Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The illness experience of patients following a myocardial infarction : implications for patient education DeAdder, Dawna Nadine 1990

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

Item Metadata

Download

Media
831-UBC_1991_A5_7 D42.pdf [ 4.94MB ]
Metadata
JSON: 831-1.0098543.json
JSON-LD: 831-1.0098543-ld.json
RDF/XML (Pretty): 831-1.0098543-rdf.xml
RDF/JSON: 831-1.0098543-rdf.json
Turtle: 831-1.0098543-turtle.txt
N-Triples: 831-1.0098543-rdf-ntriples.txt
Original Record: 831-1.0098543-source.json
Full Text
831-1.0098543-fulltext.txt
Citation
831-1.0098543.ris

Full Text

THE ILLNESS EXPERIENCE OF PATIENTS FOLLOWING A MYOCARDIAL INFARCTION: IMPLICATIONS FOR PATIENT EDUCATION By DAWNA NADINE DeADDER B.N., Dalhousie University, 1984 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING In THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December, 1990 @ Dawna Nadine DeAdder, 1990 4 • 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 The University of British Columbia Vancouver, Canada Date hetemLui /S /Wo DE-6 (2/88) Abstract THE ILLNESS EXPERIENCE OF PATIENTS FOLLOWING A MYOCARDIAL INFARCTION: IMPLICATIONS FOR PATIENT EDUCATION This study used the research method of phenomenology to e l i c i t the patient's perspective of the i l l n e s s experience following a myocardial i n f a r c t i o n (MI). The purpose of studying t h i s experience was to gain an understanding of what i t meant to men and women to have a MI, what the learning needs were following a MI, and how these learning needs were met. It was proposed that patients would view the i l l n e s s experience d i f f e r e n t l y from health professionals, thus the patients would i d e n t i f y d i f f e r e n t learning needs. Anderson's (1985) adaptation of Klelnman's health care system framework was used to conceptualize t h i s problem. Three males and two females, ranging in age from 42 to 77 years, participated in the study. Data were coll e c t e d through 11 in-depth interviews. From analysis of t h i s data s i g n i f i c a n t statements were extracted to provide a description of the phenomenon under study. The findings of t h i s study suggest that health professionals and patients do view the MI experience from d i f f e r e n t perspectives. The emphasis of the patients on understanding the MI experience from the r e a l i t y of their world i s r e f l e c t e d in th e i r attempts to r a t i o n a l i z e the occurrence of the MI and their desires to know more about their own MI, prognosis, and treatment. In order to plan patient education that w i l l a s s i s t post-MI patients in their recovery health professionals must assess patients i n d i v i d u a l l y for t h e i r : (1) b e l i e f s regarding r i s k factors and causes of MI; (2) desire for Information; (3) preference for method of in s t r u c t i o n ; and, (4) preference for timing of education. iv Table of Contents Page Abstract 1 i Table of Contents iv Acknowledgements v i chapter 1: INTRODUCTION Background to the Problem 1 Conceptualization of the Problem 5 Problem Statement and Purpose 7 De f i n i t i o n of Terms 8 Assumptions 8 Limitations 9 Summary 9 Chapter 2s REVIEW OF THE LITERATURE Introduction 11 Outcomes Following a MI 11 Learning & Information Needs 19 Causal Explanations 24 Di f f e r i n g Perspectives of Patients, Nurses, & Physicians 26 Summary 29 Chapter 3: METHODOLOGY Introduction 30 Methodology. 30 V a l i d i t y and R e l i a b i l i t y 32 Sample Selection & Selection C r i t e r i a 32 Selection Procedure 34 Patient Education Protocol 36 Data C o l l e c t i o n Procedures 37 Et h i c a l Considerations 39 Data Analysis 40 Summary 41 V Chapter 4: THE PARTICIPANTS' ACCOUNTS Introduction 42 Character i s t i c s of Participants 42 MI Event 45 Causes of MI 56 Adjustments 58 Concerns About Damage, Prognosis, & Treatment 71 Cardiac Education 73 Education from health professionals. 74 Self education 82 Summary 89 Chapter 5: DISCUSSION OF THE FINDINGS Introduction 91 Meaning of the Ml 92 Learning Needs 98 Meeting Learning Needs 101 Relation of Findings to Conceptual Framework 105 Summary of Findings 106 Conclusions 107 Implications for Nursing Practice 109 Implications for Nursing Education 110 Implications for Nursing Research I l l Summary 112 References 113 Appendix A 119 Appendix B 121 Appendix C 123 Appendix D 124 Acknowledgements V i I would l i k e to thank the members of my thesis committee, Professors Carol J i l l i n q s (chair) and Helen Niskala, for their support and guidance through the research process. Special thanks are extended to my family and friends for their love and encouragement throughout t h i s endeavor. As well, I would l i k e to acknowledge the time and e f f o r t of the five subjects whose p a r t i c i p a t i o n made thi s project possible. 1 Chapter 1 Introduction Background to the Problem "Chronic i l l n e s s is a twentieth-century phenomenon" (Dimond, 1983, p.636). Heart disease is one of the most commonly occurring chronic i l l n e s s e s . In Canada, one of every four deaths in 1982 was caused by heart disease and in 1982-1983 over 250,000 patients were discharged from hospital after being treated for heart disease (Minister of Supply & Services, 1987). Included in the growing number of people being treated for heart disease are the survivors of myocardial infarctions (Mis). The occurrence of a MI often marks the sudden recognition of the presence of coronary artery disease. Coronary artery disease, l i k e other chronic i l l n e s s e s , requires individuals to make l i f e s t y l e changes in order to adapt. According to Dimond (1983) there are four major factors to consider when looking at s o c i a l adaptation of the c h r o n i c a l l y i l l : "(1) [the] nature of the i l l n e s s ; (2) (the] d e f i n i t i o n s and the meaning of the i l l n e s s ; (3) [the] responses to chronic i l l n e s s ; and (4) the environment and i l l n e s s " (p.637). The meaning of an i l l n e s s to a patient is one factor that is often overlooked by health professionals. Dimond (1983) 2 contends t h a t "most of the f a c t o r s t h a t d etermine the meaning of i l l n e s s [ f o r the i l l p e rson] are r e l a t e d i n some way t o the s o c i o c u l t u r a l w o r l d of the i l l p e r s o n " (p.641). N u r s e s , l i k e o t h e r h e a l t h p r o f e s s i o n a l s , however, f r e q u e n t l y d e f i n e i l l n e s s i n terms of the i l l p erson's p h y s i o l o g i c a l d e v i a t i o n s from normal, r a t h e r than from the i l l p erson's s o c i o c u l t u r a l w o r l d . " T h i s l a c k of a t t e n t i o n t o the p e r s p e c t i v e of the i l l p e r s o n i s e v i d e n t i n the t ype of p a t i e n t e d u c a t i o n programs t h a t n u r s e s , d i e t i c i a n s , p h y s i c i a n s and o t h e r h e a l t h p r o f e s s i o n a l s have dev e l o p e d i n an attempt t o promote l i f e s t y l e changes i n c a r d i a c p a t i e n t s . Most of the c u r r e n t ' C a r d i a c P a t i e n t E d u c a t i o n Programs' are s t r u c t u r e d around the p a t h o p h y s i o l o g y and the p r e v e n t i o n of c o r o n a r y a r t e r y d i s e a s e . The i n f o r m a t i o n g i v e n t o p a t i e n t s u s u a l l y i n c l u d e s : (1) anatomy and p h y s i o l o g y of the h e a r t ; (2) r i s k f a c t o r s f o r c o r o n a r y a r t e r y d i s e a s e ; (3) s i g n s and symptoms of h e a r t a t t a c k ; (4) a c t i v i t y r e s t r i c t i o n s and r e h a b i l i t a t i o n ; (5) c a r d i a c d i e t i n s t r u c t i o n ; and (6) use of m e d i c a t i o n s (Wenger, 1979 ) . A m u l t i t u d e of s t u d i e s have been done t o e v a l u a t e c a r d i a c p a t i e n t e d u c a t i o n programs w i t h a m a j o r i t y of these s t u d i e s h a v i n g found t h a t c a r d i a c e d u c a t i o n programs do c o n t r i b u t e t o an i n c r e a s e i n p a t i e n t s ' knowledge ( G a r d i n g , K e r r , & Bay, 1988; Gregor, 1981; H e n t i n e n , 1986; L i n d e & J a n z , 1979; M i l l s , B a rnes, R o d e l l , & T e r r y , 1985; Owens, McCann, & Hutelmyer, 3 1978; Pozen, S t e c h m i l l e r , H a r r i s , S m i t h , F r i e d , & V o i g t , 1977; R a l e i g h & Odtokan, 1987; S t e e l e & R u z i c k i , 1987). A few s t u d i e s have shown p a t i e n t s ' knowledge g a i n t o be l i m i t e d ( S c a l z i , B urke, & G r e e n l a n d , 1980; S i v a r a j a n , Newton, Almes, Kempf, M a n s f i e l d , & B ruce, 1983; White, Lemon, & A l b a n e s e , 1980). The l i m i t e d g a i n i n two of t h e s e s t u d i e s was p a r t i a l l y a t t r i b u t e d t o the s t r e s s of a c u t e i l l n e s s a f f e c t i n g the p a t i e n t s ' a b i l i t y t o l e a r n a t t h a t time ( S c a l z i e t a l . , 1980; White e t a l . , 1980). The f o c u s of t h e s e s t u d i e s was t o e v a l u a t e knowledge g a i n , however, and not t o e v a l u a t e the u s e f u l n e s s of t h a t knowledge i n h e l p i n g p a t i e n t s w i t h c a r d i a c d i s e a s e d e f i n e and l i v e w i t h t h e i r i l l n e s s . A l t h o u g h r e s e a r c h r e s u l t s have demonstrated p a t i e n t s ' r e a d i n e s s f o r new i n f o r m a t i o n and t h e i r a b i l i t y t o l e a r n c o n t e n t , t h e r e i s no e v i d e n c e t h a t t h i s l e a r n i n g i n f l u e n c e s p a t i e n t s ' h e a l t h b e h a v i o r ( R u n i o n s , 1988). S i v a r a j a n e t a l . (1983) found t h a t , when o v e r a l l b e h a v i o r a l changes were examined, t h e i r r i s k - f a c t o r t e a c h i n g and c o u n s e l i n g program demonstrated o n l y l i m i t e d e f f e c t i v e n e s s . As w e l l , t h e r e i s e v i d e n c e t h a t p a t i e n t s and h e a l t h p r o f e s s i o n a l s view the c a r d i a c p a t i e n t ' s l e a r n i n g needs ( K a r l i c k & Y a r c h e s k i , 1987; P f i s t e r e r , 1975) and the c a u s a l a t t r i b u t e s ( F i e l d i n g , 1987; Rudy, 1980) of c a r d i a c d i s e a s e d i f f e r e n t l y . G i v e n t h e s e two f a c t o r s : (1) the l a c k of e v i d e n c e t h a t l e a r n i n g does i n f l u e n c e p a t i e n t s ' h e a l t h b e h a v i o r s ; and the f a c t t h a t (2) the 4 p a t i e n t ' s p e r s p e c t i v e may d i f f e r from t h a t of the p r o f e s s i o n a l , l e a d s one t o ask, as d i d Runions (1988): "Are n u rses r e s p o n d i n g t o l e a r n i n g needs and d e s i r e s [of p a t i e n t s ] or p r o j e c t i n g t h e i r own l e a r n i n g i n t e r e s t s on the p a t i e n t s ? " (p.261). The response of nurses t o p a t i e n t s ' l e a r n i n g needs i s s i g n i f i c a n t because n u r s i n g p l a y s a major r o l e i n c a r d i a c r e h a b i l i t a t i o n . One of the f o c u s e s of c a r d i a c n u r s i n g i s the a n a l y s i s of "the s u b j e c t i v e e x p e r i e n c e of c a r d i a c i l l n e s s : i t s meaning, impact, and e f f e c t on b a s i c needs; the r e s p o n s e s of i n d i v i d u a l s t o i t s impact; i n d i v i d u a l v a r i a b l e s ( m a t u r a t i o n a l , s i t u a t i o n a l , s o c i o c u l t u r a l ) s h a p i n g the p e r c e p t i o n s and d e f i n i t i o n s of i l l n e s s and the changes, l o s s e s , or g a i n s t h a t r e s u l t " ( J i l l i n g s , 1988, p.46). I t becomes i m p e r a t i v e t h e n t h a t n urses undertake r e s e a r c h t h a t w i l l e n a b le them t o b e t t e r u n d e r s t a n d c a r d i a c i l l n e s s e s , such as MI, from the p e r s p e c t i v e of t h e i r p a t i e n t s . The impetus f o r t h i s s t u d y a r o s e from the c o n c e r n t h a t p r e s e n t c a r d i a c p a t i e n t e d u c a t i o n programs d i d not a d d r e s s the e x p e r i e n c e of h a v i n g a MI from the p a t i e n t ' s p e r s p e c t i v e . Anderson's (1985) a d a p t a t i o n of Kleinman's h e a l t h c a r e system framework was used t o c o n c e p t u a l i z e the problem i n t h i s s t u d y because i n I t Kleinman r e c o g n i z e s t h a t p a t i e n t s and n urses may v i ew i l l n e s s from d i f f e r e n t p e r s p e c t i v e s . 