re l iab i l i ty o f the U S S was .92. T h e four factors had the f o l l o w i n g a lpha coef f ic ients : lack o f c lar i ty . 81 ; not be ing able to forete l l the future .67; dependabi l i ty / re l iab i l i ty .86; and be ing i nc l i ned to d isbe l ie f .76. M i s h e l Uncer ta in ty i n I l lness Sca le ( M U I S ) ( C o m m u n i t y Ve rs ion ) T h e M U I S (communi ty vers ion) is a 28- i tem L i k e r t - format scale w h i c h measures the pat ient 's percept ion o f uncertainty i n the areas o f symptomato logy , d iagnos is , treatment, re lat ionships w i th caregivers, and prognos is ( M i s h e l , 1983) (see A p p e n d i x E ) . T h e M U I S (commun i ty vers ion) was deve loped f r o m the o r ig ina l M U I S scale w h i c h was des igned to measure the exper ience o f uncertainty dur ing i l lness by hospi ta l patients. T h e o r ig ina l M U I S scale was constructed by in i t ia l l y conduc t ing an exploratory study i n w h i c h 45 hosp i ta l ized patients were in te rv iewed to ident i fy events perce ived as uncertain. T h e in terv iews focussed on four i l lness-re lated tasks: symptoms, treatment, technica l env i ronments and un fami l ia r rout ines, and assessment o f the future and independence ( M o o s , 1977). F r o m these . in terv iews a l is t o f statements was c o m p i l e d and was submit ted to a group o f nurses, doctors , and patients for judgement. A statement was j udged to produce uncertainty i f one o f the eight uses o f the term " u n c e r t a i n " was present i n the pat ient 's statement: vague, hav ing mul t ip le meanings, probabi l i ty , ambiguous, inconsistent , l ack o f in fo rmat ion , unpredictable, or unc lear ( M i s h e l , 1981). A total o f 6 2 i tems ref lected uncertainty and were rewri t ten in to 54 i tems. T h e scale was adminis tered to 259 hosp i ta l ized patients and factor ana lyzed w i th an or thogonal (Va r imax ) rotat ion. Three va l ida t ion studies were carr ied out us ing a total o f 259 hosp i ta l i zed patients. The purpose o f the f irst va l ida t ion study was to test the hypothesis that patients undergo ing rule-out d iagnost ic procedures perce ive more uncertainty than med i ca l and surg ica l patients w i th determined diagnoses ( M i s h e l , 1981). S ign i f i cant di f ferences were found between the d iagnost ic , m e d i c a l and surg ica l patients. T h e diagnost ic patients demonstrated s ign i f i can t ly more uncertainty than the patients w h o had a def in i te d iagnosis . T h e second va l ida t ion study tested the hypothesis about the re lat ionship between perce ived uncertainty and stress as exper ienced by 100 med ica l patients. T h e results ind icated that a pat ient 's perce ived uncertainty was strongly re lated to his rat ing on the Hosp i t a l Stress Events Sca le . T h e th i rd va l ida t ion study p rov ided ev idence o f the construct va l id i ty o f M U I S by conve rg ing the scale w i th a di f ferent method for measur ing the same construct. It was hypothes ized that uncertainty w o u l d be related to the l ack o f comprehens ion . T h e M U I S and the Comprehens ion In terv iew were g i ven to 26 cancer patients. T h e results ind icated that a h igh leve l o f uncertainty was corre lated w i th a l owe r leve l o f comprehens ion . In a subsequent study, M i s h e l (1983) attempted to deve lop uncertainty scales that were spec i f ic to the concerns o f selected patient populat ions. C lus te r analyses w i th 268 hosp i ta l ized and c l i n i c patients (card iovascular disease, gastrointest inal cond i t ions , cancer , lupus, pr imary treatment, and card iac catheter izat ion) were car r ied out. A l l populat ions, except those w i th gastrointest inal p rob lems, showed the predic ted factors o f uncertainty f r o m the clusters. F o r examp le , clusters w h i c h emerged f r o m the card iovascu lar group were re lated to ambigu i ty , w h i c h refers to the ambigu i ty concern ing the severi ty o f heart disease and the comp lex i t y regard ing the effect iveness o f the treatment. In the 28 i t em M U I S (communi ty vers ion) , the four i tems related to hosp i ta l iza t ion were e l im ina ted by M i s h e l . H i l t o n (1987) reported us ing the M U I S (commun i t y vers ion) i n her doctora l study o f cop ing w i th the uncertaint ies o f breast cancer. A factor analys is f o l l o w e d by or thogonal V a r i m a x rotat ion was conducted w h i c h resul ted i n a s ix- factor so lut ion. T h e scale had an internal cons is tency re l iab i l i t y a lpha o f 0.87 and each o f s ix factors had internal consistencies w h i c h ranged f r o m 0.50 to 0.82. T h e s ix factors were : lack o f cons is tency i n the si tuat ion, l ack o f c lar i ty i n the si tuat ion regard ing the i l lness , not understanding explanat ions, indef in i teness o f the i l lness , indeterminacy o f the treatment ef fect iveness, and not k n o w i n g about the si tuat ion. A c c o r d i n g to M i s h e l (personal commun ica t i on , October , 1988) factor analys is o f the M U I S C V i tems resul ted i n a four factor so lut ion. T h e four factors were ambigu i ty , comp lex i t y , l ack o f in fo rmat ion , and unpredic tab i l i ty i n the s i tuat ion. T h e sample used to obtain the data compr i sed 372 patients d iagnosed w i th i r r i table b o w e l disease and 278 patients d iagnosed w i th arthrit is. T h e internal cons is tency a lpha coef f ic ients for the total scale were .84 and .91 respect ive ly . S i m u r d a (1988) reported us ing the M U I S (communi ty vers ion) i n her M a s t e r ' s thesis ent i t led " D i f f e r e n c e s in Uncer ta in ty and Qua l i t y o f L i f e B e t w e e n P r i m a r y and Reopera t ion Corona ry A r te ry Bypass P a t i e n t s " . A conven ience sample o f 41 p r imary C A B G patients and 11 reoperat ion patients w h o were f i ve to ten months postoperat ive comple ted the scale. S imu rda ' s study ind ica ted that there was no s igni f icant d i f ference i n uncertainty between the p r imary C A B G and the reoperat ion patients. Internal cons is tency a lpha o f the M U I S C V was 0.89. In this study, the internal consistency re l iab i l i ty o f the M U I S C V was .91 . T h e four factors had the f o l l o w i n g a lpha coef f ic ients : ambigu i ty .90, comp lex i t y .75 , in fo rmat ion .52, and unpredic tab i l i ty .64. Can t r i l S e l f - A n c h o r i n g Sca le T h e Can t r i l S e l f - A n c h o r i n g Sca le is represented as a ver t ica l ladder w i th ten d iv i s ions (see A p p e n d i x F ) . E a c h subject is asked to descr ibe the very highest and lowest l eve l o f l i fe sat isfact ion w h i c h become the top and bot tom endpoints or anchors o f the ladder (K i l pa t r i ck & Can t r i l , 1960). These anchors represent the subject 's o w n percept ions o f m i n i m a l and m a x i m a l l i fe sat isfact ion. U s i n g their personal ly de f ined anchor ing points subjects are then asked to ind icate the point on the ladder at w h i c h they w o u l d p lace themselves right n o w (present l i fe sat isfact ion), two years ago (past l i fe sat isfact ion) and two years f r o m n o w (future l i fe sat isfact ion). A s w e l l , subjects are asked to ind icate where on the ladder they w o u l d expect an average person their age to be w i t h respect to l i fe sat isfact ion. U s i n g another ladder each subject is asked to descr ibe the very best and worst health expected. T h e scale is an instrument that measures the percept ions o f people based on their o w n wor lds o f real i ty. Content va l id i ty was secured as subjects f r o m a var iety o f populat ions were in terv iewed in order to obtain substantial in fo rmat ion f r o m the subjects that def ined their anchor ing points. A c c o r d i n g to K i l p a t r i c k and Can t r i l (1960), the scale di f ferent iated aspirat ions o f people w i th di f ferent backgrounds. T h e scale has been w ide l y used both i n and outside o f nurs ing to measure i nd i v idua l percept ions, and the predominant var iab le measured has been l i fe sat isfact ion ( M c K e e h a n et. a l , 1986). T h e Can t r i l Se l f -A n c h o r i n g Sca le was used to measure l i fe sat isfact ion in the study by Pencko fe r and H o l m (1984). Pat ient In format ion Sheet T h e patient in format ion sheet used in the study was des igned to co l lec t relevant demograph ic and health related data f r o m each subject (see A p p e n d i x G ) . Items i nc luded in fo rmat ion about the subjects ' age, sex, emp loymen t status, health status, h istory o f their va l ve , and percept ions about the status o f their b i o l og i ca l va lve . E th i cs and H u m a n R igh ts T h i s study protected the human r ights o f its subjects and was conducted i n an eth ica l manner. P r i o r to conduct ing the study, permiss ion was obta ined f r o m the Un i ve rs i t y o f B r i t i s h C o l u m b i a Behav iou ra l Sc iences Screen ing Commi t t ee fo r Research and other Studies Invo l v ing H u m a n Subjects. A s w e l l , pe rm iss ion was obta ined f r o m each o f the seven card iovascu lar surgeons for a l l potent ia l patients par t ic ipat ing in the study. A l l o f the potent ia l part ic ipants rece ived an int roductory letter ou t l i n ing the purpose o f the study and the nature o f their par t ic ipat ion, as w e l l as a statement ind ica t ing that return o f the quest ionnaire ind icated their consent to part ic ipate i n the study. T h e researcher 's name and telephone number were i nc l uded i n the int roductory letter and part ic ipants were encouraged to contact the researcher shou ld they have any quest ions o r concerns about the study. A n o n y m i t y and conf ident ia l i ty have been main ta ined throughout this study. T h e names o f the part icipants does not appear on the quest ionnaires. E a c h part ic ipant was assigned a code number and the researcher d i d not have access to their names. In this w a y the part ic ipants remained anonymous to the researcher. A l l o f the potent ia l part ic ipants were i n fo rmed that they were under no ob l iga t ion to part ic ipate i n the study and cou ld w i thdraw or refuse to answer any quest ions wi thout any effect to their future med ica l or nurs ing care. In add i t ion , a l l potent ia l part ic ipants were in fo rmed i n wr i t i ng that raw data re lated to the M i s h e l Uncer ta in ty Sca le wi thout any ident i fy ing in fo rmat ion w o u l d be added to a larger p o o l o f data that was be ing gathered by a nurse researcher at the Un i ve rs i t y o f A r i z o n a . The raw data submit ted w i l l be used to establ ish a normat ive data base for c l i n i ca l populat ions w i th the M U I S C V . 45 Da ta A n a l y s i s R a w data f r o m the quest ionnaires were coded , entered into a computer f i le and ana lyzed us ing the Stat ist ical P r o g r a m for the S o c i a l Sc iences ( S P S S X ) computer p rogram. Desc r ip t i ve and parametr ic statistics were used to ana lyze the data. Desc r ip t i ve statistics p rov ided a means for descr ib ing the character ist ics o f the sample, and the var iab i l i ty i n scale responses. Research quest ions numbers one and two were ana lyzed us ing descr ipt ive statistics. Parametr ic statistics were used because they are more power fu l and of fer more f l ex ib i l i t y than nonparametr ic tests (Po l i t & Hung le r , 1983). In add i t ion , parametr ic statistics g ive stronger results w i th an adequate sample s ize , even w h e n the normal i t y assumpt ion is not quite met. T h e Pearson 's Produc t M o m e n t Cor re la t ion test was used to determine the re lat ionship between uncertainty and t ime s ince imp lant (research quest ion number three), the re lat ionship between uncertainty and l i fe sat isfact ion (research quest ion number four) , and the re la t ionship between uncertainty and age at in i t ia l imp lant (research quest ion number f ive) . T h e Pearson r is a parametr ic statistic used to determine whether the coef f ic ient is s ign i f icant ly di f ferent f r o m zero (no corre lat ion) (Burns & G r o v e , 1987). In add i t ion , the O n e w a y A n a l y s i s o f Va r i ance was used to examine di f ferences between uncertainty and t ime s ince implant between four t ime per iods. W h e n an ove ra l l s ign i f icant re lat ionship was found , a post -hoc analys is us ing the D u n c a n procedure was per formed. T h e post-hoc analys is was used to determine w h i c h pairs o f the four t ime per iods appeared to be di f ferent. T h e l eve l o f s ign i f icance establ ished for this study was 0.05. C H A P T E R F O U R Presentat ion and D i scuss ion o f Resul ts Introduct ion T h i s chapter consists o f three sect ions. T h e f irst sect ion prov ides a descr ip t ion o f the character ist ics o f the sample. T h e second sect ion presents the f ind ings , and the th i rd sect ion prov ides a d iscuss ion o f the results. Character ist ics o f the Samp le T h e sample cons is ted o f 121 patients w h o had their f i rst b i o l og i ca l va l ve imp lan ted at least twe lve months pr ior . A total o f 228 patients were ma i l ed the quest ionnaires and after one reminder letter was sent out the response rate was 7 4 % . O f the quest ionnaires sent out 53 patients had fa i l ed to respond for u n k n o w n reasons, 26 quest ionnaires were returned due to address p rob lems, seven quest ionnaires were on l y ha l f comple te , s ix patients had d ied , s ix patients ind ica ted that they were too s ick (recent surgery, stroke), f i ve patients had been imp lan ted w i th a second va lve , and four patients had language d i f f icu l t ies . T h e sample w i l l