5 Conceptualization of the Problem Klelnman (1978) views medical systems as both s o c i a l and c u l t u r a l systems. In an attempt to understand health, i l l n e s s , and healing in society as a c u l t u r a l system he developed the Health Care System Framework. In this framework the health care system consists of three s o c i a l arenas: popular, professional, and folk. The popular arena views sickness and care in the context of the family, the s o c i a l network, and the community. The non-professional healing s p e c i a l i s t s comprise the folk arena, while the professional arena includes professional s c i e n t i f i c medicine and the professionalized indigenous healing t r a d i t i o n s . Each arena of the health care system has i t s own explanatory model. Explanatory models "contain explanations of any or a l l of the five issues: etiology; onset of symptoms; pathophysiology; course of sickness (severity and type of sick r o l e ) ; and treatment" (Kleinman, 1978, pp.87-88). Kleinman propounds that health care relationships, such as the patient-practitioner r e l a t i o n s h i p , can be studied and compared as transactions between d i f f e r e n t explanatory models. In examining the experience of sickness, Kleinman (1978) denotes a difference between the terms 'disease' and ' i l l n e s s ' . Disease is viewed as the malfunctioning or maladaptation of b i o l o g i c a l and/or psychological processes, while i l l n e s s is viewed as the actual experience of the 6 disease. Because of this d i s t i n c t i o n the explanatory models of professional pra c t i t i o n e r s are frequently linked with disease and i t s theories of causation, much l i k e the biomedical model. The popular arena's explanatory models are more commonly linked with the concept of i l l n e s s "where sickness i s most frequently a r t i c u l a t e d in a highly personal, non-technical, concrete idiom concerned with the l i f e problems that r e s u l t from sickness" (p.88). Anderson (1985) adapts Kleinman's health care system framework and develops a th e o r e t i c a l framework for use in nursing practice and research. Within t h i s framework the nursing profession i s viewed as a s o c i o c u l t u r a l system that possesses i t s own knowledge, b e l i e f s , and values which may be discrepant from those of the c l i e n t . Interactions between the nurse and c l i e n t are transactions between explanatory models which d i f f e r in cognitive content, expectations and goals. (Anderson, 1985, p.238) Her framework can be used by nurses for investigation of the soci o c u l t u r a l context in which the patient's health and i l l n e s s experiences are constructed. Nurse-patient interactions, such as those that occur with patient education, are relevant topics to be investigated using Anderson's framework. The nurse and patient possess d i f f e r i n g explanatory models about the meaning of the i l l n e s s and i t s treatment. These d i f f e r i n g explanatory models w i l l a f f e c t what the nurse Identifies as being important learning needs for the patient, and what learning needs the patient i d e n t i f i e s as being important. Only through the study of i l l n e s s within t h i s s o c i o c u l t u r a l perspective can nurses understand what i l l n e s s means to a patient and e f f e c t i v e l y i d e n t i f y the learning needs of the patient. Problem Statement and Purpose In adjusting to the chronic i l l n e s s of heart disease MI patients are required to make l i f e s t y l e changes. Nurses, as health care professionals, are often involved in cardiac patient education programs that are designed to address patient learning needs and to promote these l i f e s t y l e change The nurse, as a professional, may define the i l l n e s s in a di f f e r e n t way from the patient, thus i d e n t i f y i n g learning needs that are d i f f e r e n t from those i d e n t i f i e d by patients. In order to be e f f e c t i v e , however, patient education must address the learning needs of the patient. The purpose of thi s study was to e l i c i t patients' perceptions of their i l l n e s s experience following a MI: (1) To determine what i t meant to patients to have had MI. (2) To determine what patients i d e n t i f i e d as learning needs following a MI. 8 (3) To determine how patients met these learning needs. Definition of Terms For the purpose of t h i s study the following terms were defined as: (1) Myocardial i n f a r c t i o n - "formation of an i n f a r c t in the heart muscle, due to interruption of the blood supply to the area" (Miller & Keane, 1972, p.618). This was a medical diagnosis determined by the patient's physician. (2) Learning need(s)- the concern(s) i d e n t i f i e d and expressed by the patient, for which the patient required information in order to manage on a day-to-day basis following a MI. (3) Cardiac education- the formal or Informal instruction given to patients and their families to help them understand the patient's i l l n e s s and manage i l l n e s s problems that arose in day-to-day l i v i n g . Assumptions In t h i s study the following assumptions were made: (1) a patient, having experienced a MI, would be able to speak to that experience; (2) a patient, having experienced a MI for the f i r s t time, would have learning needs; and (3) the researcher would bracket a l l preconceived ideas regarding the learning needs of patients who had had a MI. 9 Limitations The following were lim i t a t i o n s of t h i s study: (1) p a r t i c i p a t i o n in t h i s study was r e s t r i c t e d to patients who li v e d within Vancouver proper in order that they would be accessible to the researcher; (2) for communication purposes p a r t i c i p a t i o n was also r e s t r i c t e d to patients who were fluent in English; and (3) the number of subjects was limited by the time and resources of the student researcher. Summary This chapter has introduced the problem and purposes addressed in t h i s study. It is evident from the l i t e r a t u r e reviewed on cardiac patient education that knowledge gain i s only one aspect of patient education. The d i f f e r i n g perspectives of health professionals and patients regarding the i l l n e s s experience and i t s meaning may also influence patient education and the incorporation of the knowledge gained into day-to-day l i f e . Anderson's (1985) adaptation of Kleinman'n health care system framework supports the exploration of these d i f f e r i n g perspectives to further nursings understanding of the patient's subjective health and i l l n e s s experience. The remainder of t h i s thesis is organized in the following manner. In Chapter Two a more extensive review of the l i t e r a t u r e on s p e c i f i c aspects of cardiac patient education is discussed. Chapter Three includes a description of the methodology of phenomenology, the the o r e c t i c a l sampling technique, and the process of data c o l l e c t i o n chosen to implement t h i s study. The findings are described in Chapter Four, with a discussion of these findings presented In Chapter Five. Chapter Five concludes with the study summary and presentation of the implications for nursing practice, education, and research. Chapter 2 11 Review of the Literature Introduction Although there have been numerous studies done evaluating the effectiveness of cardiac education programs in increasing patients' knowledge about cardiac disease there is limited research available on the meaning of the Illness to the patient and how t h i s a f f e c t s the cardiac patient's learning needs. In t h i s chapter supportive l i t e r a t u r e on the psychosocial outcomes of cardiac disease; cardiac patients' perceptions of their learning needs and causal explanations for MI; and the d i f f e r i n g perspectives of patients, nurses, and physicians on the learning needs of post-MI patients w i l l be reviewed. Outcomes Following a MI Early studies of MI patients investigated the low return of post-MI patients to the work force (Nagle, Gangola, & Picton-Roblnson, 1971; Wishnie, Hackett, & Cassem, 1971). The low rate of return to work was attributed to the lack of i n s t r u c t i o n patients received (Nagle et a l . , 1971) and the emotional problems they experienced, post-MI, which affected th e i r r e h a b i l i t a t i o n (wishnie et a l . , 1971). Nagle et a l . (1971) surveyed 115 male patients who had suffered a MI and found that only 49.5% had returned to work. They state that cardiac damage and non-cardiac psychological and s o c i a l factors, such as anxiety and depression, were almost equally common as causes of invalidism post-MI. Wishnie et a l . (1971) interviewed 24 patients convalescing from Mis and found that most of the patients suffered from anxiety, depression, physical weakness, insomnia, and boredom. Both Nagle et a l . and wishnie et a l . contend that the psychosocial problems experienced by MI patients a f f e c t their recovery and these problems need to be addressed through education. Salonen and Puska (1980) reported the findings of a community based program for r e h a b i l i t a t i o n and secondary prevention for patients with acute MI that was i n i t i a t e d in North Karelia in 1972 as part of a comprehensive program to control cardiovascular diseases in that region of Finland. The program included health education, vocational counseling, and psychosocial counseling as well as medical treatment. The patients entered the program while in hospital and continued i t on a outpatient basis for one year. Data were collected during the fiv e year period from 1973 to 1977. Out of the 1308 patients that survived the f i r s t six months after their acute MI, 515 v i s i t e d the outpatient MI c l i n i c and 575 took part in the r e h a b i l i t a t i o n groups. One of the main objectives of the program was to improve the rate of return to work of patients after an acute Ml. Although the results could not be attributed to the r e h a b i l i t a t i o n program alone there was a non-significant reduction of 31% in the rate of new pensions among the male patients and a s i g n i f i c a n t reduction of 77% among the females. Mayou, Williamson, and Foster (1976, 1978) studied the attitudes and outcomes of patients following Mis. In their 1976 study they interviewed 40 patients and the i r r e l a t i v e s . They found that patients and their families had a lack of understanding of medical advice and information which often was not realized u n t i l they t r i e d to cope at home. One reason ci t e d for the low understanding the patients and families had of the i l l n e s s was that doctors may be unaware of the p r a c t i c a l needs of the patients. In their 1978 study, in which they interviewed 100 MI patients, they found a wide v a r i a t i o n in d i s a b i l i t y among the patients which was unrelated to their cardiac state. The patient's lack of understanding of medical advice and the cautious expectations of the patients and their families were f e l t to contribute to t h i s d i s a b i l i t y . Stern, Pascale, and Ackerman (1977) followed 68 patients for one year to study their psychosocial adjustments post-MI. Sp e c i f i c areas explored were work, family, sexual and s o c i a l a c t i v i t i e s . The patients were assessed using a variety of scales for depression and anxiety, before leaving the hospital and again at s i x weeks, three months, six months, and one year. Subjects were found to f i t into three categories; depressives, deniers, and general non-depressives. Nine patients were i d e n t i f i e d as depressed and 78% of those continued to be depressed at one year. The depressives as a group were considered poor responders. They often f a i l e d to return to work and sexual functioning, and they also had a higher readmission rate to ho s p i t a l . In t h i s study deniers continued to function as good responders, as did the general non-depressed population. Rehabilitation outcomes were s p e c i f i c a l l y poor for the 13 female subjects who had both high mortality and readmission rates. As well, 80% of the women showed signs of depression and anxiety. From these findings the researchers concluded that the population at r i s k for poor r e h a b i l i t a t i o n outcomes could be i d e n t i f i e d early in post-hospital recovery. j. Ott et a l . (1983) measured the i l l n e s s - r e l a t e d behavioral dysfunction of 258 MI patients using a questionnaire. The questionnaire measured dysfunction on both physical and psychological dimensions. The subjects were randomly assigned into three groups. Group A, the control group, received conventional medical and nursing treatment, group Bl received an additional three month exercise program, and group B2 received the exercise program plus a teaching-counseling 15 program about ri s k factors and emotional adjustments. The follow up evaluations were done three and six months after discharge from h o s p i t a l . The researchers found no differences in the sickness-related behavioral dysfunction between group A and Bl but there were differences found between group B2 and both groups A and B l . The difference was s t a t i s t i c a l l y s i g n i f i c a n t in the psychosocial dimension which included categories such as s o c i a l interaction, alertness behavior, communication, and emotional behavior. The differences in t h i s study were attributed to the teaching-counseling program and not the exercise program however, because there had been no differences between group A and Bl i d e n t i f i e d . Burgess and Hartman (1986) "hypothesized that c r i t i c a l b e l i e f s (e.g., thoughts and feelings) surround the heart attack I t s e l f and determine Its meaning to the person's immediate and future l i f e " (p.569). They randomly assigned 180 patients to either an experimental or control group. The experimental group received nursing Interventions that i d e n t i f i e d the individual's b e l i e f s and expectations that would l i m i t or promote recovery. The s p e c i a l l y trained nurses helped correct patient's b e l i e f s that u n j u s t i f i a b l y r e s t r i c t e d patient's a c t i v i t i e s . As well, subjects were surveyed using a v a r i e t y of instruments to obtain patient c h a r a c t e r i s t i c s and differences between the two groups. In their findings 90% of the patients reported job stress, with 33% blaming their jobs for their MI. The subjects viewed the heart attack as serious and expressed feelings of s u s c e p t i b i l i t y to heart attack and relapse. The patients in the experimental group at the three month follow up reported s i g n i f i c a n t l y less psychological d i s t r e s s and dependency on family. Boogaard (1984) compared return to physical a c t i v i t y , psychosocial aspects, and family interrelationships of 10 male and 10 female post-MI patients. Data were collected through semi-structured interviews and revealed several potential problem areas for women recuperating from MI: (1) women tended to resume household a c t i v i t i e s Immediately after discharge from ho s p i t a l ; (2) women delayed returning to work and sexual a c t i v i t y ; (3) women did not seem to enter structured cardiac r e h a b i l i t a t i o n programs; and, (4) women tended to express feelings of g u i l t as a resu l t of not being able to resume normal household a c t i v i t i e s . Boogaard stressed the importance of structuring cardiac r e h a b i l i t a t i o n to the individual needs of the patient, whether male or female, and that more work i s reguired in the area of r e h a b i l i t a t i o n of women post-MI. McMahon, M i l l e r , Wikoff, Garrett, and Ringel (1986) studied the adherence of 112 post-MI patients to prescribed medical regimens in four l i f e s i t uations; home, work, sports/ recreation, and s o c i a l a c t i v i t y . The subjects were surveyed while in hospital as to their intent to follow the prescribed medical regimen. A follow up survey completed six to nine months post i n f a r c t i o n , by both subjects and family members, measured the subjects actual adherence to the prescribed regimen. Their findings showed that although MI patients had strong intentions to follow the prescribed regimen while in hospital there was a s t a t i s t i c a l l y s i g n i f i c a n t decline in adherence behaviors measured s i x to nine months l a t e r . The family reports of adherence were not s i g n i f i c a n t l y d i f f e r e n t from the subjects. These researchers also hypothesized that the expectations of s i g n i f i c a n t others to the prescribed medical regimen would influence subject's adherence. Therefore, data were coll e c t e d on the subjects' perceptions of the expectations held by s i g n i f i c a n t others. Adherence in s p e c i f i c l i f e s ituations was found to be related to the subject's b e l i e f s about what others thought they should be doing six to nine months after discharge from h o s p i t a l . These findings suggest that the actual adherence to regimens once home may be more d i f f i c u l t than anticipated and that the b e l i e f s held by patients as to the expectations of others should be assessed. The e f f e c t of a Ml on a patient's family has also been investigated. Hilgenberg and Crowley (1987) interviewed 25 patients and their families at two to three months, and again at f i v e to s ix months after the patient's discharge from ho s p i t a l . This study focused on changes in family and s o c i a l a c t i v i t i e s ; communication and decision-making; d i e t and exercise; protectlveness; as well as, f i n a n c i a l and emotional changes. Changes were noted by both patients and family members in a l l areas Investigated. The researchers reported "a general decline in s o c i a l a c t i v i t i e s , together with changes in role expectations and disruption of familiar routines" (p.32). These changes were also associated with d i s t r e s s , since many of them had not been anticipated by the patient or the family.,y The e f f e c t of uncertainty on coping and di s t r e s s following a MI has also been reported in the l i t e r a t u r e . Christman, McConnell, P f e i f f e r , Webster, Schmitt, and Ries (1988) used a longitudinal exploratory design to study 60 Ml patients. They examined the Influence of uncertainty in i l l n e s s and use of coping methods on emotional d i s t r e s s and recovery following MI. The patients were evaluated using a variety of instruments at three d i f f e r e n t times after discharge from h o s p i t a l . The analysis of the data showed "high levels of uncertainty were d i r e c t l y related to high leve l s of emotional d i s t r e s s during the t r a n s i t i o n from hospital to home and return to self-ca r e following myocardial i n f a r c t i o n " (p.80). Webster and Christman (1988) used a descriptive survey to examine the relationships between perceived uncertainty, use of a f f e c t i v e or emotion-oriented and problem-oriented coping methods, and emotional d i s t r e s s in 20 patients recovering from 19 a MI. Although uncertainty was not s i g n i f i c a n t l y related to either type of coping method, increased Xeyels of uncertainty were s i g n i f i c a n t l y related to both anxiety and depression. "Perception of one's i l l n e s s as vague or unclear, exposure to varied cues about one's i l l n e s s and i t s treatment, and the perception of i n s u f f i c i e n t information about one's diagnosis were associated with greater emotional d i s t r e s s " (p.389). These researchers suggest that providing Information about a patient's Illness and i t s treatment might reduce uncertainty and thereby decrease the associated emotional d i s t r e s s . As t h i s l i t e r a t u r e demonstrates researchers have i d e n t i f i e d many areas of concern in patients' psychosocial recovery post-MI. The focus of present cardiac r e h a b i l i t a t i o n programs on the physical aspect of cardiac disease may not be meeting the needs of these patients. Learning and information Needs Early work done on patient learning needs i d e n t i f i e d that patients had a desire for more information about th e i r i l l n e s s and i t s future effects (Dodge, 1969; Llnehan, 1966). After surveying 116 patients using a verbally administered open-ended interview technique Dodge (1969) concluded "patients were p a r t i c u l a r l y concerned with receiving the kinds of information which would enable them to plan r e a l i s t i c a l l y for thei r Immediate and long-range l i v e s " (p.509). Differences between patients* cognitive needs were i d e n t i f i e d when the variables of sex, age, education, nature of involvement, and term of involvement were examined. Nature of involvement d i f f e r e n t i a t e d the patients as either medical or s u r g i c a l and term of involvement denoted a time frame of short term, less than a month, or long term, a month or more. Dodge (1969) found s u r g i c a l patients wanted to know about the i r surgery and were more concerned about t o t a l time involvement, whereas, medical patients emphasized knowledge regarding t h e i r medications and s e l f - c a r e . In examining term of involvement i t was again noted that long term patients had more questions regarding their role in self-care and the ef f e c t s of medications, while short term patients emphasized the re s u l t s of diagnostic and surgical care. Male patients wanted to know how their condition would e f f e c t their a b i l i t y to work and earn a l i v i n g , while female patients seemed more concerned with their role as the protector of the family health. Age effected the cognitive needs according to where the patient f i t in the stages of adulthood, i e . , early, middle, or l a t e . As well, the l e v e l of education of the patient was viewed in t h i s study to e f f e c t the type of information sought by the patient, with poorly educated patients wanting non-technical information, to highly educated patients wanting information that would a s s i s t them in decision-making. These early findings suggest that the 21 individual c h a r a c t e r i s t i c s of both patient and i l l n e s s e f f e c t the cognitive needs of the patient. Moynlhan (1984) examined the s p e c i f i c learning needs of post-MI patients in a small, quantitative study. Seventeen patients responded to a mailed questionnaire. The questionnaire was designed to establish what information subjects' f e l t was important in a range of topics considered important to cardiac r e h a b i l i t a t i o n , and when subjects' f e l t t h i s Information would be most b e n e f i c i a l to them. For the purposes of the study Moynihan divided the cardiac r e h a b i l i t a t i o n process into three phases: (1) time in CCU; (2) time from transfer from CCU u n t i l discharge from hospital; and, (3) time from discharge u n t i l patient returned to previous l i f e s t y l e . Subjects rated a l l education topics as important and wished that information could be reinforced in a l l three phases. However, differences were noted in what types of information patients perceived as important in the d i f f e r e n t phases. In phase one patients were concerned about the CCU environment and explanations of procedures. In phase two more s p e c i f i c information was desired about d i e t , medications, r i s k factors, etc., while in phase three topics of importance were related to a c t i v i t i e s , emotional response, and follow-up. Although the study was viewed as delineating patients' s e l f -perceived educational needs the education topics were those 22 considered by the researcher to be current and recommended components in a cardiac r e h a b i l i t a t i o n program. N i c k l i n (1986) studied postdischarge concerns of cardiac patients as presented v i a a telephone callback system. The patients had had either a MI or cardiac surgery, and a l l had been exposed to patient education. This education included: "basic anatomy and physiology of the heart, atherosclerosis, angina, MI, ris k factors of heart disease, a c t i v i t y guidelines, and diet information" (p.268). The patients were encouraged to c a l l the on-duty nursing coordinator i f problems arose post discharge. In a period of less than five months 217 telephone c a l l s were received. Forty percent of the concerns arose within the patients* f i r s t week at home. N i c k l i n concluded that patients and families appeared to need more, or d i f f e r e n t , information during the r e h a b i l i t a t i o n phase of a MI or cardiac surgery. Liddy and Crowley (1987) studied 11 post-MI patients and their spouses to see If MI patients had the information they needed for the recovery phase at home. Their study focused on s p e c i f i c categories of information such as physiology, permissible a c t i v i t i e s , d i e t , medications, smoking, psychosocial factors, and unanswered questions. Data were col l e c t e d by interviews from both the patients and their spouses two to three months following the patient's MI. Liddy and Crowley found that both groups of respondents were not well Informed in any of the designated categories. The respondents f e l t they would have benefited from more information and s p e c i f i c guidelines on how to integrate new demands into t h e i r d a i l y routines. This study was not designed to determine the reasons for the respondents inadequate knowledge and only examined the patients' information needs in s p e c i f i c categories. Phenomenological studies done with cardiac patients have shown that patients have information needs that are