be d iscussed i n terms o f its demograph ic character ist ics, heal th characterist ics and va lve implant history. D e m o g r a p h i c Character is t ics o f the Samp le D e m o g r a p h i c data co l lec ted f r o m the subjects were sex, age, emp loyment status, occupat iona l l eve l , d isabi l i ty or s ick leave status and 48 educat ional l eve l . O f the 121 b io log i ca l va l ve patients, 57 were male (47.1%) and 64 were female (52.9%). A g e o f the subjects ranged f r o m 40 to 86 years (M=66 .78 , S D = 10.99) (see Tab le I). Tab le I A g e D is t r i bu t ion F o r Samp le A g e Frequency Percent 40-45 3 2.5 46 -50 10 8.3 51-55 10 8.3 56 -60 10 8.3 61-65 16 13.2 66-70 23 19.0 • 71 -75 20 16.5 76 -80 16 13.2 81-85 11 9.1 86-90 2 1.6 To ta l 121 100.0 E m p l o y m e n t character ist ics revealed that the major i ty o r 68 subjects (56.2%) were ret i red. O f the rema in ing 32 subjects, 25 were fu l l - t ime homemakers (20.7%), 2 0 subjects (16.5%) w o r k e d fu l l - t ime outs ide the home, and 7 subjects (5.8%) w o r k e d on a part- t ime basis. T h e occupat iona l l eve l o f the subjects is presented in Tab le II and shows that the major i ty o f subjects were ret i red. O n l y 6 .6% o f the subjects were on d isab i l i t y or s ick leave. Tab le in presents the educat ional l eve l o f the sample. T h e major i ty o f the b i o l og i ca l va lve patients had either attained an educat ional l eve l o f grade 9 to 11 (30.6%) or grade 12 to 13 (30.6%). Tab le U Occupa t i on o f B i o l o g i c a l V a l v e Subjects Occupa t i on Frequency Percent P ro fess iona l 3 2.5 B l u e C o l l a r 15 12.4 U n s k i l l e d 9 7.4 H o m e m a k e r 25 20.7 Re t i red 68 56.2 M i s s i n g 1 .8 To ta l 121 100.0 Tab le H I Educa t i on L e v e l F o r Samp le Educa t i on L e v e l F requency Percent U p to grade 8 27 22.3 Grade 9-11 37 30.6 Grade 12-13 37 30.6 C o l l e g e / U n ivers i ty 19 15.7 Masters /Doctora te 1 .8 To ta l 121 100.0 Hea l th Character is t ics o f the Samp le Hea l t h data co l lec ted f r o m the b io log i ca l va lve patients were health status and health prob lems. S i x t y -seven o f the va lve patients (55.4%) reported hav ing other med i ca l o r heal th p rob lems, whereas 54 patients (44.6%) reported hav ing no other heal th p rob lems. O f the 67 w h o reported health p rob lems, 30 were categor ized as hav ing ma jo r health prob lems (24.8%) and 37 were categor ized as hav ing m i n o r health prob lems (30.6%). The ma jo r health p rob lems reported i nc luded : hyper tens ion, diabetes (contro l led and uncontro l led) , depress ion, cancer , ep i lepsy , and C r o h n ' s disease. T h e m ino r health prob lems i nc luded : hay fever, obes i ty , prostate p rob lems and hiatus hernias. Severa l subjects reported advanc ing age as a health p rob lem. V a l v e Implant H i s to r y V a l v e imp lant h istory co l lec ted f r o m the subjects were the age at in i t ia l imp lan t , t ime s ince implant , and d i f f icu l t ies exper ienced w i th their b i o log i ca l va lve . T h e age at in i t ia l imp lant ranged f r o m 32 to 81 years (M=59.67 , SD=10 .89) (see Tab le I V ) w i th the major i ty o f va lve patients be ing between 50 and 75 years o f age. T h e t ime s ince imp lant o f each subject 's b io log i ca l va l ve was recorded i n years s ince imp lant (see Tab le V ) . The mean was 7.25 years w i th the range go ing f r o m 2.11 years to 12.67 years. T h e standard dev ia t ion was 3.16 years. T h e major i ty o f the va lve patients (87.6%) had not exper ienced any d i f f icu l t ies w i t h their va l ve , but 14 subjects (11.6%) had reported hav ing prob lems and one subject d i d not respond (.8%). The most f requent ly reported 51 d i f f icu l t ies were heart f ib r i l l a t ion / palpi tat ions (8 patients) and va l ve leakage (4 patients). Tab le I V A g e A t In i t ia l Implant F o r Samp le A g e Frequency Percent 30 -34 1 .8 35-39 7 5.8 40 -44 4 3.4 45 -49 9 7.4 50-54 16 13.2 55-59 17 14.1 60-64 27 22.3 65-69 16 13.2 70 -74 16 13.2 75 -79 7 5.8 80-84 1 .8 To ta l 121 100.0 Tab le V T i m e S ince Implant o f the Samp le T i m e (years) 2-4 5-7 8-10 11-13 To ta l F requency 33 35 30 23 121 Percent 27.3 28.9 24.8 19.0 100.0 52 F ind ings T h e f ind ings o f this research w i l l be presented i n re la t ion to each o f the research quest ions. T h e re lat ionships between uncertainty and t ime s ince implant , uncertainty and past, present, and future l i fe sat isfact ion, and uncertainty and age at in i t ia l implant were ana lyzed us ing the Pearson product-moment corre la t ion statistic. A n a l y s i s o f var iance ( A N O V A ) was used to examine the di f ferences between uncertainty and years s ince implant . Research Ques t ion 1: W h a t is the perce ived leve l o f uncertainty o f patients  w i th b i o l og i ca l va lves? In terms o f the uncertainty perce ived by these subjects, the f requency and d is t r ibut ion o f the uncertainty scores were examined . In add i t ion , the means o f i tems fo r each o f the factors for the two uncertainty scales was presented to show w h i c h factors ref lect the highest uncertainty. T h e total score on the Uncer ta in ty Stress Sca le ( U S S ) for b io log i ca l va lve patients ranged f r o m a l o w o f 61 to a h igh o f 182 ( M = l 11.66, SD=24.88) (see Tab le V I ) . Scores on the M i s h e l Uncer ta in ty Sca le ( M U I S C V ) for b io log i ca l va lve patients ranged f r o m a l o w o f 34 to a h igh o f 117 (M=67.54 , SD=14.83) (see Tab le V I I ) . T h e mean score o n the overa l l uncertainty v i sua l analogue ( U S S ) was 25 .30 and standard dev ia t ion 26.16 ( m i n i m u m score=100, m a x i m u m score=0). Tab le V I To ta l Uncer ta in ty Score F o r B i o l o g i c a l V a l v e Patients w i th the Uncer ta in ty  Stress Sca le To ta l Score Frequency Percent 60 -74 ( low uncertainty) 7 5.8 75 -89 17 14.0 90 -104 23 19.0 105-119 37 30.6 120-134 16 13.2 135-149 11 9.1 150-164 6 5.0 165-179 3 2.5 180-194 (h igh uncertainty) 1 .8 To ta l 121 100.0 No te . 48 i tems scored f r o m 1 to 5 . M i n i m u m score poss ib le is 48 and m a x i m u m score poss ib le is 240. Tab le V H To ta l Uncer ta in ty Score F o r B i o l o g i c a l V a l v e Patients w i th the M i s h e l  Uncer ta in ty Sca le To ta l Score Frequency Percent 30-39 ( low uncertainty) 5 4.1 40 -49 7 5.8 50 -59 19 15.7 60 -69 40 33.0 70 -79 30 24.8 80-89 11 9.1 90 -99 6 5.0 100-109 1 .8 110-119 (h igh uncertainty) 2 1.7 To ta l 121 100.0 No te . 28 i tems scored f r o m 1 to 5 . M i n i m u m score poss ib le is 28 and m a x i m u m score poss ib le is 140. 54 Tab les V U I and I X , present the findings fo r the factors for the two uncertainty scales ( U S S and M U I S C V , respect ive ly) . The means o f i tems for each factor fo r the U S S indicate that uncertaint ies related to not be ing able to forete l l the future (2.90) and be ing i nc l i ned to d isbe l ie f (2.36) were highest and the other uncertaint ies were l ower w i th dependabi l i ty / re l iab i l i ty be ing lowest at 1.88. F o r the M U I S C V , the means o f i tems for each factor ind icate that uncertaint ies re lated to unpredictabi l i ty (3.15) and ambigu i ty i n the si tuat ion (2.33) were highest, wh i l e the lowest uncertaint ies were lack o f in fo rmat ion i n the si tuat ion (2.12). Tab le V f f l Uncer ta in ty Stress Sca le I tem and Fac tor M e a n s and Standard Dev ia t i ons Fac to r (Items i n factor) M e a n S D M e a n o f factor o f I tems I L a c k o f C la r i t y (12) 24.99 7.36 2.08 II N o t B e i n g A b l e (13) 37.64 6.86 2.90 to Fore te l l the Future III Dependab i l i t y / (11) 20.69 7.33 1.88 Re l i ab i l i t y I V B e i n g Inc l ined (12) 28.35 7.37 2.36 to D i s b e l i e f To ta l Sca le Re l i ab i l i t y (48) 111.66 24.88 Tab le I X M i s h e l Uncer ta in ty Stress I tem and Fac tor M e a n s and Standard Dev ia t ions Fac to r (Items i n Factor) M e a n o f factor S D M e a n o f I tems I A m b i g u i t y (14) 32.62 9.42 2.33 II C o m p l e x i t y (5) 10.66 3.02 2.13 III In format ion (4) 8.49 2.36 2.12 I V Unpred ic tab i l i t y (5) 15.77 3.43 3.15 To ta l Sca le (28) 67.54 14.83 Re l i ab i l i t y Research Ques t ion 2 : W h a t is the perce ived leve l o f past, present, and future  l i fe sat isfact ion o f b io log i ca l va lve patients? In terms o f l i fe sat isfact ion perce ived by these subjects, the mean and standard dev ia t ion o f their l i fe sat isfact ion ratings was examined (see Tab le X ) . T h e rat ings for past l i fe sat isfact ion on the Can t r i l S e l f - A n c h o r i n g Sca le ranged f r o m 1 to 10. T h e mean rat ing was 6.70 and the standard dev ia t ion was 2.42. T h e present l i fe sat isfact ion rat ings for the Can t r i l S e l f - A n c h o r i n g Sca le ranged f r o m 1 to 10 w i th a mean o f 7.39 and a standard dev ia t ion o f 1.96. T h e rat ings fo r future l i fe sat isfact ion on the Can t r i l S e l f - A n c h o r i n g Sca le for va l ve patients ranged f r o m 1 to 10 w i th a mean o f 7.51 and a standard dev ia t ion o f 1.97. F i n a l l y , the b i o l og i ca l va lve patients were asked what the l i fe sat isfact ion o f the average person their age was. In this sample , the rat ings on the Can t r i l S e l f - A n c h o r i n g Sca le ranged f r o m 3 to 10 w i th a mean o f 7.38 and a standard dev ia t ion o f 1.60. Tab le X Past . Present. Fu ture , and A v e r a g e Person L i f e Sat is fact ion R a t i n g F r e q u e n c y * Percent F requency * Percent Past Present 1-2 8 6.6 3 2.5 3-4 16 13.2 8 6.6 5-6 30 24.8 25 20 .6 7-8 33 27.3 48 39.7 9-10 34 28.1 37 30.6 Future Ave rage 1-2 2 1.6 0 0 3-4 9 7.4 4 3.3 5-6 21 17.4 30 24.8 7-8 49 40.5 62 51 .2 9-10 4 0 33.1 25 20.7 No te . Sca le ranged f r o m 1 = very lowest l eve l o f l i fe sat isfact ion to 10 = very highest l eve l o f l i fe sat isfact ion. * N = 121 57 Research Ques t ion 3 : W h a t is the re lat ionship between uncertainty and the t ime  s ince imp lan t o f the b io log i ca l va lve? T o address the quest ion related to the re lat ionship between uncertainty and t ime s ince imp lan t , the f ind ings o f the Pearson product -moment corre lat ion and analys is o f var iance were examined . T h e Pearson product -moment cor re la t ion ind icated that there was no s igni f icant re lat ionship between uncertainty as measured by the U S S and t ime since imp lant (r=-.13, p=.08). A l s o , there was no s igni f icant re lat ionship between uncertainty as measured by the M U I S C V and t ime s ince implant (r=-.14, p=.065). H o w e v e r , w h e n subjects were grouped accord ing to year groupings o f t ime o f imp lant and analys is o f var iance ( A N O V A ) was per formed, a s igni f icant d i f ference was f o u n d between uncertainty us ing the U S S and the groups accord ing to year o f imp lan t (F=3.30, p=.02). A D u n c a n post-hoc test was per fo rmed and the results ind ica ted that the group 1976-78 was s ign i f icant ly di f ferent f r o m the 1979-81 group and the 1982-84 group at the .05 leve l . T h e uncertainty ( U S S ) means and standard deviat ions for each o f the groups (year o f implant grouped) are presented i n Tab le X I . There was no s igni f icant d i f ference between the groups accord ing to year o f implant and uncertainty us ing the M U I S C V (F=1.93, p=.13). T h e uncertainty ( M U I S C V ) means and standard deviat ions for each o f the groups are presented in Tab le X I I . Tab le X I Uncer ta in ty Scores (USS) by Y e a r o f Implant Y e a r F requency M e a n Standard M i n i m u m M a x i m u m o f Implant Dev ia t i on Sco re Sco re 1976-78 23 98.61 17.15 76 136 1979-81 30 118.73 21.27 68 178 1982-84 35 114.89 22.71 73 182 1985-87 33 110.91 31.30 61 177 To ta l 121 111.66 24.88 61 182 No te . 1976-78 s ign i f i cant ly di f fers f r o m 1979-81 and 1982-84 Tab le X H Uncer ta in ty Scores ( M U I S C V ) by Y e a r o f Implant Y e a r F requency M e a n Standard M i n i m u m M a x i m u m o f Implant Dev ia t i on Score Score 1976-78 23 61.17 11.09 37 85 1979-81 30 69.77 13.23 47 108 1982-84 33 69.71 14.73 38 117 1985-87 33 67.64 17.67 34 112 To ta l 121 67.54 14.83 34 117 59 Research Ques t ion 4 : W h a t is the re lat ionship between uncertainty and past,  present, and future l i fe sat isfact ion for patients w i th a b i o l og i ca l va l ve implant? T o address the re lat ionship between uncertainty and past, present, and future l i fe sat is fact ion, the f ind ings o f the Pearson product -moment corre lat ion were examined . A s igni f icant negat ive re lat ionship was found between uncerta inty us ing the U S S and past, present, and future l i fe sat isfact ion (past r=-.49, p=.00; present r=-.37, p=.00; future r=-.44,p=.00). T h e corre la t ion o f uncertainty us ing the M U I S C V w i th past, present, and future l i fe sat isfact ion a lso showed a l l s igni f icant negat ive re lat ionships (past r=-.52, p=.00; present r=-.35, p=.00; future r=-.43, p=.00). H i g h e r uncertainty was associated w i th l owe r expectat ions o f past, present, and future l i fe sat isfact ion. Research Ques t ion 5 : W h a t is the re lat ionship between age at in i t ia l va l ve  imp lan t and l eve l o f uncertainty for b io log i ca l va lve patients? T h e re lat ionship between age at in i t ia l va lve imp lant and l eve l o f uncertainty was examined us ing the Pearson product -moment corre la t ion and an analys is o f var iance on two groups, g rouped by their age o f in i t ia l implant . T h e correlat ions between age at in i t ia l va l ve imp lant and l eve l o f uncertainty us ing the U S S and M U I S C V showed no s ign i f i cance ( U S S r=.07, p=.22; M U I S C V r=.12, p=.09). W h e n subjects were grouped accord ing to their age at va l ve implant , group one cons is t ing o f subjects 30 to 59 years and group two cons is t ing o f subjects 60 years and o lder at in i t ia l va l ve implant , no s ign i f icant d i f ference was found between the groups i n terms o f uncertainty when analys is o f var iance was pe r fo rmed ( U S S F= .01 , p=.91; M U I S C V F=.74, p=.39). A n c i l l a r y F ind ings Othe r analyses were per fo rmed for the purpose o f iden t i f y ing re lat ionships and di f ferences between uncertainty and the stress o f uncertainty, uncertainty and threat, uncertainty and opportuni ty , uncertainty and heal th status, and uncertainty and gender. In addi t ion, f ind ings are presented i n re lat ion to the subjects ' percept ions o f the advantages o f their va l ve , whether they foresee any prob lems w i th the type o f heart va l ve they have, and whether they perce ive that their heart va lve may need to be rep laced. Uncer ta in ty and the Stress o f Uncer ta in ty T h e results o f the U S S scale, w h i c h incorporates a sect ion that assesses the stress o f uncertainty, were used to examine the stress perce ived by these subjects. T h e f requency and d is t r ibut ion o f their stress o f uncertainty scores was examined . F o l l o w i n g this, the re lat ionship between uncertainty and stress o f uncertainty was examined us ing the Pearson product -moment corre lat ion and analys is o f var iance, accord ing to year groupings o f time o f implant . To ta l stress that the uncertainty or certainty e l ic i ts ranged f r o m a l o w o f 48 to a h igh o f 202 (M=77 .52 , SD=32.09) (see Tab le X I I I ) . A s ign i f icant Tab le X I I I To ta l Uncer ta in ty Stress Score F o r B i o l o g i c a l V a l v e Patients U s i n g the U S S To ta l Score Frequency Percent 45 -59 ( l ow stress) 51 42.1 60 -74 18 14.9 75 -89 12 9.9 90 -104 21 17.4 105-119 3 2.5 120-134 6 5.0 135-149 7 5.8 150-164 1 .8 165-179 0 .0 180-194 1 .8 195-209 (h igh stress) 1 8 To ta l 121 100.0 No te . 48 i tems scored f r om 1 to 5. M i n i m u m score poss ib le is 48 and m a x i m u m score poss ib le is 240. pos i t ive re la t ionship was found between uncertainty and stress us ing the U S S (r=.67, p=.00). Subsequent ly , the M U I S C V uncertainty scores were corre lated w i th U S S stress scores, also resul t ing in a s igni f icant re lat ionship (r=.64, p=.00). A s ign i f icant pos i t ive corre lat ion was found between uncertainty ( U S S ) and the stress v i sua l analogue (r=.49, p=.00). That is , the h igher the uncerta inty, the h igher the subjects ' overa l l percept ions o f stress. The scores on the stress v i sua l analogue ranged f r o m 0 to 100 (M=21.26 , SD=24.51) . In add i t ion , an analys is o f var iance was per fo rmed to determine i f a s ign i f icant d i f ference i n degree o f stress (using U S S ) ex is ted between groups, accord ing to year o f implant . A s igni f icant d i f ference i n stress was found between groups (F=2.97, p=.03). A D u n c a n post -hoc test was per fo rmed and revea led that the 1976-78 group was s ign i f icant ly di f ferent f r o m the 1979-81 group, 1982-84 group and the 1985-87 group. T h e stress means and standard deviat ions for each o f the groups (year o f implant) are presented i n Tab le X I V . Tab le X I V Stress o f Uncer ta in ty Scores ( U S S ) F o r Implant G r o u p s G r o u p F requency M e a n Standard M i n i m u m M a x i m u m Dev ia t i on Score Sco re 1976-78 23 60.78 22.80 48 .00 144.00 1979-81 30 84.67 28.32 48.00 145.00 1982-84 35 82.23 37.76 48.00 202.00 1985-87 33 77 .70 31.46 48 .00 144.00 To ta l 121 77 .52 32.09 48 .00 202.00 Uncer ta in ty and Threat T h e U S S also has a sect ion w h i c h assesses the threat generated by the uncertainty. T h e frequencies and d is t r ibut ion o f their threat o f uncertainty scores was examined , as w e l l as the re lat ionship between uncertainty and threat. T h e scores o n the threat v i sua l analogue ranged f r o m 0 to 100 (M=22 .31 , SD=25 .69 ) . A s ign i f icant pos i t ive re lat ionship was found between uncertainty ( U S S ) and threat us ing the threat v i sua l analogue ( U S S ) (r=.46, p=.00). Uncer ta in ty and Oppor tun i ty T h e U S S also has a sect ion w h i c h assesses the opportuni ty generated by the uncertainty. T h e frequencies and dist r ibut ion o f their oppor tun i ty o f uncertainty scores were examined , as w e l l as the re lat ionship between uncertainty and opportuni ty . T h e scores on the opportuni ty v i sua l analogue ranged f r o m 0 to 100 (M=37 .95 , SD=32.01) . In add i t ion , no s ign i f icant re la t ionship was f ound between uncertainty ( U S S ) and opportuni ty us ing the oppor tun i ty v i sua l analogue ( U S S ) (r=.05, p=.28). Uncer ta in ty and Hea l th Status In terms o f health status perce ived by these subjects, the mean and standard dev ia t ion o f their health status rat ings was examined . T h e n the re lat ionship between uncertainty and health status was examined us ing the Pearson produc t -moment corre lat ion. T h e rat ings o f present health status us ing the Can t r i l S e l f - A n c h o r i n g Sca le for subjects ranged f r o m 2 to 10. T h e mean rat ing was 7.13 and the standard dev ia t ion was 1.88. T h e rat ings o f future health status ranged f r o m 3 to 10. T h e mean rat ing was 7.40 and the standard dev ia t ion was 1.81 (see Tab le X V ) . B i o l o g i c a l va lve patients rated the mean health status o f the average person their age to be 7.26 w i th a standard dev ia t ion o f 1.63. T h e Can t r i l S e l f - A n c h o r i n g Sca le ranged f r om 3 to 10. A s igni f icant negat ive re la t ionship was f ound between uncertainty (using the U S S ) and percept ion o f present and future health status (present r=-.58, p=.00; future r=-.52, p=.00). A s w e l l , a s ign i f icant negat ive re lat ionship was found between uncertainty (us ing the M U I S C V ) and present and future health status (present r=-.53, p=.00; future r=-.43, p=.00). Tab le X V Present and Future Hea l th Status F o r Samp le Ra t i ng F requency Present Percent Future F requency Percent 1-2 1 0.8 0 0.0 3-4 12 9.9 9 7.4 5-6 31 25.6 28 23.1 7-8 47 38.9 49 40.6 9-10 30 24.8 35 28.9 To ta l 121 100.1 121 100.0 No te . Sca le ranged f r o m 1 = very lowest l eve l o f health to 10 = very highest l e ve l o f health. Uncer ta in ty and Gende r A n A n a l y s i s o f Va r i ance was f irst used to examine the di f ferences i n uncertainty between m e n and w o m e n , and secondly , to examine the di f ferences i n stress generated by uncertainty between men and w o m e n . A s ign i f icant d i f ference was found i n uncertainty ( U S S and M U I S C V ) between men and w o m e n us ing analys is o f var iance ( U S S F=8.6 , p=.00; M U I S C V F=8.44, p=.00). T h e f ind ings ind icated that females had a h igher l eve l o f uncertainty than males . F i n a l l y , a s igni f icant d i f ference was found i n the stress o f uncertainty ( U S S ) between males and females (F= 11.40, p=.00). Fema les exper ienced a h igher l eve l o f stress generated by uncertainty than males. T h e uncertainty and stress means and standard deviat ions are presented i n Tab le X V I . Tab le X V I Uncer ta in ty and Stress M e a n and Standard Dev ia t i on Scores B y Gende r Sex Frequency M e a n Standard M i n i m u m M a x i m u m Dev ia t i on Uncer ta in ty ( U S S ) M a l e F e m a l e 57 64 104.84 117.73 19.11 27.83 61 68 151 182 Uncer ta in ty ( M U I S C V ) M a l e F e m a l e 57 64 63.51 71.13 10.58 17.08 35 34 85 117 Stress ( U S S ) M a l e F e m a l e 57 64 67.51 86.44 21.73 37.03 48 48 139 202 No te . U S S consists o f 48 i tems scored f r o m 1 to 5. M i n i m u m score poss ib le is 48 and m a x i m u m score poss ib le is 240. M U I S C V consists o f 28 i tems scored f r o m 1 to 5. M i n i m u m score poss ib le is 28 and m a x i m u m score poss ib le is 140. 66 Advan tages and Prob lems o f the B i o l o g i c a l V a l v e T h e subjects were asked to comment on what they perce ived as the advantages o f their va l ve , whether they foresaw any prob lems w i th the type o f heart va lve they had , and whether they perce ived that their heart va l ve m a y need replacement. Tab le X V I I presents the subject 's percept ions o f advantages o f their heart va lve . T h e major advantages were that the va lve w o r k e d w e l l , i t was quiet and it was s im i la r to their natural va lve . N ine ty subjects d i d not Tab le X V I I Pe rce i ved Advantages o f B i o l o g i c a l V a l v e s G i v e n B y Subjects Advantages F requency Percent o f Responses W o r k s w e l l Quietness o f va lve S i m i l a r to natural va l ve N o ant icoagulat ion medicat ion D o not k n o w L o n g e r l i fe Du rab i l i t y P roduc t conf idence (best type) N o re ject ion A c t i v i t y tolerance L e s s catastrophic fa i lure Breathe easier M isce l l aneous 24 23 22 19 13 9 8 8 7 7 4 4 13 14.9 14.3 13.6 11.8 8.1 5.6 5.0 5.0 4.3 4.3 2.5 2.5 8.1 To ta l Responses 161 100.0 foresee any prob lems (74.4%) w i th their b i o log i ca l va l ve , 28 subjects (23.1%) expected to have p rob lems, and 3 subjects d i d not k n o w (2.5%). O f the 28 subjects w h o foresaw prob lems w i th their va l ve , 33 comments were g iven as to the d i f f icu l t ies they perce ived (see Tab le X V I I I ) . T h e d i f f icu l t ies i nc luded va lve re-replacement, wear ing out, va lve leak ing , and ca lc i f i ca t ion . Interest ingly enough , 29 comments regard ing potent ia l d i f f icu l t ies were g iven by the 9 0 subjects w h o d i d not foresee that their va l ve w o u l d have any p rob lems. These d i f f icu l t ies were s im i la r to the group o f patients that perce ived that they w o u l d have d i f f i cu l ty w i th their heart va l ve i n the future. Tab le X V I H Prob lems Tha t Subjects Fo resaw W i t h The i r B i o l o g i c a l V a l v e P rob lems Y e s N o To ta l V a l v e re-replacement 13 7 20 W e a r i n g out 12 6 18 V a l v e L e a k i n g 2 1 3 Ca l c i f i ca t i on 0 1 1 In fect ion 2 0 2 N o idea h o w l o n g va lve lasts 0 3 3 V a l v e lasts a l i fe t ime 0 2 2 R e p l a c e d w i th mechan ica l va lve 1 0 1 P rob lems i f surgery requ i red 1 1 2 Pos i t i ve l i festy le (exercise) 2 6 8 P roduc t con f idence 0 2 2 To ta l 33 29 51 68 W h e n the subjects were asked whether they perce ived that their heart va l ve migh t need to be rep laced, approx imate ly one-ha l f o f the sample responded that their heart va lve w o u l d need to be rep laced (48.8%) and the other ha l f o f the sample perce ived (47.1%) that it w o u l d not require rep lacement , w i th 4 . 1 % ind ica t ing that they d i d not k n o w . It is interest ing to note, that a l though 7 5 % o f the sample d i d not perce ive any d i f f icu l t ies w i th their va l ve , ha l f o f the sample ind icated that their va lve may require replacement. D i scuss ion o f the Resul ts T h e d iscuss ion o f the results is o rgan ized under the f o l l o w i n g headings: character ist ics o f the sample, uncertainty, percept ions o f l i fe sat is fact ion, and the re lat ionships between uncertainty and t ime since implant , age at imp lan t and l i fe sat is fact ion. Cons idera t ion o f the anc i l la ry f ind ings w i l l be incorporated into the d iscuss ions where appropriate. The results o f this study w i l l be d iscussed i n re lat ion to the theoret ical f ramework , other research studies, and methodo log ica l p rob lems inherent i n the study. Character is t ics o f the Samp le T h e response rate was 7 4 % , w h i c h represents a good rate cons ider ing the lack o f personal contact. A c c o r d i n g to B u m s and G r o v e (1987) the response rate for ma i l ed quest ionnaires is usual ly 25 to 3 0 % , and usua l l y a response rate o f 5 0 % is suf f ic ient to prevent response bias. Canad ian statistics f r o m 1982 to 1983, the last per iod fo r w h i c h nat ional statistics are ava i lab le , indicate the number o f heart va lve operat ions per fo rmed o n ma le and female patients i n designated age categories (Statist ics Canada , 1987) (see A p p e n d i x H ) . T h e largest number o f heart va lve operat ions were per fo rmed on patients i n the age group 55 to 64 years o f age (Statist ics Canada , 1987). Th i s sample 's mean age at in i t ia l va lve implant was 59.7 years w i th a range f r o m 32 to 81 years, w h i c h showed s imi lar i ty to the nat ional statistics. T h e inc idence o f heart va lve operat ions increases w i th age (Statist ics Canada , 1987). O f the va l ve operat ions per fo rmed in Canada between 1982 and 1983, 4 8 . 6 % o f the cases were male and 5 1 . 