often not met (Dubyts, 1988; Dunn, 1985; Kent, 1985; Yamada, 1984). These studies focused on patients' experiences with MI, angina, and coronary artery bypass graft surgery. Although their focus was not on patients learning needs areas of concern were discussed in t h e i r findings, such as the problems perceived by the patients were often not the same as those depicted in patient education manuals (Yamada, 1984). To solve t h i s problem one researcher reports patients often a c t i v e l y sought information from books and the media to help them cope with cardiac i l l n e s s and i t s management (Dubyts, 1988). Patient c h a r a c t e r i s t i c s , such as age, sex, and education, and i l l n e s s factors, such as type and duration, have been shown to influence patients' learning needs. Patients and spouses have acknowledged the desire for more Information, s p e c i f i c a l l y in the recovery phase at home, when cardiac 24 patients learning needs have been studied. Causal Explanations In 1980 Rudy studied patients' and spouses' causal explanations of a MI. Her sample consisted of 50 f i r s t - t i m e MI patients and their 50 spouses or s i g n i f i c a n t others. During the acute phase, and again during the convalescent phase of the i l l n e s s , data were collected by interviews using a structured questionnaire. At both phases of the study, both patients and spouses reported that tension was the most frequent cause of the patient's MI. Rudy noted that in general patients who had an i d e n t i f i a b l e medical r i s k factor did not name, nor did their spouses name, that r i s k factor as an explanation for the patient's heart attack. It i s therefore Interesting to note that a high percentage of patients changed their smoking, d i e t , and exercise behavior even when they did not consider these factors as having caused the i r heart attack. F i e l d i n g (1987) studied 102 MI patients and argued that poor outcomes following Mis occur because patients and health professionals view causal attributes of MI d i f f e r e n t l y . In his study, the most frequently c i t e d causative factors l i s t e d by patients were overwork, smoking, and worry, while physicians emphasized smoking, hypertension, and serum cho l e s t e r o l . His study led him to conclude that the b i o l o g i c a l focus of cardiac r e h a b i l i t a t i o n programs f a i l s to address the s p e c i f i c areas of concern held by MI patients. Murray (1989) Interviewed 25 MI patients, the day of or the day before discharge from h o s p i t a l , to assess the patients' perceptions of the causes of their MI and their knowledge regarding r i s k factors of coronary heart disease. Patients generally reported that they f e l t well prepared to go home but as one patient reported, not having been home how would they know i f they had had enough information. In t h i s study stress, worry, and overwork comprised 68% of the ci t a t i o n s as to the cause of MI, while standard risk factors such as smoking, hypertension, cholesterol, etc. were ci t e d only 60%. T h i r t y - s i x percent of the patients c i t e d standard r i s k factors as the most important cause of the i r MI, while 48% c i t e d stress, worry, and overwork. As reported by Murray these findings are broadly in l i n e with the findings of Fi e l d i n g (1987). These studies have shown that patients emphasize the psychosocial aspects of their l i f e s t y l e as causal explanations for their MI. Poor outcomes, in r i s k factor modification post-MI, may be the re s u l t i f patients and health professionals hold c o n f l i c t i n g views as to the cause of a patient's MI. 26 D i f f e r i n g Perspectives of Patients. Nurses, and Physicians In a 1975 study P f i s t e r e r examined how patients, doctors, and nurses perceived the learning needs of a small sample of cardiac patients being discharged from h o s p i t a l . The patients' cardiac diagnoses varied from MI to valve stenosis. Using open-ended questionnaires information was obtained from the patients, the doctors, and the nurses when the patient was discharged. As well, each patient completed a second questionnaire on the f i f t h day at home. P f i s t e r e r found that with one exception agreement among doctors, nurses, and patients about the patient's learning needs never exceeded 50% and that four out of the seven patients had unmet needs for information, i n the presentation of the findings P f i s t e r e r Is not e x p l i c i t as to what learning needs the patients, doctors, or nurses i d e n t i f i e d or what needs the patients' f e l t went unmet. Casey, O'Connell, and Price (1984) studied coronary care nurses', MI patients', and c a r d i o l o g i s t s ' perceptions of what patients need to know post-MI. Twelve physicians, 33 nurses, and 30 patients completed a questionnaire in which they were asked to rate the importance of 21 topics that might be taught in a post-MI education program. A l l three groups rated: '"knowing the signs and symptoms of a heart attack'; 'knowing how to modify or change personal r i s k factors'; 'knowing the names, dosages, and side e f f e c t s of medications'; and, 27 'knowing personal r i s k factors'" (p.77) as important. Although the three groups were b a s i c a l l y congruent with the topics rated as being most important there were s t a t i s t i c a l l y s i g n i f i c a n t differences among the groups in 10 of the 21 items. Patients were asked to complete the questionnaire while in h o s p i t a l , therefore, how b e n e f i c i a l topics were to their r e h a b i l i t a t i o n at home could not be assessed. Karlik and Yarcheskl (1987) did a comparative study of nurses' views of cardiac patients' learning needs and cardiac patients' views of their own learning needs. They also studied nurse educators to i d e n t i f y a possible source of pra c t i c i n g nurses' b e l i e f s regarding the learning needs of these patients. The sample consisted of 24 male and six female patients and 30 nurses: 15 post-coronary care (CCU) nurses and 15 nurse educators. The data were co l l e c t e d through questionnaires. They found nurses ranked the learning needs d i f f e r e n t l y than the patients did. Out of eight information categories the CCU nurses ranked medication knowledge as the number one patient learning need, while the patients ranked the category of r i s k factor knowledge as number one. It is interesting to note that nurse educators also ranked the category of medication knowledge as the most important patient learning need. The members of the health care team perceive themselves as a support to the patient who has to make l i f e s t y l e changes 28 or adjustments post-MI. This may not be the perception o£ the patient, however. A content analysis of l i f e adjustments post i n f a r c t i o n done by M i l l e r , McMahon, Garrett, and Ringel (1989) examined the issue of who MI patients viewed as being support persons during recovery. F i f t y nurse/patient Interactions were analyzed to i d e n t i f y support persons or groups, and to judge the q u a l i t y of the communication as being p o s i t i v e , negative, or ambiguous. It was found that patients viewed themselves as their greatest positive support, with spouses, children, and other r e l a t i v e s viewed as providing both tangible and emotional support of a positive nature. Although the health team ranked second as support persons their support was often perceived as negative or ambiguous with almost a t o t a l absence of emotional support. This led these researchers to conclude that " i f the health team, as the major provider of information, i s going to f a c i l i t a t e patient and family adjustment post i n f a r c t i o n , reasons need to be i d e n t i f i e d for negative qu a l i t y of support, unclear messages, and absence of emotional support" (p.566). D i f f e r i n g perceptions, as to the learning needs of patients post-MI and the role of health professionals in the r e h a b i l i t a t i o n process, have been i d e n t i f i e d . In order to make patient education more b e n e f i c i a l for post-MI patients these d i f f e r i n g perceptions must be c l a r i f i e d . Summary A review of the l i t e r a t u r e suggests t h a t p a t i e n t outcomes f o l l o w i n g a c a r d i a c event such as a MI are o f t e n e f f e c t e d by the p a t i e n t s * p e r c e p t i o n of the cause of the i l l n e s s , the p a t i e n t s ' r e c o g n i t i o n of t h e i r l e a r n i n g needs, and the presence of p s y c h o s o c i a l problems. L e a r n i n g needs are o f t e n viewed d i f f e r e n t l y by nurses and p a t i e n t s , which may cause these needs to go unmet. As w e l l , p a t i e n t s may not recog n i z e t h e i r l e a r n i n g needs u n t i l they t r y to manage t h e i r i l l n e s s a t home. Although these areas of concern have been i d e n t i f i e d there has been l i m i t e d r e s e a r c h on the p a t i e n t s ' p e r c e p t i o n s of the i l l n e s s experience f o l l o w i n g a MI. T h i s study was undertaken to expl o r e t h i s issue and a d e s c r i p t i o n of the methodology used i s presented i n the next chapter. Chapter 3 30 Methodology Introduction The q u a l i t a t i v e methodology of phenomenology was selected to guide t h i s study. In t h i s chapter a description of phenomenology and the c o r r e l a t i o n between th i s methodology and the methods of participant s e l e c t i o n , data c o l l e c t i o n , and data analysis are discussed. A description of the selection process and the data c o l l e c t i o n procedure w i l l also be presented. Methodology The q u a l i t a t i v e research method of phenomenology was used in t h i s study to research the meaning of the MI experience and the a f f e c t that experience had on the day-to-day l i v e s of patients and their learning needs. "The aim of phenomenology i s to describe experience as i t i s l i v e d by people" (Oiler, 1986, p.70), thus i t is a method which allows the researcher to focus on the perspective of the patient (popular arena) rather than the perspective of the nurse (professional arena). Glorgi (1975) outlined eight c h a r a c t e r i s t i c s of the phenomenological approach: (1) " f i d e l i t y to the phenomenon as i t i s l i v e d " (p.99), the phenomenon is studied in the context of the one l i v i n g through the s i t u a t i o n . Therefore, everything the subject feels i s worth mentioning i s included in the data.; (2) "primacy of the l i f e - w o r l d " (p.99), allows the emphasis to remain on the everyday world as i t i s l i v e d Instead of explanations or th e o r e t i c a l Interpretations of It; (3) "descriptive approach" (p.100), the phenomenon i s communicated through language thus description is the main technique of t h i s approach; (4) "expression of s i t u a t i o n from viewpoint of subject" (p.100), the data col l e c t e d are s t r i c t l y the subject's viewpoint; (5) "s i t u a t i o n as unit of research implies s t r u c t u r a l approach" (p.100), the research s i t u a t i o n creates a l i v e d experience with meaning for both the subject and the researcher; (6) "[biographical] emphases" (p.101), with the use of human subjects the data collected are biographical and personal; (7) "engaged researchers" (p.101), the researcher plays an active role in the constitu t i o n of the data therefore, a l l presuppositions that exist must be made as e x p l i c i t as possible; and (8) "search for meaning" (p.101), with t h i s approach the measurement of the phenomenon is i t s meaning. The phenomenological approach provides the researcher with a method of investigating a l i v e d experience from the perspective of the subject. In t h i s study the phenomenological approach was used to e l i c i t from the subjects the meaning of the i l l n e s s experience following a MI. V a l i d i t y and R e l i a b i l i t y The issue of v a l i d i t y or c r e d i b i l i t y in q u a l i t a t i v e research rests with how f a i t h f u l the researcher's description and interpretation of the experience i s to the subject's actual l i v e d experience (Sandelowsk1, 1986). According to Sandelowskl (1986) c r e d i b i l i t y i s represented when "people having that experience would immediately recognize i t from those descriptions or interpretations as their own" (p. 30), and when "other researchers or readers can recognize the experience when confronted with i t aft e r having only read about i t in a study" (p. 30). Unlike quantitative research where r e p e a t a b i l i t y of the data Is desired, the aim of q u a l i t a