4 % were female (Statist ics Canada , 1987). There fore , w i th respect to age at implant and sex, the sample o f this research study appears to ref lect nat ional trends. H o w e v e r , the statistics kept on va lve operat ions by Statist ics C a n a d a are general . T h e y do not separate into the type o f va lve operat ion. F o r examp le , a l l mechan ica l and b io log i ca l va lves implanted are categor ized together as va lve operat ions. B a r w i n s k y estimates that i n Canada the f requency o f u t i l i za t ion o f b i o l og i ca l and mechan ica l prostheses is essent ial ly equal (personal commun i ca t i on , 1988). T h e major i ty o f the subjects were ret i red w h i c h is consistent w i t h the mean age o f the sample (M=66.8 years). A p p r o x i m a t e l y 8 8 % o f the sample reported that they were not exper ienc ing any d i f f icu l t ies w i t h their heart va lve . T h i s is consistent w i th nat ional trends as most patients become N Y H A class I or II postoperat ive ly (Jamieson et a l , 1989a; L e v i n e et a l , 1981; N i s t a l et a l , 1986). Uncer ta in ty In the d iscuss ion to f o l l o w , the perce ived leve l o f uncertainty o f b i o l og i ca l va l ve patients is d iscussed and poss ib le reasons for the var iab i l i t y i n pe rce ived uncertainty are presented. The factors re f lect ing uncertainty w i t h the two uncertainty instruments are compared to f ind ings i n the l i terature. F i n a l l y , the uncertainty instruments are d iscussed in terms o f their re l iab i l i t y and d i f f icu l t ies inherent i n their use. B i o l o g i c a l va lve patients perce ived moderate ly l o w levels o f uncertainty w i th a mean score o f 111.7 us ing the U S S instrument and 67.5 on the M U I S C V instrument. N o studies were found i n the l i terature that evaluated b i o l og i ca l va lve pat ient 's percept ions o f uncertainty. H o w e v e r , S i m u r d a (1988), w h o a lso used the M U I S C V i n her study o f p r imary and reoperat ion coronary artery bypass graft ( C A B G ) patients found that both groups perce ived moderate ly l o w leve ls o f uncertainty w i th means 60.8 and 65.2 respect ive ly . O n e factor that m a y exp la in the moderate ly l o w levels o f perce ived uncertainty i n this study is the di f ference i n the pat ient 's card iac status preoperat ive ly and postoperat ive ly. T h e major i ty o f patients w i t h nat ive va lve 71 disease are ser ious ly i l l preoperat ive ly (class U l o r I V N Y H A ) and their health status improves s ign i f icant ly postoperat ively (class I or II N Y H A ) (Jamieson et a l , 1989a). It may be that patients fee l so w e l l postoperat ive ly that they cannot foresee any prob lems. Therefore, patients w h o have a s ign i f icant improvement postoperat ive ly m a y have less uncertainty. It is poss ib le that the l o w levels postoperat ive ly are a func t ion o f increased patient conf idence in the health care system. Patients m a y fee l that the health care system w i l l p rov ide the necessary care i n the future shou ld they need it. A l s o , patients may fee l that there is no point i n wo r r y i ng about va l ve fa i lure unt i l i t happens. Therefore, patients may be cop ing w i th their uncertaint ies by us ing the cop ing strategy o f m i n i m i z i n g the si tuat ion. It was interest ing to note that, a l though 7 5 % o f the sample d i d not perce ive any d i f f icu l t ies w i th their va lve , that ha l f o f the sample ind icated that their va l ve migh t need replacement at a future date. T h i s indicates that many o f the subjects are aware that their va l ve may need to be rep laced, but m a y a lso be aware that their psycho log i ca l health depends upon be ing able to put it out o f their m i n d as m u c h as poss ib le i n order to be able to p lan for the future. A n o t h e r reason fo r the moderate ly l o w levels o f uncertainty may be a func t ion that subjects may not have the knowledge to expect va l ve fa i lure. In 1976, there was no exper ience o f b io log i ca l va lve fa i lure, so subjects d i d not k n o w h o w l o n g their va lve w o u l d last ( G a l l u c c i , et a l , 1984; M i l l e r et a l , 1985). B y the ear ly 1980 's in fo rmat ion was avai lab le on va lve fa i lure, but it is not k n o w n i f this in fo rmat ion was commun ica ted to patients w h o had been p rev ious ly imp lanted. Ano the r poss ib le reason for the moderate ly l o w levels o f uncertainty m a y be related to the present age o f the sample and the deve lopmenta l stage attained by the subjects. T h e mean age o f the sample is 67 years and the major i ty o f subjects are ret ired. O l d e r adults (over 65 years) may have reached the deve lopmenta l stage where they bel ieve they have comple ted the major part o f their l i fe w o r k and have l i v e d their l i ves w e l l (Brunner & Suddar th , 1988). T h u s , they m a y have a l ower leve l o f uncertainty re lated to the potent ia l o f heart va l ve fa i lure than a younger person. There was var iab i l i t y i n the uncertainty perce ived by subjects, w i th some subjects hav ing very l o w uncertainty and others hav ing moderate ly h igh uncertainty. O n e reason for the moderate ly h igh levels o f uncertainty may be re lated to the patient rece iv ing inadequate counse l l i ng and support upon be ing g i ven in fo rmat ion on the potent ia l fo r va l ve fa i lure. It is poss ib le that counse l l i ng w o u l d have fac i l i ta ted the reduct ion o f uncertainty. Fur ther invest igat ion may reveal what counse l l i ng and support are ava i lab le to these subjects. A c c o r d i n g to the frequencies w i th in the factor b reakdown obta ined by this researcher us ing the U S S , not be ing able to forete l l the future p rov ided the most uncertainty fo r b io log i ca l va lve patients. Th i s was f o l l o w e d by be ing i nc l i ned to d isbel ie f , doubts about cho ices , treatments, strategies, and behaviours . L a c k o f c lar i ty about the si tuat ion and lack o f dependabi l i ty / re l iab i l i t y p rov ided further uncertaint ies. These results cannot be compared to other studies s ince no other comparab le studies have been done us ing the U S S instrument. U s i n g the M U I S C V instrument, the factor re f lec t ing the highest uncertainty was unpredic tabi l i ty i n the si tuat ion. Th i s was f o l l o w e d by ambigu i ty and comp lex i t y i n the si tuat ion, and f ina l l y , l ack o f in fo rmat ion . In the study by S i m u r d a (1988) unpredictabi l i ty i n the si tuat ion also showed the highest l eve l o f uncertainty. C o m p a r i s o n o f this s tudy 's results w i th S i m u r d a (1988) is d i f f i cu l t since the latter study used a s ix factor analys is o f the M U I S C V i n contrast to the four factor analysis used i n this study. H o w e v e r , both studies f ound moderate ly l o w levels o f uncertainty w i th card iac patients. T h e i tem means for these two studies can be rev iewed i n A p p e n d i x I. There appears to be a h igh degree o f consis tency between the two studies i n the i tems scored to ref lect h igher uncertainty. In add i t ion , b io log i ca l va lve and C A B G patients appear to have s im i la r appraisals o f uncertainty, w i th uncertainty generated p r imar i l y by the unpredictabi l i ty o f the si tuat ion. A l t h o u g h uncertainty scores ind icated that the b io log i ca l va l ve patients exper ienced moderate ly l o w leve ls o f uncertainty and the uncertainty instruments ref lected h igh re l iab i l i ty , it is poss ib le that the instruments d i d not represent a l l the uncertaint ies exper ienced by this group o f patients. T h e U S S instrument had an internal cons is tency a lpha coef f ic ient o f .92 re f lec t ing h igh re l iab i l i ty . The four factors had internal consistencies rang ing f r o m .67 to .92 re f lec t ing h igh re l iab i l i ty . T h e M U I S C V instrument had an internal cons is tency a lpha coef f ic ient o f .91 re f lect ing h igh re l iab i l i ty . T h e four factors had internal consistencies rang ing f r o m .53 to .90 re f lect ing m e d i u m re l iab i l i t y . Therefore this indicates conf idence i n the re l iab i l i ty o f the scales except fo r the factor on in fo rmat ion i n the M U I S C V w h i c h seems to be tapping in to other th ings. There were some d i f f icu l t ies w i th the instruments that were ident i f ied by the subjects, d i rect ly on the quest ionnaire. These d i f f icu l t ies i nc luded the f o l l o w i n g : that it was d i f f i cu l t to disagree w i th a negat ive ly wo rded i tem; the te rm doctor was ambiguous and c o u l d mean f am i l y pract i t ioner, card io log is t or surgeon; the term insurance was ambiguous and cou ld mean l i fe or d isab i l i t y insurance; and the term people was ambiguous and c o u l d mean relat ives or the health care profess ionals . In summary , the U S S and M U I S C V demonstrated h igh re l iab i l i ty . H o w e v e r , there were some d i f f icu l t ies ident i f ied w i th some o f the quest ions or i tems o n par t icu lar instruments w h i c h may need further attention i n future research. T i m e S ince Implant T h i s study revealed that there was no s igni f icant d i f ference between uncertainty (us ing the U S S or the M U I S C V ) and the t ime since imp lan t i n the overa l l analys is o f the sample. H o w e v e r , f ind ings revealed that there was a s ign i f icant d i f ference between uncertainty and the t ime since imp lant fo r subjects grouped accord ing to year o f implant . Subjects imp lan ted between 1976 and 1978, w h o have had their b i o log i ca l va lve implanted for the longest pe r iod o f t ime, approx imate ly 11 to 13 years, exper ienced the lowest l eve l o f uncertainty ( U S S M=98 .61 ) . Whereas the highest l eve l o f uncertainty was exper ienced by subjects imp lan ted between 1979 and 1981 w h o have had their b i o l og i ca l va lves imp lan ted for approx imate ly 8 to 10 years ( U S S M = l 18.73). Subjects imp lan ted between 1982 and 1984 w h o have had their b i o l og i ca l va lve imp lan ted for 5 to 7 years exper ienced the second highest l eve l o f uncertainty ( U S S M = l 14.89). F i n a l l y , subjects imp lan ted between 1985 and 1987, w h o have had their b i o l og i ca l va lves implanted 2 to 4 years, exper ienced the second lowest l eve l o f uncertainty ( U S S M = 110.91). A D u n c a n post-hoc test ind ica ted that the group 1976-1978 was s ign i f icant ly di f ferent f r o m the 1982-84 group, and the 1976-78 group was s ign i f icant ly di f ferent f r o m the 1982-1984 group at the .05 leve l . O n e factor that may help to exp la in the l o w leve l o f uncertainty exper ienced by subjects implanted between 1976 and 1978 is that w h e n these patients were imp lan ted there was no know ledge o f b io log i ca l va l ve fa i lure. Patients were to ld by their surgeons that they d i d not k n o w h o w long a va l ve w o u l d last because there was no exper ience o f b io log i ca l va lve fa i lure at the t ime the va lves were imp lan ted ( G a l l u c c i , et a l , 1984; M i l l e r et a l , 1985). N o w that their va l ve has lasted 11 to 13 years, these patients m a y have conf idence that their va l ve w i l l last fo r the rest o f their natural l i fe . H e n c e , these l o n g term va lve surv ivors may perceive that their death w i l l be a func t ion o f natural ag ing or some other health p rob lem, unrelated to their heart va lve . A s igni f icant d i f ference in uncertainty was found between those subjects w h o had their va l ve imp lan ted between 1976 and 1978 and those w h o had , had it imp lan ted between 1979 and 1981. O n e reason w h i c h might account fo r the 1 9 7 9 - 8 l ' s h igher l eve l o f uncertainty is the fact that these people are n o w reach ing the t ime w h e n b io log i ca l va lves are more l i ke l y to fa i l due to structural va lve deter iorat ion. K n o w l e d g e o f va l ve fa i lure is n o w avai lab le to patients and therefore this group m a y be more aware that their va l ve may fa i l . F o r examp le , i t is k n o w n that twenty percent o f patients require e lect ive or urgent reoperat ion to replace the b i o l og i ca l va l ve w i th in 10 years o f the in i t ia l imp lant due to structural va l ve deter iorat ion (Jamieson et a l , 1988; C o h n et a l , 1984). U n l i k e the ear ly group, these patients may have had some knowledge per ta in ing to va lve fa i lu re at the t ime o f imp lant that m a y have contr ibuted to their h igher l eve l o f uncertainty. Subjects imp lan ted between 1982 and 1984 exper ienced the second highest l eve l o f uncertainty ( U S S M = l 14.89). In add i t ion , a s ign i f icant d i f ference i n uncertainty was found between the 1976-78 group and the 1982-84 group. O n e reason that may help to exp la in the 1982-84 g roup 's l eve l o f uncertainty is that more complete in format ion on va lve fa i lure was ava i lab le at time o f in i t i a l implant . Pat ients were aware that their va lve c o u l d poss ib ly fa i l i n several years and that this w o u l d mean that they w o u l d require va lve reoperat ion. Research conducted i n the ear ly eighties not on l y p roved the poss ib i l i t y o f va l ve fa i lure but quant i f ied the risk o f it occur r ing . F o r examp le , C o h n and co l leagues (1984) found that w i th in ten years o f in i t ia l imp lan t 2 0 % o f patients w o u l d require reoperat ion to replace the b io log i ca l va lve . A factor that might exp la in the 1982-84 group 's l owe r l eve l o f uncerta inty than the 1979-81 group, is the fact that the patients i n the 1982-84 group were a l l imp lan ted w i t h the new generat ion Carpent ie r -Edwards supra-annular porc ine bioprosthesis (va lve imp lan ted since 1982). T h i s new generat ion va lve has an imp roved va lve design and preservat ion i n compar i son to the prev ious generat ion Carpent ie r -Edwards va lve (Carpent ier , 1982; Carpent ier , 1984; Jamieson et a l , 1989b). Th i s has increased the surgeons ' con f idence i n the durabi l i ty o f the new va lve w h i c h m a y have been transferred to the patient. T h i s may have attr ibuted to a s l ight ly l ower l eve l o f uncertainty than the 1979-81 group. Perhaps, the 1982-84 's l eve l o f uncertainty w o u l d have been m u c h h igher than the 1 9 7 9 - 8 l ' s group and s ign i f icant ly di f ferent had a new va lve not been in t roduced. F i n a l l y , subjects imp lan ted between 1985 and 1987 w h o have had their b i o l og i ca l va lves imp lan ted for approx imate ly 2 to 4 years had a mean uncertainty l eve l o f 110.91 ( U S S ) . The i r l eve l o f uncertainty may be the resul t o f the o p t i m i s m s temming f r o m their i m p r o v e d health status f r o m their re la t ive ly recent surgery. Th i s group migh t s t i l l be i n a honeymoon type phase. H o w e v e r , over t ime this op t im i sm may be subdued by the poss ib i l i t y o f future va l ve fa i lu re . F o r some o f the subjects i n this group the threat o f surgery may not seem to be a l l that l ong ago and may be ref lected in this g roup 's l eve l o f uncertainty. T h e study by Chr i s tman and col leagues (1988) prov ides part ia l support fo r the exp lanat ion that a di f ference exists between uncertainty and t ime found i n this study. These researchers measured perce ived uncertainty o f myoca rd ia l 79 in farc t ion patients at three t ime per iods. T h e highest uncertainty mean score us ing the M U I S (not the commun i t y vers ion) was pr ior to d ischarge, w i th a s ign i f i cant ly l o w e r mean score occur r ing one week after hospi ta l d ischarge. F o u r weeks after d ischarge f r o m hospi ta l uncertainty increased to a leve l not s ign i f i cant ly di f ferent f r o m the uncertainty exper ienced pr io r to d ischarge. Stress o f Uncer ta in ty T h e b io l og i ca l va lve patients perce ived l o w leve ls o f stress generated by the uncertainty related to their heart va lve w i th a mean score o f 77 .52 . F i nd ings f r o m this study revea led that a s igni f icant pos i t ive re lat ionship ex is ted between uncertainty and stress. Th i s f i nd ing is not surpr is ing s ince, it is reasonable to expect that the h igher the leve l o f uncertainty the h igher the subjects ' overa l l percept ions o f stress (Suls & M u l l e n , 1981). In this study, b i o l og i ca l va l ve patients were f ound to exper ience moderate ly l o w levels o f uncertainty and l o w leve ls o f stress. M i s h e l (1984) found that there is a strong re lat ionship between uncertainty and stress and suggests that it is vagueness, l ack o f c lar i ty , and lack o f i n fo rmat ion about a si tuat ion that generate a stressful eva luat ion o f it. A g e at Implant Resu l ts suggest that there was no s igni f icant re lat ionship between uncertainty and the age o f the patient at implant . A l s o , there was no s ign i f icant d i f ference between subjects imp lan ted at 30 to 59 years or subjects imp lan ted at 60 years and older. These results are a l i t t le surpr is ing g iven the fact that the f reedom f r o m structural va l ve deter iorat ion i n the age group 30 to 59 years is l owe r than the 60 years and o lder group, 7 7 % and 8 3 % respect ive ly (Jamieson et a l , 1988). T h e lack o f a s igni f icant d i f ference between the groups m a y be re lated to whether or not the patients had know ledge o f the above fact. Fur ther invest igat ion migh t revea l their know ledge leve l o f va lve fa i lure. Percept ions o f L i f e Sat is fact ion T h e mean rat ings o f past, present, and future l i fe sat isfact ion showed past l i fe sat isfact ion to be rated the lowest , present l i fe sat isfact ion was rated h igher than past l i fe sat is fact ion, and future l i fe sat isfact ion was rated s l ight ly h igher than present l i fe sat isfact ion. T h i s trend suggests that l i fe sat isfact ion has i m p r o v e d fo r the heart va lve patient over t ime and there is o p t i m i s m about the future. N o studies have been found by the researcher that exam ined the l eve l o f l i fe sat isfact ion o f va l ve patients. H o w e v e r , studies by S i m u r d a (1988), and Pencko fe r and H o l m (1984) examined l i fe sat isfact ion w i th another group o f card iac pat ients, C A B G patients. T h e f ind ings o f the present study w i l l be compared to the f ind ings o f these two studies (see Tab le I X X ) . In each study, the Can t r i l S e l f - A n c h o r i n g Sca le was used to measure l i fe sat isfact ion. 81 Tab le I X X C o m p a r i s o n o f M e a n L i f e Sat is fact ion Rat ings Present S i m u r d a ( C A B G ) Pencko fe r and L i f e Study H o l m ( C A B G ) Sat is fact ion V a l v e s P r i m a r y Reoperat ion 3-5 mos . 6 -8mos. Past 6.7 5.6 5.0 3.6 3.4 Present 7.4 7.3 6.3 5.4 8.0 Future 7.5 6.8 7.9 7.9 8.8 T h e trend i n l i fe sat isfact ion f ound in the present study is consistent w i th the studies by S i m u r d a (1988) and i n the study by Pencko fe r and H o l m (1984). H o w e v e r , the b i o l og i ca l va l ve patients rated their past l i fe sat isfact ion substant ia l ly h igher than patients i n the other two studies. O n e poss ib le exp lanat ion for the di f ferent f ind ings is the d i f fe r ing postoperat ive per iods o f each study. T h e mean postoperat ive per iod for this study was 7.3 years compared to S i m u r d a ' s (1988) study where patients were on l y f i ve to ten months postoperat ive, and Pencko fe r and H o l m ' s study where patients were three to e ight months postoperat ive. H e n c e , subjects respond ing to the past l i fe sat isfact ion quest ion w o u l d have been responding to this quest ion i n their ex tended postoperat ive per iod (7.3 years) referr ing to their ear l ier postoperat ive per iod . Whereas , subjects i n the other two studies w o u l d have been respond ing to this quest ion dur ing the ear ly postoperat ive per iod , but referr ing to a t ime in terva l o f two years i n the past w h i c h was rea l ly dur ing their preoperat ive t ime per iod . In the major i ty o f cases the b io log i ca l va l ve pat ients ' health status is s ign i f icant ly imp roved f r o m the preoperat ive per iod (Jamieson et a l , 1989; L e v i n e et a l , 1981). T h e l i terature indicates that l i fe sat isfact ion is i n f l uenced by the pat ient 's percept ion o f health status (Garr i ty , 1973; Pa lmo re & Lu i ka r t , 1972). That i s , a pos i t ive percept ion o f health status is associated w i th a h igher rat ing o f l i fe sat isfact ion. Therefore it is poss ib le that the l i fe sat isfact ion o f patients respond ing to their preoperat ive exper ience w o u l d be l ower than those respond ing to their postoperat ive exper ience. In this study, percept ions o f past and future health status o f the b i o l og i ca l va l ve patients were f ound to be moderate ly good . These results are not surpr is ing as the major i ty o f va l ve patients become class I or I I N Y H A , postoperat ive ly (Jamieson et a l , 1989a). Those patients that are symptom-f ree f o l l o w i n g va lve surgery w i l l most l i ke l y have a more favorable percept ion o f their heal th. In addi t ion, this study found that the h igher the uncertainty l eve l the poorer the perce ived present and future health status. It is poss ib le that h igh levels o f uncertainty interfere w i th the c o p i n g processes needed to manage the stress generated by the uncertainty i tself. Th is c o u l d lead to va lve patients be ing ove rwhe lmed emot iona l l y , w h i c h may contr ibute to their pe rce ived poorer heal th status. T h e b io l og i ca l va lve patients rated the l i fe sat isfact ion o f the average person their age to be the same as their rat ing o f present l i f e sat isfact ion (M=7.40) . It m a y be that the heart va lve patients fee l so w e l l f o l l o w i n g va l ve rep lacement that they perceive their l i fe sat isfact ion to be as good as someone their o w n age w h o has never had va lve surgery. A c c o r d i n g to Laza rus and F o l k m a n ' s (1984) theory, appraisal and c o p i n g are used to exp la in the re lat ionship between uncertainty and l i fe sat isfact ion. In this theory the appraisal o f uncertainty in f luences c o p i n g strategies w h i c h are u t i l i zed to manage the situation and w h i c h in f luence the outcomes such as l i fe sat isfact ion. Uncer ta in ty m a y be appraised as a threat or as an opportuni ty by ind iv idua ls . I f uncertainty is perce ived as a threat it may interfere w i t h the c o p i n g processes needed to manage stress generated by the uncertainty and m a y result i n a poorer l i fe sat isfact ion. In this study uncertainty was associated w i th stress and threat, but not opportuni ty. A s igni f icant negat ive re lat ionship was f ound between uncertainty ( U S S and M U I S C V ) and past, present, and future l i fe sat isfact ion. M o r e spec i f i ca l l y , the study f ound that h igher uncertainty was associated w i th the ou tcome o f poorer l i fe sat isfact ion. T h e l i terature prov ides par t ia l support fo r the negative associat ion between uncertainty and l i fe sat isfact ion found in this study. In S imu rda ' s (1988) study o f C A B G patients, a s igni f icant negat ive re lat ionship is reported between uncertainty and present l i fe sat is fact ion, and uncertainty and future l i fe sat is fact ion. S i m u r d a (1988) suggests that h igher levels o f uncertainty interfere w i th the c o p i n g processes that are requ i red to manage the stress generated by the uncertainty i tself , lead ing the patients to fee l emot iona l l y ove rwhe lmed and less capable o f d raw ing on c o p i n g resources, w h i c h further contr ibutes to a poorer l i fe sat isfact ion. A study o f the uncertainty exper ienced by w o m e n w i th gyneco log ica l cancer prov ides support fo r the negative re lat ionship between uncertainty and future l i fe sat isfact ion f ound i n this study ( M i s h e l et a l , 1984). M i s h e l and co l leagues (1984) f ound that h igher levels o f uncertainty were associated w i th an increased number o f sad feel ings and negative expectat ions about the future. S u m m a r y T h e character ist ics o f the sample, the f ind ings , and a d iscuss ion o f the results have been presented i n this chapter. T h e sample was compr i sed o f 121 b io log i ca l va lve patients; 57 were ma le and 64 were female. T h e ages ranged f r o m 40 to 86 years. T h e age o f in i t ia l va l ve imp lan t ranged f r o m 32 to 81 years w i th a mean o f 59.67 years. T h e major i ty o f the va lve patients had not exper ienced any d i f f icu l t ies w i th their va l ve (87.6%). T h e mean t ime since va lve imp lant was 7.25 years. O v e r a l l , the b i o l og i ca l va lve patients perce ived moderate ly l o w levels o f uncertainty as measured by two instruments. T h e nature o f the uncertainty exper ienced appears to be p r imar i l y generated by the b io log i ca l va l ve patient not be ing able to forete l l the future ( U S S ) and by their unpredic tabi l i ty i n the si tuat ion ( M U I S C V ) . F i nd ings revea led that there was a s igni f icant d i f ference i n uncertainty depend ing o n the t ime s ince imp lant fo r subjects grouped accord ing to year o f implant . There are many factors w h i c h may contr ibute to these di f ferences such as the qual i ty o f the in format ion and know ledge o f va l ve fa i lure ava i lab le to the patient at the t ime o f va lve implant ; the f o l l ow-up and counse l l i ng patients rece ive; and the in t roduct ion o f a new generat ion porc ine va lve . Resul ts suggest that there was not a s igni f icant re lat ionship between uncertainty and the age o f a patient at implant . These results were a l i t t le surpr is ing g i ven the fact that the f reedom f r o m structural va l ve deter iorat ion in the age group 30 to 59 years is l owe r than the 60 years and o lder group. O v e r a l l , the b io log i ca l va lve patients perce ived l o w levels o f stress generated by the uncertainty related to their heart va lve . A s igni f icant pos i t i ve re lat ionship ex is ted between uncertainty and stress, w h i c h is consistent w i th the l i terature. S ign i f i can t negat ive relat ionships were found between uncertainty and the adaptat ional outcomes o f past, present, and future l i fe sat isfact ion and percept ions o f health status. H i g h e r levels o f uncertainty are appraised as stressful by the b i o l og i ca l va lve patients and contr ibute to a poorer l i fe sat isfact ion and health status. T h e percept ion o f past and future health status by the b i o l og i ca l va l ve patients were f ound to be moderate ly h igh . These results are not surpr is ing as the major i ty o f b i o log i ca l va lve patients were very s ick preoperat ive ly , c lass in or I V N Y H A , and their health status imp roved s ign i f icant ly postoperat ive ly to a c lass I o r II N Y H A . Therefore , va l ve patients w o u l d be more l i ke l y to have a more favorab le percept ion o f their health now than i n the past. T h e results o f the study were i n the expected d i rec t ion . T h e f ind ings o f thestudy were d iscussed i n re lat ion to the theoret ical f ramework , other research studies, and methodo log ica l prob lems inherent in the study. 