t i v e research Is to remain true to the unique experience of the individual (Sandelowskl, 1986). Thus, r e l i a b i l i t y In q u a l i t a t i v e studies Is not measured by the a b i l i t y to r e p l i c a t e the findings but on the a b i l i t y of others to follow the "decision t r a i l s " of the researcher and to arrive at the same or comparable conclusions (Sandelowskl, 1986). Sample Selection and Selection C r i t e r i a In t h e o r e t i c a l sampling the participants are selected by the researcher according to the th e o r e t i c a l needs and the d i r e c t i o n of the research (Morse, 1986). This study required individuals who would be able to speak to the experience of having had a MI therefore, a t h e o r e t i c a l sampling technique was used to obtain the sample. A d e f i n i t i v e sample size was not predetermined. The sample size in t h i s study was limited to f i v e , due to a lower than normal census of MI patients at the p a r t i c i p a t i n g agency and the time r e s t r a i n t experienced by a student researcher. As well, c r i t e r i a established for s e l e c t i o n of participants had to be modified during the subject recruitment stage in order to obtain the sample. The sample was selected using the following c r i t e r i a : (1) O r i g i n a l l y , i t was proposed that the participants were to be between the ages of 30 and 65, to Involve those of working age. Studies have shown that there i s a low rate of return to work in post-MI patients (Nagle et a l . , 1971; Wishnie et a l . , 1971) and i t was hoped that participants would be able to speak to t h i s problem. However, the majority of patients being admitted for MI were over 65, thus, t h i s r e s t r i c t i o n was l i f t e d . The c r i t e r i a then changed to include patients of any age who had the physical and mental capacity to be interviewed, i e . no hearing d e f i c i t s . (2) The participants had to understand and speak English as the data were coll e c t e d by t h i s researcher through interviews which were conducted in English. (3) The participants had to be experiencing their f i r s t MI. This excluded patients whose learning needs may have been Influenced by their previous experience of the phenomenon 34 b e i n g s t u d i e d . (4) The p a r t i c i p a n t s were p a t i e n t s f r o m a c o r o n a r y c a r e u n i t o f a h o s p i t a l w i t h i n t h e c i t y o f V a n c o u v e r a n d t h e y were w i l l i n g t o be i n t e r v i e w e d i n t h e i r homes two t o f o u r weeks f o l l o w i n g d i s c h a r g e f r o m t h e h o s p i t a l . (5) The p a r t i c i p a n t s h a d t o l i v e w i t h i n t h e c i t y o f V a n c o u v e r t o be a c c e s s i b l e f o r t h e r e s e a r c h e r . I t was a n a s s u m p t i o n o f t h i s s t u d y t h a t a l l p a t i e n t s , m a l e o r f e m a l e , who had e x p e r i e n c e d a Ml f o r t h e f i r s t t i m e w o u l d h a v e l e a r n i n g n e e d s , t h e r e f o r e p a r t i c i p a t i o n was n o t r e s t r i c t e d b y g e n d e r . T h i s r e s e a r c h e r a c k n o w l e d g e s t h a t t h e r e may be d i f f e r e n c e s b e t w e e n g e n d e r s In how I n d i v i d u a l s p e r c e i v e a n d / o r r e s p o n d t o a n I l l n e s s e x p e r i e n c e ( M e l n l n g e r , 1 9 8 6 ; S o r e n s e n , P l r i e , F o l s o r a , L u e p k e r , J a c o b s , & G i l l u m , 1 9 8 5 ) . H o w e v e r , i t I s b e l i e v e d t h a t t h e s e d i f f e r e n c e s h a v e a d d e d b r e a d t h t o t h e d a t a . Selection Procedure S u b j e c t s were o b t a i n e d f r o m a c o r o n a r y c a r e u n i t o f a h o s p i t a l w i t h i n t h e c i t y o f V a n c o u v e r . P e r m i s s i o n was s o u g h t f r o m t h e f o u r c a r d i o l o g i s t s c o v e r i n g t h e c o r o n a r y c a r e u n i t t o a p p r o a c h t h e i r p a t i e n t s f o r p a r t i c i p a t i o n i n t h i s s t u d y ( s e e A p p e n d i x A ) . T h r e e o f t h e f o u r c a r d i o l o g i s t s c o n s e n t e d a t t h e t i m e o f i n i t i a l c o n t a c t a n d s u b j e c t r e c r u i t m e n t c o m m e n c e d . Due t o a d e c r e a s e d c e n s u s and a l a c k o f MI a d m i s s i o n s u n d e r these c a r d i o l o g i s t s only two subjects were obtained in the following three month period. Therefore, the fourth c a r d i o l o g i s t was again approached and with t h i s added assistance three more subjects were obtained. The subject recruitment phase continued for a t o t a l of five months. The names of potential participants were passed on to the researcher by the ca r d i o l o g i s t s themselves, or by the head nurses of the units involved. The head nurses often acted as l i a i s o n s between the researcher and the c a r d i o l o g i s t s . The researcher's i n i t i a l contact with the MI patient did not occur u n t i l the c a r d i o l o g i s t either Introduced the researcher to the patient, or gave verbal permission to the researcher to approach the patient. Patients were approached prior to the i r discharge from hospital and at that time the study was explained and written consent obtained (see Appendix B). The researcher then contacted the subjects by telephone approximately two weeks post discharge to arrange for the f i r s t interviews. The patients' response to the study was generally p o s i t i v e . Seven patients were approached and of these seven, six consented. The one patient not wishing to participate c i t e d a personal d i s l i k e of research as the reason for nonparticlpation. One of the remaining s i x moved following discharge from hospital and did not contact the researcher. The sample size remained at five throughout the data 36 c o l l e c t i o n phase. Patient Education Protocol This study focused on each individual subject's experience and because i t followed the phenomenological paradigm there was no e f f o r t made to control what each subject received in the area of patient education. However, since a l l subjects were obtained through the same In s t i t u t i o n i t was thought that the information given to the patients would be r e l a t i v e l y consistent. The p a r t i c i p a t i n g i n s t i t u t i o n did in fact have an established protocol for the teaching of MI patients. A l l MI patients were to receive the publication The heart talk series  heart attack (1988). This written information was to be complimented by individual instruction from the nursing s t a f f and r e f e r r a l to a d i e t i c i a n where applicable. The nursing s t a f f were required to complete a chart form e n t i t l e d "Cardiac Patient Teaching Checklist" which outlined the basic steps in the teaching process in ch e c k l i s t format on the front side, and supplied the nurse with an overview of what material to cover on the reverse side. The use of these teaching tools was incorporated into the orientation program attended by a l l of the nursing s t a f f working in the intensive care and the medical unit where a l l fiv e subjects in th i s study were patients. 37 Data C o l l e c t i o n Procedures C o l l e c t i o n of data in t h i s study involved in-depth, taped Interviews with participants in their homes. At the f i r s t interview demographic data were coll e c t e d on each participant (see Appendix C). The i n i t i a l interviews were guided by a set of trigger questions (see Appendix D). Subsequent interviews with each participant were guided by the analysis of the f i r s t Interview and by questions that arose during the actual process of interviewing. The part i c i p a n t s ' accounts were constructed through a series of eleven taped interviews, one coincidental meeting, and two telephone follow-ups. A l l five participants were interviewed twice and one participant three times. P a r t i c i p a t i o n of spouses had not been d i r e c t l y sought, nor had i t been discouraged, therefore one participant's spouse a c t i v e l y took part in two interviews. Due to the extended subject recruitment phase both second interviews and one t h i r d interview were conducted with the f i r s t two subjects before the remaining three subjects had had their i n i t i a l interviews. A telephone follow-up was also done with the f i r s t two subjects. Data c o l l e c t i o n took place over a four and a half month period. The time spent at par t i c i p a n t s ' homes during the Interviewing process ranged from 45 minutes to two and a quarter hours. A t o t a l of nine hours was audiotaped with 38 recording times ranging from 20 to 60 minutes. The presence of the tape recorder did not appear to af f e c t the participants. At no time did any participant request the tape stopped or erasure of any of the recording. One participant asked that the tape not be replayed in his presence because he did not wish to hear himself t a l k i n g . Often participants ended the recording session but then proceeded to carry on further conversations with the researcher. Notes were made of these conversations as soon as possible following departure from the participant's home. A l l f i r s t Interviews were done between two weeks, two days and three weeks, f i v e days of discharge from h o s p i t a l . Four of the five were done during week three at home. One subject's f i r s t interview was delayed into week four due to readmission to hospital for treatment of chest pain. Second interviews ranged from five weeks, six days to 14 weeks, three days post discharge. Three were done around the six week mark, one at eight weeks, and one subject was delayed Into week 15 because he was away on a t r i p . A coincidental meeting with one participant was the impetus for a t h i r d interview. At the time of the chance meeting i t appeared that the subject wished an opportunity to talk about his recent h o s p i t a l i z a t i o n for angioplasty. A t h i r d Interview was done at approximately the nine week mark. Telephone follow-ups were done with the f i r s t two 39 subjects at 21 weeks, two days and 16 weeks, four days. Although the researcher used t h i s opportunity to address the management of l i f e s t y l e changes with each participant, the p r i n c i p a l reason for the follow-up was to gather information on their return to work. These participants were the only two In the study who were in the work force at the time of their MI. E t h i c a l Considerations Before data c o l l e c t i o n began the researcher obtained approval to conduct t h i s study from the University of B r i t i s h Columbia Behavioral Sciences Screening Committee and the p a r t i c i p a t i n g hospital's Research Committee. The potential participants were informed that their p a r t i c i p a t i o n in t h i s study was s t r i c t l y voluntary and that there would not be any e f f e c t on the care they received i f they did not wish to p a r t i c i p a t e . They were also informed that the e f f e c t s of p a r t i c i p a t i n g in the study could not be predicted; however, by sharing their experience they would help nurses to better understand t h i s experience which could Improve care for MI patients In the future. Written consent was obtained from a l l participants and a l l participants received a copy of the information-consent l e t t e r (see Appendix B). They were informed that they could withdraw from the study at any time. The participants were aware that data would be coded to protect their anonymity and the audiotapes would be destroyed following completion of the thesi s . The participants were also n o t i f i e d of the intention to publish the findings of t h i s study and that they would not be i d e n t i f i e d in any publication. Data Analysis The audiotapes were transcribed verbatim by the researcher. The data, comprised of both transcripts and f i e l d notes, were reviewed continuously as the data c o l l e c t i o n process proceeded. The f i r s t interviews were transcribed before second Interviews were conducted with each individual participant, allowing the researcher to validate the i n i t i a l analysis with that participant. Following C o l a i z z l ' s (Knaack, 1984) steps of data analysis s i g n i f i c a n t statements were extracted from the verbatim t r a n s c r i p t s . These statements helped the researcher to formulate meanings that were clustered into themes which in turn provided a description of the phenomenon under study. The researcher was unable to validate the f i n a l analysis with each participant due to geographical r e s t r a i n t s at the time of analysis. However, in each step of the analysis process the researcher returned