87 C H A P T E R F I V E S u m m a r y , Conc lus i ons , Impl ica t ions, and Recommenda t ions Introduct ion T h i s study was des igned to determine the perce ived l eve l o f uncertainty o f peop le w h o have had a b io log i ca l va l ve implanted. In add i t ion , the study invest igated the re lat ionship between uncertainty and factors that m igh t in f luence this uncertainty such as t ime since implant , age at in i t ia l imp lan t , and the re lat ionships between uncertainty and l i fe sat isfact ion. T h i s chapter w i l l i nc lude a summary o f the study, f o l l o w e d by conc lus ions , imp l i ca t ions for nurs ing pract ice, theory, and educat ion, and recommendat ions fo r future research. S u m m a r y A rev iew o f the l i terature indicates that uncertainty is a major var iab le i n cases o f phys i ca l i l lnesses and d isabi l i ty (Lazarus & F o l k m a n , 1984; M i s h e l , 1984; M i s h e l , 1988; S imu rda , 1988). H o w e v e r , no nurs ing research has been reported w h i c h addresses the uncertainty exper ienced by the patient w i th a b i o l og i ca l va l ve and factors that m a y in f luence uncertainty such as t ime since implant , and age at implant . Fur thermore, research has not addressed the in f luence that uncertainty has on the qual i ty o f l i fe o f these patients. T w o indicators o f qual i ty o f l i fe are the pat ient 's percept ion o f l i fe sat isfact ion and health status. Severa l research studies w i th other patient groups exist w h i c h suggest that uncertainty has a negat ive in f luence on the adaptat ional ou tcome o f qua l i ty o f l i fe . T h e purpose o f this study was des igned to address some o f the gaps ident i f ied i n the l i terature. T h i s descr ip t ive corre la t ional study was conducted i n a large c i ty i n western Canada . D a t a were co l lec ted f r o m a conven ience sample o f 121 subjects w h o had their f i rst b i o log i ca l va lve implanted at least 12 months pr ior . T h e subjects were ma i l ed the quest ionnaires. A l l subjects comple ted the Uncer ta in ty Stress Sca le ( U S S ) , the M i s h e l Uncer ta in ty i n I l lness Sca le (Commun i t y Ve rs ion ) ( M U I S C V ) , the Can t r i l Se l f -A n c h o r i n g Sca le , and a patient in format ion sheet. Desc r ip t i ve and parametr ic statistics were used to ana lyze the data. T h e sample was compr i sed o f 57 males and 64 females. T h e mean age o f the subjects was 66.8 years. T h e major i ty o f the subjects were ret i red (56.2%), 2 0 . 7 % were fu l l - t ime homemakers , 16 .5% w o r k e d fu l l - t ime outs ide the h o m e , and 5 % w o r k e d on a part- t ime basis. T h e major i ty o f the b i o l og i ca l va l ve patients had either attained an educat ional l eve l o f grade 9 to 11 (30.6%) or grade 12 to 13 (30.6%). T h e mean age at in i t ia l implant was 59.7 years. S ix t y -seven o f the va lve patients (55.4%) reported hav ing other med i ca l o r health p rob lems, whereas 54 patients (44.6%) reported hav ing no other health prob lems. O f the 67 w h o reported health p rob lems, 30 were categor ized as hav ing major heal th prob lems (24.8%) and 37 were categor ized as hav ing m ino r health prob lems (30.6%). T h e major i ty o f the va lve patients (87.6%) had not exper ienced any d i f f icu l t ies w i t h their va l ve , but 14 subjects (11.6%) had reported hav ing prob lems and one subject d i d not respond (.8%). T h e most f requent ly reported d i f f i cu l t y was heart f ib r i l la t ions or palp i tat ions. T h e mean t ime s ince imp lant o f each subject 's b io log i ca l va lve was 7.25 years. O v e r a l l , the b i o l og i ca l va lve patients perce ived moderate ly l o w levels o f uncertainty as measured by two instruments. T h e nature o f the uncertainty exper ienced appears to be p r imar i l y generated by the b io log i ca l va l ve patient not be ing able to forete l l the future ( U S S ) and by their unpredic tab i l i ty i n the si tuat ion ( M U I S C V ) . These f ind ings were found to support ear l ier research w h i c h addressed uncertainty i n a sample o f C A B G patients. There was no s igni f icant re lat ionship between uncertainty and t ime s ince imp lan t i n the overa l l analys is o f the sample ( U S S r=-.13, p=.08; M U I S C V r=-.14, p=.065). H o w e v e r , there was a s igni f icant d i f ference i n uncertainty depend ing on the t ime s ince implant for subjects grouped accord ing to year o f imp lan t (F=3.30, p=.02). T h e 1976-78 group was s ign i f icant ly d i f ferent f r o m the 1982-84 group, and the 1976-78 group was s ign i f icant ly 90 di f ferent f r o m the 1982-84 group at the .05 l eve l . There are many factors w h i c h may contr ibute to these di f ferences i n uncertainty such as: the qua l i ty o f the in fo rmat ion and know ledge o f va lve fa i lure avai lab le to the patient at the t ime o f va l ve implant , the fo l l ow-up and counse l l i ng patients rece ive , their con f idence i n the health care system, the use o f cop ing strategies such as m i n i m i z i n g the s i tuat ion, the in t roduct ion o f a new generat ion porc ine va lve , and the deve lopmenta l stage attained by these subjects. In terms o f past l i fe sat isfact ion, the subjects had a mean rat ing o f 6.7 on the Can t r i l S e l f - A n c h o r i n g Sca le . The mean present l i fe sat isfact ion rat ing was 7.4 and the mean future l i fe sat isfact ion rat ing was 7.5. T h e mean l i fe sat isfact ion o f the average person the va lve subject 's age was 7.4. A s igni f icant negat ive relat ionship was found between uncertainty and past l i fe sat isfact ion (r=-.49, p=.00). A s igni f icant negat ive re lat ionship was a lso f ound between uncertainty and present l i fe sat isfact ion (r=-.37, p=.00). F i n a l l y , a s ign i f icant negat ive re lat ionship was found between uncertainty and future l i fe sat isfact ion (r=-.44, p=.00). Therefore, h igher uncertainty was associated w i th l o w e r expectat ions o f past, present, and future l i fe sat isfact ion. In terms o f present health status, the subjects had a mean rat ing o f 7.1 on the Can t r i l S e l f - A n c h o r i n g Sca le . T h e mean future health status rat ing was 7.4. T h e mean health status o f the average person the va lve subject 's age was 7.3 . A s igni f icant negat ive re lat ionship was f ound between uncertainty and percept ion o f present and future health status ( U S S present r=-.58, p=.00; future r=-.52, p=.00; M U I S C V present r=-.53, p=.00; future r=-.43, p=.00). H i g h e r levels o f uncertainty are appraised as stressful by the b i o l og i ca l va l ve patients and contr ibute to a poorer l i fe sat isfact ion and health status. Resul ts suggest that there was not a s igni f icant re lat ionship between uncertainty and the age o f a patient at implant ( U S S r=.07, p=.22; M U I S C V r=.12, p=.09). In add i t ion , a s igni f icant re lat ionship was f ound in uncertainty between men and w o m e n us ing analys is o f var iance ( U S S f=8.6, p=.00; M U I S C V f=8.4, p=.00). T h e f ind ings ind icated that females had a h igher l eve l o f uncertainty than males. T h e b io l og i ca l va lve patients perce ived l o w levels o f stress generated by the uncertainty re lated to their heart va lve w i th a mean score o f 77 .5 . A s ign i f icant pos i t ive re lat ionship ex is ted between uncertainty and stress (r=.67, p=.00). These f ind ings are consistent w i th other research and indicate that the h igher the leve l o f uncertainty the h igher the subjects ' overa l l percept ions o f stress. F i n a l l y , a s igni f icant d i f ference was found i n the stress o f uncertainty ( U S S ) between males and females (f= 11.40, p=.00). Fema les exper ienced a h igher l eve l o f stress generated by uncertainty than males. Laza rus and F o l k m a n ' s (1984) theory o f appra isa l , and cop ing was u t i l i zed to exp la in the re lat ionship between uncertainty and l i fe sat is fact ion. In this theory the appraisal o f uncertainty in f luences c o p i n g strategies w h i c h are u t i l i zed to manage the si tuat ion and w h i c h in f luence the outcomes such as l i fe sat is fact ion. Resu l ts f r o m this study indicate that this mode l is appropriate and supports the emp i r i ca l w o r k o f Laza rus and F o l k m a n . In this study, uncertainty is associated w i th h o w subjects perceive their l i fe sat isfact ion. T h e study supports the re lat ionship between appraisal and threat and stress. Uncer ta in ty w i th b io log i ca l va l ve patients is v i e w e d as stressful. A s w e l l , the tempora l factor o f t ime s ince imp lant is in f luent ia l i n the appra isa l , and, thereby outcomes. H o w e v e r no re lat ionship was f ound between uncertainty and oppor tuni ty , and uncertainty and age at implant . Conc lus ions B a s e d on the ut i l izat ion o f conven ience sampl ing procedures, the results o f this study cannot be genera l ized. H o w e v e r , the f ind ings o f this study suggest some s imi lar i t ies and di f ferences among subjects. T h e f o l l o w i n g conc lus ions are based on the f ind ings o f this study. O v e r a l l , b i o l og i ca l va lve patients perceive moderate ly l o w levels o f uncertainty. T h e nature o f uncertainty appears to be p r imar i l y generated by the b i o l og i ca l va l ve patients not be ing able to foretel l the future and by the unpredic tab i l i ty i n the si tuat ion. T i m e since imp lant is a factor i n the uncertainty o f i nd iv idua ls w i th a b i o l og i ca l va lve . Ind iv idua ls w h o have had their va lves imp lan ted the longest are more l i ke l y to perce ive less uncertainty, whereas those ind iv idua ls i n the t ime per iod o f pred ic ted va lve fa i lure are more l i ke l y to show more uncertainty. F i n a l l y , those ind iv idua ls w i th the most recent va l ve implants m igh t s t i l l be i n a honeymoon phase and seem to have more uncertainty than those ind iv idua ls w h o have had their va l ve the longest, but have less uncertainty then those i n the t ime per iod o f pred ic ted b io log i ca l va l ve fa i lure. Qua l i t y o f l i fe indicators o f b i o log i ca l va lve patients may be adversely in f l uenced by uncertainty. H i g h e r levels o f uncertainty are appraised as stressful and threatening and contr ibute to a poorer past, present, and future l i fe sat isfact ion and health status. A g e o f a patient at imp lant does not appear to be a s igni f icant factor i n their uncertainty. H o w e v e r , females tend to exper ience a h igher l eve l o f uncertainty than males. Impl ica t ions for N u r s i n g Pract ice and Theo ry T h e f ind ings o f this study suggest several important imp l i ca t ions for nurs ing pract ice, theory, and educat ion. F i rs t , nurses need to ga in a more thorough understanding about the b io log i ca l va lve pat ient 's exper ience, i n order to p rov ide comprehens ive care. Th i s study f ound that b io log i ca l va lve patients perce ive moderate ly l o w levels o f uncertainty, so an understanding o f elements w h i c h affect the pat ient 's exper ience w i l l a l l ow the nurse to p lan appropriate intervent ions a imed at m i n i m i z i n g pat ients ' anxiety and stress, and m a x i m i z i n g their understanding. Second , this study found that uncertainty was associated w i th a l owe r qua l i ty o f l i fe o r a l owe r l i fe sat isfact ion. Nurses w o r k i n g w i th b i o l og i ca l va l ve patients need to conduct a thorough ind i v idua l i zed assessment to determine the degree and nature o f uncertainty exper ienced by these patients. T h e n nurses need to p lan and imp lement intervent ions w h i c h meet the i nd i v i dua l needs o f the patient. T h e nurs ing intervent ions w i l l be a imed at reduc ing the uncertainty exper ienced by the patient o r at assist ing the patient i n manag ing the affects o f uncertainty where it may not be reduc ib le . Uncer ta in ty generated f r o m a lack o f in format ion and a l ack o f c lar i ty can be reduced by the nurse p rov id ing patient educat ion. P r o v i d i n g in fo rmat ion and know ledge of ten does reduce uncertainty and contr ibute to feel ings o f con t ro l ove r the si tuat ion. F o r examp le , it w o u l d be important to p rov ide the patient w i th in fo rmat ion that va lve fa i lure w o u l d rarely result i n their sudden death. H o w e v e r , some patients may exper ience more uncertainty and more stress w i th the more in fo rmat ion and knowledge g iven to them about va lve I 95 fa i lure. Therefore , nurses w o u l d f irst need to assess the i nd i v i dua l needs o f the patient and then, w o u l d need to p rov ide the necessary counse l l i ng and support i n order to reduce this uncertainty. In addi t ion, it is important fo r nurses to assess whether misconcept ions exist and to d ispe l them through patient educat ion. Uncer ta in ty generated f r om not be ing able to foretel l the future o r unpred ic tab i l i ty o f the si tuat ion is a f o rm o f uncertainty that the patient may need to learn to tolerate or accept. T h e impact o f this uncertainty can be lessened by he lp ing the patient to deve lop and use suitable cop ing strategies. S ince , there was a s igni f icant d i f ference i n uncertainty depending oh the t ime s ince imp lant for subjects grouped accord ing to year o f implant , it is important fo r nurses to p rov ide adequate counse l l i ng and support dur ing these t imes. In order to do this a va lve fo l l ow-up c l i n i c m a y need to be establ ished to meet the ongo ing needs o f the patient postoperat ively. T h i s c l i n i c cou ld be s im i l a r to a pacemaker c l i n i c where patients are seen in the ambulatory outpatient sett ing by appropriate health care professionals. H e r e , patients w o u l d rece ive i nd i v i dua l i zed assessments o f their card iac and psychosoc ia l status. T h e n , the patients w o u l d be p rov ided w i th appropriate educat ion, counse l l i ng and support f r om the nurses as determined f r o m the i nd i v i dua l i zed assessments. F o r example , a patient w h o has had their b i o log i ca l va l ve imp lan ted fo r approx imate ly 8 to 10 years, w h o had the highest l eve l o f uncertainty c o u l d be seen i n the va lve c l i n i c and p rov ided w i th educat ion and counse l l i ng to reduce uncertainty or to help them to deve lop suitable cop ing strategies to manage the uncertainty. I f ca lc i f i ca t ion o f the va lve was ident i f ied through echocard iogram, the patient c o u l d be f o l l o w e d at regular intervals i n va lve c l i n i c to determine i f the pat ient 's cond i t ion was chang ing . If their va l ve was show ing signs o f structural va lve deter iorat ion patients c o u l d be g iven in fo rmat ion and counse l l i ng on va lve reoperat ion. A n d if, the status o f their b i o log i ca l va lve has not changed, patients c o u l d be g iven reassurance that their va l ve was func t ion ing sat isfactor i ly . T h i s may lead to conf idence i n the durab i l i ty o f their va l ve . Th is invest igat ion and counse l l i ng may decrease the pat ient 's l e ve l o f uncertainty and may faci l i tate the deve lopment o f cop ing strategies w h i c h are needed to cope w i th future changes i n the pat ient 's cond i t ion . F i n a l l y , the theoret ical f ramework used in this study p rov ided d i rec t ion to exp la in the re lat ionships between uncertainty and t ime since implant , age at implant , stress o f uncertainty, and the adaptat ional outcomes o f l i fe sat isfact ion and percept ions o f health status. U s e o f Lazarus and F o l k m a n ' s (1984) theory o f stress and c o p i n g migh t result i n greater re levance o f nurs ing intervent ions d i rec ted toward the reduct ion o f uncertainty. Therefore , nurses shou ld use this 97 theoret ical f ramework as a guide when assessing uncertainty, stress, c o p i n g , and adaptat ional outcomes w i th b io log i ca l va lve patients. Fur thermore, nurses migh t cons ider us ing Laza rus and F o l k m a n ' s theory w i th other populat ions w h o m a y be exper ienc ing uncertainty undergo ing d iagnost ic , treatment, and recovery stages o f an i l lness. Recommendat ions for Future Research F i n d i n g s o f this study st imulate suggestions for further research i n a number o f areas. F i rs t , a prospect ive t ime series des ign w o u l d p rov ide a more comprehens ive assessment for exp lo r ing the changes in the degree and nature o f uncertainty exper ienced by the b io log i ca l va lve patients over t ime. T h e study c o u l d commence preoperat ive ly and cont inue up to 10-15 years postoperat ive ly . S e c o n d , the moderate ly l o w levels o f uncertainty exper ienced by the b i o l og i ca l va lve patients m a y have been related to the instruments used to measure uncertainty. T h e uncertainty instruments shou ld be re f ined to remove any ambigu i t ies that exist. T h i r d , further invest igat ion us ing qual i tat ive research m a y ident i fy other uncertaint ies that va l ve patients are exper ienc ing. Qual i ta t ive research w o u l d not on l y be usefu l for substantiat ing the degree and nature o f uncertainty exper ienced by va lve patients, but the impact that uncertainty has on their qua l i ty o f l i fe . Fou r th , a s igni f icant negat ive re lat ionship was found between uncertainty and the adaptat ional outcomes o f l i fe sat is fact ion, and uncertainty and heal th status i n this study. It c o u l d on l y be in ferred that h igher leve ls o f uncertainty are appra ised as threatening o r stressful by b io log i ca l va l ve patients. H i g h e r leve ls o f uncertainty may interfere w i th the cop ing processes needed to manage the stress generated by the uncertainty i tself , w h i c h i n turn affect adaptat ional outcomes. In order to understand these relat ionships more c lear ly , further research is needed w h i c h examines the re lat ionships between b io l og i ca l va l ve pat ients ' percept ions o f uncertainty, stress, the use o f var ious cop ing strategies, and adaptat ional outcomes. T h e impact o f uncertainty on patients w i th a b i o l og i ca l va l ve is an important area o f concern for nurs ing. Future research is needed on the outcomes o f cop ing strategies used as they relate to appra isa l o f the threat, w h i c h w o u l d be usefu l fo r nurses w h o are he lp ing ind iv idua ls adapt to l i v i n g w i th their b io log i ca l va lve . F i f t h , it w o u l d be usefu l to explore what f o l l ow-up and counse l l i ng patients rece ive upon d ischarge f r o m hospi ta l . F o r example , patients c o u l d be in te rv iewed or sent quest ionnaires i n w h i c h they responded to quest ions regard ing the f o l l ow-up care they rece ived at var ious t ime intervals. A n o t h e r research study w o u l d be usefu l to determine whether the amount and source o f fo l l ow-up w o u l d in f luence the subjects leve l o f pe rce ived uncertainty. A research study w i l l need to be conducted i n w h i c h a group o f subjects rece ive counse l l i ng and are compared to a s imi la r group o f subjects i n character ist ics w h o do not receive any counse l l i ng o r f o l l ow-up . F i n a l l y , a retrospect ive comparat ive study is needed to determine i f a d i f ference i n pe rce ived leve l o f uncertainty exists between the Carpent ier -E d w a r d s standard va lve and the new generat ion Carpent ie r -Edwards supra-annular va lve . T h i s research study c o u l d be conducted i n di f ferent inst i tut ions i n Canada . 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T e n year durab i l i t y and per formance o f porc ine bioprostheses. Ze i tschr i f t F u r  K a r d i o l o g i e . 74 (6), 15-18. M i s h e l , M . H . (1980). Pe rce i ved ambigu i ty o f events associated w i th the exper ience o f i l lness and hospi ta l izat ion: Deve lopmen t and test ing o f a  measurement too l . U n p u b l i s h e d Doc to ra l D isser ta t ion, C la remon t Graduate S c h o o l . M i s h e l , M .H . " (1981) . T h e measurement o f uncertainty i n i l lness. N u r s i n g  Research . 30 , 258-263 . M i s h e l , M . H . (1983). Ad jus t i ng the f i t -development o f uncertainty scales for spec i f i c cont ro l populat ions. Wes te rn Journa l o f N u r s i n g Research . 5 (4), 355 -369 . M i s h e l , M . H . (1984). Pe rce i ved uncertainty and stress i n i l lness. Research i n  N u r s i n g and Hea l th . 7 , 1 6 3 - 1 7 1 . M i s h e l , M . H . (1988a). C o p i n g w i th uncertainty i n i l lness. Presented at the Un i ve rs i t y o f Rochester . M i s h e l , M . H . (1988b). Uncer ta in ty i n i l lness. Journa l o f N u r s i n g Scho la rsh ip . 20 (4), 225 -32 . M i s h e l , M . H . & B r a d e n , C . J . (1987). Uncer ta in ty : A mediator between support and adjustment. Western Journa l o f N u r s i n g Research . 9 ( 1 ) , 43 -57 . M i s h e l , M . H . , Hostet ter, T . , K i n g , B . , & G r a h a m , V . (1984). Pred ic tors o f psychosoc ia l adjustment i n patients new ly d iagnosed w i th gyneco log i ca l cancer. C a n c e r N u r s i n g . 7, 291 -299 . M i s h e l , M . H . & M u r d a u g h , C . (1987). Redes ign ing the d ream: F a m i l y exper iences w i th heart transplantat ion. N u r s i n g Research . 36 (6), 332-38. M o o s , R . H . & T s u , V . (1977). C o p i n g w i th phys i ca l i l lness. N e w Y o r k : P l e n u m M e d i c a l B o o k C o . Neugar ten , B . L . (1985). T i m e , age, and the l i fe cyc le . In M . B l o o m , L i f e span  deve lopment , bases for prevent ive and intervent ive he lp ing (360-368) . N e w Y o r k : M a c M i l l a n Pub l i sh ing C o m p a n y . N i s t a l , F . , A r t i nano , E . , & G a l l o , I. (1986). P r i m a r y t issue va l ve degenerat ion i n g lutara ldehyde-preserved porc ine bioprostheses: H a n c o c k I versus Carpen t ie r -Edwards at four and seven year 's f o l l ow-up . A n n a l s o f  Tho rac i c Surgery . 42 , 568-72 . 105 Pain ter , P . H . (1981). Pe rce i ved uncertainty and its re lat ionship to pe rce ived  recovery and act iv i ty i n the pos t -myocard ia l in farc t ion patient. U n p u b l i s h e d master 's thesis, C a l i f o r n i a State Un i ve rs i t y , L o s Ange les . P a l m o r e , E . , & Lu i ka r t , C . (1972). Hea l t h and soc ia l factors re lated to l i fe sat isfact ion. Journa l o f Hea l t h and S o c i a l Behav iou r . 13. 68-80 . Pat r i ck , D . , & E l i n s o n J . (1984). S o c i o m e d i c a l approaches to disease and treatment outcomes in card iovascu lar care. Qua l i t y o f L i f e and  Card iovascu la r Ca re . I, 45 -53 . Pencko fe r , S . , & H o l m , K . (1984). E a r l y appraisal o f coronary revascu lar iza t ion on qual i ty o f l i fe . N u r s i n g Research . 33 . 60 -63 . P o l i t , D . , & H u n g l e r , B . (1983). N u r s i n g Research . (2nd E d . ) , Ph i l ade lph ia : J . B . L ipp inco t t . S a d o w s k y , D . (1982). Unders tand ing and cop ing w i t h uncertainty. Journa l o f  Den ta l Educa t i on . 46 (6), 342-43 . S i m u r d a , L . (1988). D i f fe rences in uncertainty and qual i ty o f l i fe between p r imary and reoperat ion coronary artery bypass patients. U n p u b l i s h e d master 's thesis, Un i ve rs i t y o f B r i t i sh C o l u m b i a , Vancouve r . Stat ist ics Canada . (1987). Surg ica l procedures and treatments 1981-82, 1982-83 (Cata logue N o . 82-208) . O t tawa: M in i s t e r o f Supp l y and Serv ices Canada . Steger, H . G . (1977). T r a u m a i n the y o u n g adult. In P . E . M a n n e l l (ed.) T h e  exper ience o f dy i ng . E n g l e w o o d C l i f f s , N J : P ren t i ce -Ha l l , Inc. S u l s , J . , & M u l l e n , B . (1981). L i f e events, perce ived con t ro l , and i l lness : T h e ro le o f uncertainty. Journa l o f H u m a n Stress. 7, 30-34. W e e k s , C C . (1980). M S : T h e mal ignant uncertainty. A m e r i c a n Journa l o f  N u r s i n g . 80 (2), 298-99 . W e i l a n d , A . P . (1983). A rev iew o f card iac va lve prostheses and their se lect ion. Hear t and L u n g . 12 ,498 -504 . 106 W e n g e r , N . (1984a). Qua l i t y o f l i fe and the care o f patients w i t h card iovascu lar disease. Qua l i t y o f L i f e and Card iovascu la r Ca re . 1, 2 -4 . W e n g e r , N . (1984b). T h e concept o f qua l i ty o f l i f e - A n appropriate cons iderat ion i n c l i n i ca l dec is ion m a k i n g af fect ing patients w i th card iovascu lar disease. Qua l i t y o f L i f e and Card iovascu la r C a r e . 1, 8-13. Y a r c h e s k i , A . (1988). Uncer ta in ty i n i l lness and the future. Wes te rn Journa l o f  N u r s i n g Research . 10 (4), 401 -13 . A p p e n d i x A : Tab le A - l N e w Y o r k Hear t Assoc ia t i on Func t iona l C lass i f i ca t ion 108 N e w Y o r k Hear t Assoc ia t i on Func t i ona l C lass i f i ca t ion I Pat ients w i th card iac disease but wi thout resul t ing l im i ta t ion o f phys i ca l act iv i ty . Ord ina ry phys i ca l act iv i ty does not cause undue fat igue, pa lp i ta t ion, dyspnea, or ang ina l pa in . II Pat ients w i th card iac disease resul t ing in sl ight l im i ta t ion o f phys i ca l act iv i ty . T h e y are comfor tab le at rest. Ord ina ry phys i ca l act iv i ty results i n fat igue, pa lp i ta t ion, dyspnea, o r anginal pa in . III Pat ients w i th card iac disease resul t ing i n marked l imi ta t ion o f phys i ca l act iv i ty . T h e y are comfor tab le at rest. L e s s than ord inary phys i ca l ac t iv i ty results i n fat igue, pa lp i ta t ion, dyspnea, o r angina pa in . I V Pat ients w i th card iac disease resul t ing i n inab i l i t y to carry on any phys i ca l act iv i ty wi thout d iscomfor t . Symp toms o f card iac insu f f i c iency or o f the anginal syndrome may be present even at rest. If any phys i ca l act iv i ty is undertaken, d iscomfor t is increased. No te . F r o m Wes te rn Tho rac i c Surg i ca l Assoc ia t i on D a t a F o r m Def in i t i ons . A p p e n d i x B Introductory Let ter A p p e n d i x C R e m i n d e r Let ter A p p e n d i x D Uncer ta in ty Stress Sca le ( U S S ) 115 UNCERTAINTY STRESS SCALE Please read the following statements. To the right of each statement you will see live columns labelled I - Strongly Agree, 2 - Agree, 3 - Undecided, 4 - Disagree and 5 - Strongly Disagree. You are asked to circle the number which most closely measures how you have felt during the past 24 hours about the uncertainties related to the heart diagnosis/disorder you have had. To the far right of each statement you will find five more columns of numbers. These columns are labelled I • No stress, 2 - Some stress. 3 - Moderate stress, 4 - Considerable stress and 5 = A great deal of stress. You are asked to circle the number In the column which most closely reflects the degree of stress you feel related to the uncertainty or certainty generated from each Item area. Please respond to every statement. There are no 'right' or 'wrong' answers. (1) Strongly Agree (1) No stress (2) Agree (2) Some stress (3) Undecided (3) Moderate stress (4) Disagree (4) Considerable stress (5) Strongly Disagree (5) A great deal of stress \ \ 1. I am clear about what questions to ask my doctors about my cardiac situation.. 1 2 3 4 5 1 2 3 4 5 2. I am confident any problems with my disorder would be detected early _ 1 2 3 4 5 1 2 3 4 5 3. I wonder about the stability of my condition 1 2 3 4 5 1 2 3 4 5 4. It's not clear to me what caused the heart problem 1 2 3 4 5 1 2 3 4 5 5. I know whether or not I will be able to maintain my present level of functioning. 1 2 3 4 5 1 2 3 4 5 6. The present state ol my cardiac situation is clear 1 2 3 4 5 1 2 3 4 5 7. I am certain about whether changing my diet will help my condition 1 2 3 4 5 1 2 3 4 5 8. I wonder if it would be difficult to get Insurance 1 2 3 4 5 1 2 3 4 5 9. I am not sure how to interpret what I am told 1 2 3 4 5 1 2 3 4 5 10. I can rely on the effectiveness of my medical and/or surgical treatments 1 2 3 4 5 1 2 3 4 5 11. I wonder if my heart condition is under control 1 2 3 4 5 1 2 3 4 5 12. I am not sure «the heart condition will cause me to have symptoms 1 2 3 4 5 1 2 3 4 5 13. I am certain about what to say to others about my medical situation 1 2 3 4 5 1 2 3 4 5 14. Differing explanations have caused me to be uncertain 1 2 3 4 5 1 2 3 4 5 15. I am sure about my chances to be well _ 1 2 3 4 5 1 2 3 4 5 16. I don't know if my medical situation will be the same in 5 years — 1 2 3 4 5 1 2 3 4 5 17. I wonder if my symptoms can be controlled, (if no symptoms circle 5) 1 2 3 4 5 1 2 3 4 5 18. I am not sure if my cardiac situation will interfere with my ability to do my usual activities 1 2 3 4 5 1 2 3 4 5 19. I feel certain about my doctor's abilities 1 2 3 4 5 1 2 3 4 5 20. I am not sure how to manage any symptoms I have, (if no symptoms circle 5)... 