to the data to ensure that the meanings remained f a i t h f u l to the o r i g i n a l data and that no data were ignored. Summary Phenomenology was the q u a l i t a t i v e research methodology chosen to guide t h i s study. A the o r e t i c a l sample of five post-MI patients participated in the study. Participant accounts were constructed using data collected in eleven i n -depth interviews, one coincidental meeting, and two telephone follow-ups. The data Included f i e l d notes and verbatim tra n s c r i p t s of the audiotapes. The data were continuously reviewed during the data c o l l e c t i o n and analysis phases. The descriptions derived from t h i s analysis are presented in Chapter Four. 42 Chapter 4 The Participants' Accounts Introduction The accounts of the Illness experience of fi v e MI patients w i l l be presented in thi s chapter. Prior to presenting the accounts the c h a r a c t e r i s t i c s of the participants w i l l be described. In the t e l l i n g of the i r s t o r i e s the participants have recounted the experience from their own unique perspectives with common themes, as well as occasional contrasts, having been Identified. These themes and contrasts were used as a framework to present the data In th i s chapter. To f a c i l i t a t e t h i s presentation the i l l n e s s experience accounts have been organized under the following headings: MI event; causes of MI; adjustments; concerns about damage, prognosis, and treatment; and, cardiac education, which included that done by both s e l f and health professionals. characteristics of participants Three males and two females, ranging in age from 42 to 77 years, participated in the study. The two participants in their early f o r t i e s were both male, one was divorced and the other separated, while the remaining three participants in 43 t h e i r s e v e n t i e s were a l l m a r r i e d . E n g l i s h was t h e p r i m a r y l a n g u a g e o£ a l l f i v e s u b j e c t s , w i t h two b e i n g B r i t i s h b o r n a n d t h e o t h e r t h r e e b e i n g C a n a d i a n . A l l t h r e e men had h i g h s c h o o l e d u c a t i o n , w i t h two h a v i n g g r a d e 12 a n d t h e o t h e r h a v i n g g r a d e 1 0 . Of t h e two men e m p l o y e d a t t h e t i m e o f t h e i r M I , one was a p o l i c e m a n a n d t h e o t h e r a h y d r a u l i c t e c h n i c i a n . The t h i r d ma le s u b j e c t was r e t i r e d f r o m a management j o b a t a w e l d i n g s u p p l i e s s t o r e . B o t h women were 75 y e a r s o f age a n d h o s p i t a l t r a i n e d n u r s e s , a l t h o u g h n e i t h e r woman h a d n u r s e d p r o f e s s i o n a l l y f o r many y e a r s (one f o r a l m o s t 50 a n d t h e o t h e r f o r c l o s e t o 25 y e a r s ) , a n d b o t h l i s t e d h o u s e w i f e a s t h e i r o c c u p a t i o n . The women were b o t h m a r r i e d , w i t h one h a v i n g a w o r k i n g h u s b a n d a n d t h e o t h e r ' s h u s b a n d b e i n g r e t i r e d . G e n e r a l l y , a l l s u b j e c t s l i s t e d v e r y l i t t l e u n d e r t h e h e a d i n g o f o t h e r h e a l t h p r o b l e m s on t h e d e m o g r a p h i c s h e e t ( s e e A p p e n d i x C ) . A l t h o u g h one s u b j e c t l i s t e d many p r o b l e m s , he h a d v e r y few t h a t were a c t u a l l y a c t i v e a t t h e t i m e o f t h e s t u d y . O n l y one s u b j e c t had a p r e v i o u s l y d i a g n o s e d h e a r t p r o b l e m , w h i c h was a n g i n a . Two o f t h e s u b j e c t s , who were i n t h e i r s e v e n t i e s , had d i a b e t e s w i t h one b e i n g d i e t c o n t r o l l e d a n d t h e o t h e r t a k i n g o r a l h y p o g l y c e m i c s . The o n l y o t h e r m a j o r I l l n e s s l i s t e d was b y one o f t h e y o u n g e r m a l e s u b j e c t s who had h a d a c a n c e r o u s k i d n e y r e m o v e d . A l l f i v e s u b j e c t s r e p o r t e d a f a m i l y h i s t o r y o f cardiovascular disease including one, or more, of the following; angina, stroke, MI, or heart f a i l u r e . The younger male subjects had strong family h i s t o r i e s with both having reported their fathers having had Mis in either their late f o r t i e s or early f i f t i e s . The younger male subjects were also smokers at the time of their Ml. of the remaining subjects, the older male subject reported having quit smoking 21 years ago after a 30 year history of heavy smoking, while both women reported n e g l i g i b l e smoking h i s t o r i e s . During the course of data c o l l e c t i o n the subjects reported to the researcher their perceptions about the information they had received while in hos p i t a l . A l l fiv e had received and taken home the publication The heart talk series heart attack. Three of the five stated they had received d i e t instruction from a d i e t i c i a n while in hos p i t a l . Only two subjects related receiving any follow-up from the nursing s t a f f on the written material received. A l l reported having discussions with their c a r d i o l o g i s t s regarding t h e i r MI, but there was a va r i a t i o n in how informative the subjects f e l t these discussions had been. Further discussion of the subjects* perceptions regarding information required and received during their i l l n e s s experience w i l l be presented l a t e r in thi s chapter. MI Event o£ the five participants only one had been diagnosed with a prior cardiac condition, therefore when describing the actual MI event three subjects related how they thought something other than a heart attack was occurring. ... I didn't recognize t h i s as being a heart attack. I thought ah when i t got r e a l l y bad that somehow I'd managed to collapse a lung because that's what i t f e l t l i k e was that I was short of breath and my lungs were burning, ah that I had run a thousand miles, and ah i t never even occurred to me that i t was the heart... We were having a drink and a pizza with our friends who l i v e r i g h t near us and fine and dandy u n t i l about one o'clock in the morning and that was when i t started, so I then walked around the house try i n g to get r i d of the, what I thought was indigestion and i t didn't go away, It was just as bad in the morning so we phoned the doctor then. It was a tightness but It was ah gas as far as I was concerned, that I couldn't get r i d of... Two participants related that they knew they were having heart attacks. One subject whose father had had Mis said he knew what i t was and that he had to get help. ... I knew what i t was ... I don't know why, i t ' s just d i f f e r e n t . We a l l get headaches and t h i s and that or whatever but there was just something about that, that ya know deep down inside that uh, you're not going to be able to make t h i s go away and ah, you got to get help ... 46 Even the participant who had previously been diagnosed with angina did not think at f i r s t that i t was a heart attack u n t i l her symptoms worsened. ... I knew as soon as I started having the pain in my arms, which got more, and more, and more, and the pain in my chest got ti g h t e r , and ti g h t e r , and ti g h t e r , I knew pretty well. In fact I think I may even have voiced those words to my fr i e n d , uhm, so I, I was pretty c e r t a i n that i t was a heart attack. A l l subjects related a degree of surprise, after finding out that what had occurred was a MI. Their reactions ranged from surprise to d i s b e l i e f and these reactions were often shared with their families and friends. For three of the subjects t h e i r surprise was compounded by the fact that they f e l t they had been taking good care of themselves. ... ya in terms of people I think they find that they're surprised ... I mean I'm not l i k e superbly f i t or I wasn't before my a c e , my heart attack but I use to t r y ya know and ah I guess you think God damn i t , ya know why me? Ya, I think everybody is ah surprised, not that, I mean I was surprised too because I'm a reasonably active person and uh f a i r l y young ... ... I was in very good health and of course been rather slender and I think I do a l l the right things and I exercise and eat the right foods, I hope, and, and generally have taken ah care of myself. 47 Oh well, I was shocked of course and didn't f e e l well I didn't believe them, no I didn't believe them. I said no I think i t ' s gas but they, they t o l d me In no uncertain terms you have, It i s not gas, you're having a heart attack. So, by that time I guess I was going to have one, whether I had It or not. In conjunction with t h i s element of surprise, four of the subjects compared the i r s i t u a t i o n to that of others and described feelings of i n j u s t i c e . ... I know I f e l t a l i t t l e b i t t e r at f i r s t , ya know, I use to think my God what is thi s ... truckers, ya know they're ah, I see them, ya know they're huge guys, ya know overweight and they're smoking ... ... l e t ' s put It thi s way there are a l o t of people that don't take care of themselves or take as good care as, as I do and uh they're s t i l l walking around, my brother is one of them and ah he's three years older, so. Ah, the guy, a friend of mine, gosh he, he should've been underground 50 years ago for the, he ate fat str a i g h t out of the pan. ... I said to a friend the other day there's no j u s t i c e , I've done a l l these things, in fact a very dear friend of mine, ... she's far too heavy, and loves a l l the r i c h , r i c h , r i c h things and she says you do a l l the right things . . . 48 The response to the emergency admission to hospital varied among the subjects. Three subjects f e l t a sense of secur i t y and r e l i e f to be there. Pretty safe ac t u a l l y , a l l In a l l , I f e l t as though I was in good hands. And there were people that r e a l l y knew what they were doing ... ... I didn't have much time to worry about anything out there [hospital] but ah I knew I was in a place where I would get attention. I was very relieved to be there [ h o s p i t a l ] , to be in somewhere, you know, to have somebody around that could make i t a l i t t l e b i t easier for me. The remaining two subjects were bewildered by, or couldn't remember, what took place In the hospital during the f i r s t few hours or days. ... I don't know what they were doing. I was being swarmed with a bunch of students and what have you, so you don't r e a l l y know what you, you're kind of bewildered i f ya know what I mean ... ... I'm not sure of what happened afte r that ... Being discharged from hospital also evoked d i f f e r e n t responses from the subjects. For some i t was a nervous time where the fear of having another heart attack was prevalent. uhmm, oh i t was pretty scary a c t u a l l y ya know, uh l i k e to be out of that hospital and to be away ya know from a l l the equipment ... you think well uhmm oh gees what i f anything happens ya know what am I going to do ... just those f i r s t couple of days I found i t ah, ya a l i t t l e apprehensive, ya a l i t t l e nervous. ... you're away from the people taking care of, and you're suddenly sort of ah on your own and I think I was a l i t t l e b i t nervous that, would I have another heart attack ... that was with me quite a b i t in the beginning and i t ' s c e r t a i n l y isn't anything l i k e , so much now ... For others coming home held no fear and they were glad to be there. ... I was comfortable in as much as I didn't think I was going to come home and die O.K., uh I would've been comfortable i f they'd released me ah, a week e a r l i e r in that regard ... Well, I was glad to get home ... The impact the MI experience had on the personal l i v e s of the subjects depended on how they viewed the MI I t s e l f . One young man viewed i t as a warning and an impetus to make changes in his l i f e . ... I just f e e l r e a l l y lucky that I've been given a warning and p o t e n t i a l l y that i f I r e a l l y watch myself I ' l l be O.K. ... I just f e e l the urge now that I want to change my l i f e a l o t , ya know I, in terms of my job as well, and ah just get some things done that I haven't done ... For two of the older subjects the impact was minimal. This might be a serious problem, i t ' s hard to say, but I don't r e a l l y think i t ' s that serious, but I'm not going to worry about i t ... It hasn't r e a l l y thrown me that much I don't think. I think I ' l l come back a l l right ... One man's response r e f l e c t e d somewhat his personal philosophy about l i f e . He did not foresee the heart attack as an impetus for many changes in his l i f e . He was w i l l i n g to make some concessions regarding his diet and exercise but he was not prepared to be f a n a t i c a l about either because as he saw i t there would be no guarantees. ... I have a reasonable amount of f a i t h that ah ya know, that ah t h i s i s going to be something that ah I go through and ah eventually get better and ah ya know i f He decides that ah I, I'm coming home then obviously I'm going to have to go but ah there's not much I can do about i t , one way, or another. The two subjects who f e l t the MI had Impacted a great deal on the i r l i v e s also related having days where they were down or blue. ... the odd day i t ' s s t i l l sort of gets me down a l i t t l e . 