1 2 3 4 5 1 2 3 4 5 21. I have doubts about the choice of medical and/or surgical treatment(s) I am having or have had 1 2 3 4 5 1 2 3 4 5 22. I am not sure if my heart disorder will recur. 1 2 3 4 5 1 2 3 4 5 23. I am certain about the adequacy of the follow-up I am having 1 2 3 4 5 1 2 3 4 5 24. I have a dear understanding of the medical and surgical treatment(s) I am having or have had 1 2 3 4 5 1 2 3 4 5 25. It's dear how I should approach health care protessionats regarding my care.- 1 2 3 4 5 1 2 3 4 5 26. It's unclear if my medical situation will be involved in my death 12 3 4 5 1 2 3 4 5 27. it's clear to me about whether my medical and/or surgical treatments have been effective "- 3 4 5 12245 28. I wonder It any change in my appearance affects my relationship with others.fif no change circle 5) 1 2 3 4 5 1 2 3 4 5 29. I wonder If the cardiac situation will affect my life goals 1 2 3 4 5 1 2 3 4 5 30. I don't know if what I am doing will help me 1 2 3 4 5 1 2 3 4 5 31. I can depend on test results as an indicator of my condition 1 2 3 4 5 1 2 3 4 5 32. I know whether my heart condition will affect my sex life 1 2 3 4 5 1 2 3 4 5 33. I am not certain a delay In getting medical or surgical treatment wiU Influence my chances of successful recovery 1 2 3 4 5 1 2 3 4 5 34. It is clear how serious my medical situation is 1 2 3 4 5 1 2 3 4 5 35. I have no doubts that my medical and/or surgical treatments eliminated or will eliminate the problem 1 2 3 4 5 1 2 3 4 5 116 (1) Strongly Agree (1) No stress (2) Agree (2) Some stress (3) Undecided (3) Moderate stress (4) Disagree (4) Considerable stress (5) Strongly Disagree (5) A great deal ot stress \ \ 36. I am confident in my ability to handle my emotions related to the hean disorder 1 2 3 4 5 1 2 3 4 5 37. The symptoms I have are unpredictable.(if no symptoms circle 5) 1 2 3 4 5 1 2 3 4 5 38. I'm not sure whether eliminating my bad habits will help my condition. 1 2 3 4 5 1 2 3 4 5 39. I am unsure whether I will have difficulty coping with my medical situation.— 1 2 3 4 5 1 2 3 4 5 40. I have doubts about the quality of the information I have 1 2 3 4 5 1 2 3 4 5 41. I never know how long my symptoms will last. (It no symptoms circle 5) 1 2 3 4 5 1 2 3 4 5 42. I wonder sometimes if my doctor(s) is telling me the truth 1 2 3 4 5 1 2 3 4 5 43. I am uncertain HI would choose to have all the treatments which win be recommended to me _ _ 1 2 3 4 5 1 2 3 4 5 44. When I get unusual symptoms, H is dear what they mean In terms of my cardiac situation _ 1 2 3 4 5 1 2 3 4 5 45. They might find something wrong when I go for a checkup 1 2 3 4 5 1 2 3 4 5 46. I am sure that I will be well cared tor by the health professionals 1 2 3 4 5 1 2 3 4 5 47. The cause of my symptoms Is not clear. (If no symptoms circle 5) 1 2 3 4 5 1 2 3 4 5 48. I can depend on people who are important to me to be there when I need tnem 1 2 3 4 5 1 2 3 4 5 The following four questions have a line which represents levels of a particular feeling or perception. Please make a cross (X) on the Una which best Indicates your level right now. I. Overall, my uncertainty level about my heart condition is: 100 No uncertainty Very high uncertainty 2. Overall, the stress generated Irom the uncertainty in my situation is: 100 No stress Very high stress 3. Overall, the threat generated from the uncertainty in my situation is: 100 No threat Very high threat 4. Overall, the opportunity (that Is the positive possibilities) generated from the uncertainty in my situation is: 100 No opportunity Very high opportunity £ \ 1988 B. Ann H i l t o n . May not be reproduced or d i s t r i b u t e d without written permission of the author. Reprinted by permission. A p p e n d i x E M i s h e l Uncer ta in ty i n I l lness Sca le C o m m u n i t y V e r s i o n ( M U I S C V ) J 118 MISHEL UNCERTAINTY IN ILLNESS S C A L E : Please read each statement. Take your time and think about what each statement says. Then place an "X" under the column that most closely measures how you are feeling TODAY. If you agree with a statement, then you would mark under cither "Strongly Agree" or "Agree". If you disagree with a statement, then mark under either "Strongly Disagree" or "Disagree". If you are undecided about how you feci, then mark under "Undecided" for that statement. Plase respond to every statement. 1. I don't know what is wrong with me. Strongly Agree Agree Undecided Disagree Strongly Disagree (5) (4) (3) (2) (1) 2. I have a lot of questions without answers. Strongly Agree (5) Agree (4) Undecided (3) Disagree (2) Strongly Disagree (1) I am unsure if my illness is getting better or worse. Strongly Agree Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree 0) It is unclear how bad my pain will be. Strongly Agree Agree (5) (4) Undecided (3) Disagree (2) Strongly Disagree (1) 5. The explanations they give about my condition seem hazy to me. Strongly AgTee Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree (1) 6. The purpose of each treatment is clear to me. Strongly Agree Agree Undecided Disagree (1) (2) (3) (4) Strongly Disagree IS) 7. When 1 have pain, I know what this means about my condition. Strongly Agree Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree (1) My symptoms continue to change unpredictably. Strongly Agree Agree Undectded Disagree (5) (4) (3) (2) Strongly Disagree (1) 9. I understand everything explained to me. Strongly Agree 0) Agree (2) Undecided (3) Disagree (4) Strongly Disagree <5) 119 10. The doctors say things to me that could have many meanings! Strongly Agree Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree (1) 11. My treatment is too complex to figure out. Strongly Agree (5) Agree (4) Undecided (3) Disagree 02 Strongly Disagree (1) 12. It is difficult to know if the treatments or medications I am getting are helping. Strongly Agree (5) Agree (4) Undecided (3) Disagree (2) Strongly Disagree (1) 13. Because of the unpredictability of my illness. I cannot plan for the future. Strongly Agree Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree (1) 14. The course of my illness keeps changing. 1 have good and bad days. Strongly Agree Agree Undecided Disagree (5) (4) (3) a Strongly Disagree (1) 15.1 have been given many differing opinions about what is wrong with me. Strongly Agree Agree Undecided Disagree (5) (4) O) CO Strongly Disagree (1) 16. It is not clear what is going to happen to me. Strongly Agree Agree Undecided (5) (4) (3) Disagree CD Strongly Disagree (1) 17. I usually know if I am going to have a good or bad day. Strongly Agree Agree Undecided Disagree (1) (2) O) (4> Strongly Disagree 0) 18. The results of my tests are inconsistent. Strongly Agree Agree Undecided Disagree 13) (4) O) CD Strongly Disagree 0) 19. The effectiveness of the treatment is undetermined. Strongly Agree Agree Undecided Disagree Strongly Disagree (5) (4) O) CD 0) Strongly Disagree (5) 21. Because of the treatment, what I can do and cannot do keeps changing. Strongly Agree Agree Undecided Disagree <5) (4) (3) (2) 22. I'm certain they wi l l not (find anything else wrong with me. Strongly Agree (1) Agree (2) Undecided O) Disagree (4) Strongly Disagree (1) Strongly Disagree (5) 23. The treatment i am receiving has a known probability of success. Strongly Agree Agree Undecided Disagree (1) (2) (3) (4) Strongly Disagree (5) 24. They have not given me a specific diagnosis. Strongly Agree Agree Undecided Disagree (5) (4) (3) (2) Strongly Disagree (1) 25. M y physical distress is predictable. I know when it is going to get better or worse. Strongly Agree Agree Undecided Disagree Strongly Disagree (1) (2) (3) (4) (S) 26. M y diagnosis is definite and wi l l not change. Strongly Agree Agree Undecided Disagree (1) (2) (3) (4) Strongly Disagree (5) 27. The seriousness of my illness has been determined. Strongly Agree Agree Undecided Disagree U) (2) O) (4) Strongly Disagree (S) 28. The doctors and nurses use everday language so I can understand what they are saying. Strongly Agree Agree Undecided Disagree Strongly Disagree (1) 0) <3) (4) (5) © 1987 Merle H. Mishel. May not be reproduced or distributed without w r i t t e n permiss ion of the au tho r . Repr in ted by permission. A p p e n d i x F Can t r i l S e l f - A n c h o r i n g Scales C A N T R I L S E L F - A N C H O R I N G S C A L E I N S T R U C T I O N S : Desc r i be what, fo r y o u , w o u l d be the highest l eve l o f l i fe sat isfact ion. Nex t , descr ibe what you fee l is the lowest l eve l o f l i fe sat isfact ion. B e l o w is a p ic ture o f a ladder. T h e highest leve l o f l i fe sat isfact ion that you have just descr ibed is the top o f the ladder ( i . e . 1 0 ) . The lowest l eve l o f l i fe sat is fact ion that y o u have just descr ibed is at the bot tom (i.e. 1). 10 Bes t L e v e l o f L i f e Sat is fact ion 9 8 7 6 5 4 3 2 1 W o r s t L e v e l o f L i f e Sat is fact ion 1. O n w h i c h step o f the ladder w o u l d you say y o u are r ight n o w ? (Please wr i te d o w n the number o f the step) 2 . O n w h i c h step o f the ladder were you two years ago ? 3. O n w h i c h step o f the ladder do y o u expect to be two years f r o m n o w ? 4. O n w h i c h step o f the ladder w o u l d you say the l i fe sat isfact ion o f the average person your age is ? No te . F r o m T h e Pattern o f H u m a n Concerns (p. 22) by H . Can t r i l , 1965. N e w B r u n s w i c k : Rutgers Un ive rs i t y Press. M o d i f i e d for use. C A N T R I L S E L F - A N C H O R I N G S C A L E I N S T R U C T I O N S : B e l o w is a picture o f a ladder. T h e top o f the ladder repre-sents the best heal th expected ( i . e . 1 0 ) , and the bot tom represents the worst heal th poss ib le (i.e. 1 ) . 1. O n w h i c h step o f the ladder w o u l d you say you r health is r ight n o w ? 10 Best Hea l t h Expec ted W o r s t Hea l th E x p e c t e d (Please wr i te d o w n the number o f the step) 2. O n w h i c h step o f the ladder w o u l d you say your health w i l l be s ix months f r o m now ? 3. O n w h i c h step o f the ladder w o u l d you say the health o f the average person you r age is ? No te . F r o m T h e Pattern o f H u m a n Concerns (p. 22) by H . Can t r i l , 1965. N e w B r u n s w i c k : Rutgers Un ive rs i t y Press. M o d i f i e d for use. A p p e n d i x G Pat ient In format ion Sheet PATIENT INFORMATION SHEET W h a t was the date o f your heart va l ve implant? 19 P lease indicate the type o f heart va l ve you have? tissue / b io log i ca l / p i g / porc ine mechan ica l W h a t do y o u perceive are the advantages o f your type o f heart va l ve? A r e y o u hav ing any d i f f icu l t ies w i th your heart va lve? Y e s N o (If yes, please descr ibe) D o y o u foresee any prob lems w i th the type o f heart va lve y o u have? Y e s N o (Please comment) D o you perceive that your heart va lve may need to be rep laced? Y e s ; N o (Please comment ) H o w l o n g were y o u o f f w o r k before your heart va l ve rep lacement? 126 8. D o y o u have other health p rob lems? Y e s N o (If yes, please state what they are) 9. A r e you current ly tak ing any medicat ions? Y e s N o (If yes, what medicat ions are y o u tak ing?) 10. W h a t is your age? years 11. W h a t is you r sex? M a l e F e m a l e 12. W h a t is the highest l eve l o f educat ion that you have comple ted? U p to grade 8 G r a d e 9 - 11 Grade 1 2 - 1 3 C o l l e g e or Un i ve rs i t y Mas te rs , Doctorate 13. W h a t is you r current emp loyment status? E m p l o y e d fu l l - t ime outside the home E m p l o y e d part- t ime Fu l l - t ime homemaker /housewi fe Re t i red f r o m a j ob outside the home 14. A r e y o u current ly on d isab i l i t y /s ick leave? Y e s N o (If yes, please exp la in) 15. W h a t is you r occupat ion? Thank you for participating. Your contribution is very much appreciated. A p p e n d i x H : Tab le H - l F requency o f Hear t V a l v e Operat ions in Canada for 1982-1983 128 F requency o f Hear t V a l v e Operat ions i n Canada for  1982-1983 A g e Groups 25-34 35-44 45 -54 54-64 65+ T o t a l M a l e 88 155 250 391 353 1237 F e m a l e 116 171 263 389 370 1309 To ta l 204 326 513 780 723 2546 No te . F r o m Stat ist ics Canada . (1987). Su rg i ca l procedures and treatments 1981-82,1982-83 (Cata logue N o . 82-208) . Ot tawa: M i n i s t e r o f S u p p l y and Serv ices Canada . A p p e n d i x I: Tab le 1-1 M U I S C V I tem M e a n s for B i o l o g i c a l V a l v e Pat ients and P r ima ry and Reoperat ion C A B G Patients M U I S C V I tem M e a n s for B i o l o g i c a l V a l v e Patients and P r i m a r y and Reopera t ion  C A B G Patients M U I S C V V a l v e P r ima ry C A B G Reoperat ion C A B G I tem Patients Patients Patients I tem M e a n I tem M e a n I tem M e a n 1 1.9 1.8 1.5 2 2.2 2.2 2.2 3 2.4 2.1 2.1 4 2.6 2.0 2.9 5 2.1 2.0 1.7 6 2.0 2.2 1.6 7 2.8 2.4 2.0 8 2.4 2.1 2.8 9 2.3 2.2 1.9 10 2.4 2.1 2.3 11 2.1 1.8 2.1 12 2.2 2.1 2.3 13 2.5 2.4 1.9 14 * 2.8 2.6 3.4 15 1.9 1.7 1.9 16 * 2.7 2.7 3.1 17 * 3.2 2.8 3.3 18 2.1 2.2 2.1 19 2.1 2.0 2.4 2 0 * 3.1 2.9 3.1 21 2.3 2.1 2.4 22 * 3.3 3.0 3.0 23 2.2 1.7 1.9 24 2.0 1.9 1.9 25 * ' 3.4 2.7 2.8 26 * 2.6 2.6 3.1 27 2.0 2.0 1.7 28 2.1 1.9 1.7 No te . * = i tems scored to ref lect h igher uncertainty by b io l og i ca l va lve patients and p r imary and reoperat ion C A B G patients. 

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