51 ... I just figure i t ' s something that I have to come to terms with and uhm, i t ' s me that's going to do i t and nobody else, ya know ... ... I thought i t would be you just, a slow steady progress and not any f a l l i n g back and I haven't r e a l l y f a l l e n back but some days I'm more ah bluer than others and the days that I'm blue I notice are related to my energy feelings. The Mi's most s i g n i f i c a n t impact appeared to be of a physical nature, as a l l fiv e subjects reported a notable decrease in their physical stamina. I didn't have any stamina, ... ya that's what I noticed, how quickly I l o s t a l l that ... ... but ri g h t now I don't seem to be able to do a h e l l of a l o t anyway ... But ah I'm kind of weak ya know, I get so t i r e d l a t e l y that I have to go and s i t down for awhile ... ... the f i r s t few days at home, when I f e l t absolutely grim, ya know I just wasn't up to that [stretching and walking] ... These reports of fe e l i n g p h y s i c a l l y limited continued to be expressed by most subjects in subsequent interviews. I f e e l I guess limited ... I know there's a l i m i t I guess to what I can do Well, I'm s t i l l favoring things ya see, uh I'm not doing what I think i s beyond what I can do. One woman f e l t her limi t a t i o n s r e f l e c t e d where she was in her recovery and that with time she would f e e l better. I'm perhaps limited but ah, after a l l i t ' s not even two months yet ya know. So, I think that ah another couple of months I'm, ya know, may fee l d i f f e r e n t l y even. The MI event also appeared to have an impact on the subjects and their contact with family members. For some It was demonstrated In a desire to see the i r families, or in thei r families desire to see them. ... that was the f i r s t thing, well ya know other than my own s e l f s u r v i v a l , uh that was the, the f i r s t thing that came to mind that, that night was that I want to see her [daughter] again, l i k e r i g ht now, and uh i t , when she came over then, i t was d i f f i c u l t for me, for me to see her go off again ... ... the family a l l came to see me and I wasn't to sure ah why they were a l l there except that I must be kind of serious l y s i c k . ... he [brother] said, well ya know If we hadn't been coming on July the 6th I'd have been beside you now. Ah so, i t ' s , ya know, he f e l t he needed to see me so. One man with a younger family delayed seeing his children u n t i l he had been s t a b i l i z e d in ho s p i t a l . ... I made the decision, I didn't want them to see me when I was hooked up to, ya know everything and I guess i t was the ah, the right thing ... by the time she [daughter] saw me I, I think I just had the one Intravenous in uhm and I think ya know she relaxed a l i t t l e b i t after that ... In general, a l l subjects reported their families and friends as being supportive throughout the experience. For those subjects who were married the support of the i r spouses was evident. Thank goodness we grow old together ... i f you're alone now that would be a whole l o t d i f f e r e n t story ... ... i t ' s a 50/50 proposition right down the center, so there's t r u s t , and there's love, and there's what have you ... ... my husband's been tremendously helpful and my neighbors have ya know, been r e a l l y tremendous ... There were two subjects not married at the time of their Mis One f e l t that going through the experience without a spouse made him f e e l the importance of a good re l a t i o n s h i p . . b u t a c t u a l l y at the time o£ the heart attack t h a t ' s when I f e l t gees I wish I was married, ya know ... I wish there was somebody that was right there with me ... The other unmarried subject who described himself as a loner did not f e e l he lacked support even though he was l i v i n g alone. ... I guess uh everybody i s , i s ah pulled together on thi s and uh I c e r t a i n l y haven't lacked support, sometimes I've had more support then I've wanted ... For one subject the family pets were seen as being a positive influence and support in the period following her MI. i t ' s because a dog, i t doesn't talk back, they're your best f r i e n d , and very t r u l y they are, ah so tolerant of you and they allow you to pet them, they don't care what you do r e a l l y for them as long as you feed them. Both women in the study viewed their families as supportive but there also appeared to be expectations placed upon them during recovery by their families. So, t h e y ' l l [sons and husband] a l l be watching me and they a l l walk and exercise and swim and everything else so they're not going to l e t me s i t around too much without doing what I'm t o l d . But he [husband] wants me to do a l l the things that I'm supposed to do of course, he doesn't want me s i t t i n g around in the bed a l l day long and I don't want to 55 e i t h e r . in summary, the occurrence of a MI for the subjects in this study was an unanticipated event which gave r i s e to a range of feelings from surprise to d i s b e l i e f . A majority of the subjects expressed a degree of in j u s t i c e at having had a MI. Three of the subjects considered the hospital a secure and safe place to be. For two subjects being at home after discharge from hospital was i n i t i a l l y a nervous time in which they feared having another MI. The impact the MI had on the subjects' personal l i v e s depended on how they viewed the event. The subjects' responses varied from a minimal a f f e c t to an impetus for change. For two subjects the MI had an ef f e c t on psychological wellbelng, in that some days they f e l t down or blue. A decrease in energy appeared to be of significance In the physical recovery of the subjects, with feelings of limi t a t i o n s being expressed by some subjects weeks after the MI. Generally, the subjects viewed their families and friends as being supportive throughout the MI experience, with spouses being of s i g n i f i c a n t importance to the married subjects In the study. Both of the female subjects perceived their families as having c e r t a i n expectations for the subject during the recovery period. 56 Causes of MI The responses to the question "what do you think caused you to have a MI?" varied with each participant. The two younger men in the study acknowledged the family tendency in the course of their interviews but neither related i t as a factor when asked the question as above. L i f e s t y l e practices were considered major contributing factors, with one man considering them as factors but unsure as to the extent of their influence. Uhmm, just my l i f e s t y l e . The way I uhm, just not watching what I was doing ya know not, not watching what I was eating, smoking ... exercise I think I was reasonably good at but i t was just too much of the other s t u f f ... I think that was probably the two ah, two biggest things. ... I've been told what e f f e c t stress has but I don't know how long ah, or how much stress i t would take in order to create the problem that I have. ... I don't know what proportion of ah my smoking ah would do to i t ... I mean obviously I can vary my die t ah which is no problem, I can stop smoking that doesn't appear to be any problem, uhm stress i s going to be something else. ... If I can eliminate the two out of the three ah or cut them down, obviously I think that I ' l l be better off for i t ... The three older subjects whose r i s k factors included diabetes, hypertension, angina or being overweight gave other reasons for the i r MI. I guess I Inherited a ce r t a i n amount of i t i f ah, i f 57 that's possible from my, my mother ... I don't know why I had a heart attack r e a l l y unless that chronic a ah, noise and, and whatever showed up on that cardiogram was something to do with ah, from b i r t h . I don't know that, no one ever suggested i t , I just sort of thought about that a f t e r I had the attack ... The only thing that I can think of ah that contributed to i t was possibly stress that I didn't know I had and ah, maybe too much s a l t ... The t h i r d older subject expressed disappointment In herself because she f e l t pushing herself to hard may have caused her to have the MI. I don't know what to answer to that r e a l l y . I'm disgusted with myself of course. ... I don't fe e l very happy with myself about i t . No, I'm not disgusted with myself, that's a b i t too strong, but I, I'm, I'm sorry i t happened. ... I just did have a fee l i n g that I was pushing myself a b i t too much so, ya know, maybe that's, maybe I just did push too much. Another l i f e s t y l e component often mentioned by the subjects was stress. For some stress was viewed as a d i r e c t cause of the i r MI, as noted in some of the previous quotes, while for the others i t was viewed as a factor present in thei r l i v e s . I think I, I handle i t [stress] r e a l l y well but i t ' s just that at that p a r t i c u l a r time [going through divorce] I didn't and uhm ya, and as I say ya know I got my cigarettes way up there and I just didn't bring them down again. 58 ... I never relax, never relax ... I've always been that way ever since I was very, very small ... that's why i t doesn't surprise me that i t , t h i s may be stress, i t may not be diet at a l l ... ... you can't raise a family and run a great big house without some stress and I had i t ... Ah, well ya, stress i s not the greatest thing and I, you can have stress and not even know i t , and of course in my work I, I guess I had quite a b i t of stress at that, but you don't r e a l i z e ya got stress, at least I didn't. ... I'm sure i t [stress] comes Into almost everybody's l i f e in some kind of way, whether i t resorts to a heart attack I don't know, but uhm I'd l i k e to say 'no' to that but I'm sure that, that there probably i s an element of that ... In association with th e i r discussions about stress in their l i v e s three subjects also used terms such as 'p e r f e c t i o n i s t ' or 'worry wart' when describing themselves. In summary, the subjects in thi s study c i t e d such things as d i e t , smoking, stress, family tendency, and pushing too hard as possible causes of their MI. As well, for a l l subjects stress was a l i f e s t y l e factor that was either currently present, or had once been a part of their l i v e s . Adjustments In describing t h e i r day-to-day routine subjects reported 59 adjustments they had made or were planning to make in their l i f e s t y l e s . Four of the fi v e subjects stated they had used the MI book The heart talk series heart attack received In hospital as a guide in making these adjustments. As well, a l l subjects reported receiving some instruction from their c a r d i o l o g i s t before leaving hospital on changes they were to make in their l i f e s t y l e s . Four of the subjects were making some changes in their d i e t . Three of the four were following directions they received from d i e t i c i a n s while in the ho s p i t a l . The fourth subject had been referred to a d i e t i c i a n after discharge from hospital when i t was found that his cholesterol l e v e l was elevated. This was the only subject aware of having a high cholesterol l e v e l . The only other subject who knew what his cholesterol l e v e l was had been t o l d his was within normal range. Most of the subjects perceived t h e i r diet changes as amounting to the deletion of one or two things from their d i e t . ... ah s a l t ya I, I'm cutting out the s a l t ah ... and she's [wife] cut down on the s a l t on the cooking a b i t ... I w i l l cut down and on the fat and that sort of s t u f f uh I don't know i f I can cut down on s a l t since I don't use i t uhmm I suppose I could cut down on the amount of taco chips or whatever but that sort of thing, I'm not a big eater of that sort of st u f f anyway uh but ah when I went over my diet with, with the d i e t i c i a n , other than 60 the eggs and the cheese i t wasn't r e a l l y a l l that bad ... The ah, the die t is ah very low f a t , and low sugar, and low s a l t , you see ... I'm careful about v i s i b l e fat ya know and I guess when I see s t u f f l i k e that ya know I do back away from i t ... but I was suckering myself Into the, the hidden s t u f f ... The subjects q u a l i f i e d t h e i r diet changes somewhat with statements of l i m i t a t i o n either of a personal nature, or of what they interpreted from in s t r u c t i o n received. ... I don't have to cut out s a l t completely so when I've been making porridge the l a s t two days I've put just a l i t t l e dash of s a l t i n , tastes a l o t better ... [Participant's spouse] Well, Dr. X says she doesn't want him [husband who i s the subject in the study] to change the ah ... change too much because she says sometimes i t does more harm than good ... ... but the, the big thing I think i s , I think i s the diet and ah I'm c e r t a i n l y prepared to go half way but I'm not ya know, i f I want a pizza and beer, which doesn't happen that often, but i f I want one I'm going to have i t . Two subjects had been instructed to lose weight and during the time of follow-up in t h i s study one had continued to lose while the other a c t u a l l y gained weight while away on a t r i p . 61 The only subject not making any die t changes viewed her die t to be consistent with what was suggested in the MI book. The subjects follow-up post Ml Included scheduled appointments with their attending c a r d i o l o g i s t s , and v i s i t s or telephone c a l l s to their family physician as Individual needs dictated. This method of follow-up did not create a problem for four of the subjects. However, for one man, who was scheduled for an angioplasty at another i n s t i t u t i o n under another c a r d i o l o g i s t , having three physicians led to several misunderstandings e s p e c i a l l y in the prescribing of medications. This subject was somewhat confused over how t h i s should have been coordinated. And I, I don't know ah who was suppose to coordinate that but there should be somebody I would think. This incident led the subject to certain conclusions about future health care services. ... I don't know what the answer i s but I ' l l t e l l you one thing is that I probably would not want Dr. X to do i t ... I think I ' l l be going to X Hospital the next time i f there is one. ... Well, I just don't want something l i k e t h i s happening again that's a l l , i t r e a l l y made me nervous ... Generally, the subjects stated they f e l t prepared to deal with the possible recurrence of chest pain. Following discharge from hospital four of the subjects experienced episodes of chest pain which did require them to use their n i t r o g l y c e r i n e . The number of episodes for each subject varied, from one episode since being discharged, to one with almost every walk. One subject was readmitted to hospital just one week after his i n i t i a l discharge because of an episode of chest pain. ... i t f e l t l i k e angina pain but, but to be honest with you I can't be r e a l l y sure and uh I took a couple of nitros and uhmm I don't know i f i t was panic or what, but I started to get a steady pain in my chest. Uhmm, I guess I wasn't confident enough to just sort of s i t i t out and I thought well ta heck with i t I'm going back up there [hospital] ... This same subject, later in his recovery, experienced another episode of chest pain which he successfully treated with nitroglycerine at home. The subjects reported that they carried their nitroglycerine p i l l s or spray with them for the most part. One subject, when he rea l i z e d during an outing that he had l e f t his nitr o g l c e r i n e p i l l s at home, went to the drugstore and purchased another b o t t l e . Incorporating medications into the d a i l y routine did not present a problem for the subjects generally. The one married man in the study reported that he would not have remembered his afternoon p i l l i f not for his wife, at which time she informed the researcher that she l a i d out his p i l l s for him every day and made sure he took them. One man was discharged on warfarin which i n i t i a l l y required him to go for blood tests twice a week, t h i s was l a t e r cut down to once a week and eventually discontinued. The warfarin dose was adjusted by the family physician based on the test r e s u l t s . The subject was contacted by phone i f there was a change to be made In the dosage. Other adjustments In medications were generally made by the attending c a r d i o l o g i s t without d i f f i c u l t y , except for the subject previously mentioned who had had a misunderstanding with the medications prescribed because two ca r d i o l o g i s t s had been p a r t i c i p a t i n g in his care. Both men who had been smokers at the time of their MI had quit smoking while in ho s p i t a l . Although neither had resumed smoking both reported having the occasional urge which, so far, they had been able to r e s i s t . Certain housekeeping a c t i v i t i e s presented obstacles for some subjects, thus requiring them to make adjustments. One of the single men i n i t i a l l y found shopping for groceries t i r i n g . ... i t ' s never occurred to me before because I guess ya know i t just gets done so quickly was shopping at the store, ... I noticed how quickly I became t i r e d and uh started to f e e l l i g h t headed, uh thi s was the f i r s t weekend I guess when I got out, and so that I just sat the basket on the floor and walked slowly around and picked up s t u f f and put i t in the basket ... The other single man, because he could not drive his car, reported grocery shopping as an inconvenience and he found i t demeaning to have to depend on other people. ... i t ' s a l i t t l e demeaning in as much as I have to b a s i c a l l y depend on other people ya know to drive me up there [grocery store] but ah i t hasn't r e a l l y been a major problem I just don't l i k e to depend on other people that's a l l . Neither of the single men reported any s p e c i f i c concern about doing housework or cooking but both also appeared to have returned to other pre-MI a c t i v i t i e s more quickly than the other subjects in the study. One man was already d r i v i n g his car and had returned to work part-time at the time of his f i r s t interview, only three weeks after discharge from h o s p i t a l . The other man, who stated he was not f a n a t i c a l about housework, reported following the guidelines for i t l a i d out in the MI book. Both women in the study reported th e i r husbands a s s i s t i n g with some household chores such as the laundry and in one subject's case, her husband had taken over the cooking and shopping as well. These subjects had domestic help come to do the i r heavy housework prior to having their MI and they found t h i s to be very helpful to them following their MI. However, for one woman the managing of the household and things such as shopping and banking had i n i t i a l l y been a concern. 65 But those few days I r e a l l y didn't f e e l very well ph y s i c a l l y , so I was a b i t concerned uhm about how I was going to manage and I have a cleaning lady who's only been coming once every two weeks but in point of fact has come every week since, uhm since I've got home, which i s a great r e l i e f ... so, what I've been doing of course Is taking care of the meals and uhm a l i t t l e b i t of shopping, a l o t of my friends and neighbors have helped me a great deal, some I've gone with the odd time, which I haven't enjoyed too much, ... is almost too much for me ... I just find It ah after being to the bank and going to there [store] for a few minutes I was r e a l l y glad to be home. This subject reported she accepted help offered by her friends and by spreading the jobs out amongst them she had f e l t more comfortable with accepting t h i s help. By the time of the second interview both women reported doing more around the house but s t i l l expressed gratitude for having hired domestic help to do the heavy work. As previously mentioned the return to some a c t i v i t i e s , s p e c i f i c a l l y s o c i a l and recreational, was slower for the older subjects in t h i s study. For the younger subjects t r i p s and outings did not present a problem, with one man even going on a three week t r i p to England. However, those subjects in the i r seventies appeared cautious In resuming some a c t i v i t i e s even six to eight weeks after discharge from h o s p i t a l . ... I haven't been out anywhere else. Although, I'm going to a wedding on, t h i s Saturday, and ah but for a while I thought I wouldn't go but I've turned down everything else . .. 66 We've been down [to their cottage] for the day and back but ah to check things out but that's ah, that's the f i r s t time we stayed down. ... I'm s t i l l at the stage where I'm quite happy to be uhm ya know leading a quiet l i f e , f a i r l y quiet l i f e . But tomorrow i s , tomorrow is ah our wedding anniversary so my husband and I are going to the faculty club for dinner ... that's sort of a major outing cause we haven't been out to dinner ... Two of the three older subjects f e l t they had slowed down before their Mis. ... I'm slowed down anyway, before t h i s ever happened I was slowed down. ...my l i f e s t y l e wasn't ah such that we were on the go a l l the time, even when we're down to the Bay we st i c k around pretty well. We're not prancing a l l over the place but ah no, i t ' s ah, our l i f e s t y l e hasn't changed that much. The other senior subject related that she would have to change her busy l i f e and had decided to stop some a c t i v i t i e s , l i k e choral singing, but was not upset about that. ... I'm quite happy to l i s t e n and ah ya know just sort of cut back on things a l i t t l e b i t , which doesn't mean that I don't do interesting things at a l l , so. Oh, I think there comes a time in everybody's l i f e when some things have to be given up, so. These subjects appeared to have considered their age when examining adjustments to the i r l i f e s t y l e following MI and for two of them some adjustments had already been made. ... those things had to change, we just couldn't, we knew we had ph y s i c a l l y to stop some of that carry on, when you get to be that age you do. ... the main reason was because when you get to 77 ya gotta be a l i t t l e b i t r e a l i s t i c . Ah, how much more do I need to have that, and ah i f something happened to me she'd have i t a l l to do. However, taking these subjects' l i f e stages into account the three senior subjects had s t i l l not resumed what they considered to be their normal s o c i a l and recreational a c t i v i t i e s s i x to eight weeks after their Mis. Another adjustment only expressed by the three older subjects, In r e l a t i o n to the resumption of a c t i v i t i e s , was thei r desire to l i s t e n to what their bodies t o l d them when i t came to their physical l i m i t a t i o n s . ... In other words I'm taking care, car., ah be, tryin g to be careful of what I do and how long I do i t . She [doctor] said to go according to what your body t e l l s ya and I've been trying to do just that. ... you see in the past ah I've tended, I, I've been aware of what my body's t o l d me but I ignored i t and now I'm l i s t e n i n g more. 68 ... i f you're going to be sick your body warns you, then's your time to s t a r t f r e t t i n g about doing something wrong. An adjustment only mentioned by the two women in the study was developing the a b i l i t y to say "no" to a c t i v i t i e s they did not f e e l capable of doing. This appeared to be a new option for them following their MI. ... I don't think I want to go to everything, although I hate being a crybaby and saying I can't come, never have done that, but ah you can't also be a good ol'soak and say oh sure I ' l l be there whenever they say because that i s what stresses you out sometimes ... ... i t has made me fe e l ah that I can say 'no' to things and ah I don't want to do that, or I can't go, or whatever i t may be uhm before I didn't f e e l that was uhm a thing that I wanted to do. Returning to the a c t i v i t y of dr i v i n g a car was influenced by each participant's desire and the necessity of doing so. Most subjects were told not to drive for at least s i x weeks and for one woman, who had given up her car the year before and whose husband s t i l l drove, t h i s was not an adjustment. For the two younger subjects not being able to drive was inconvenient and one returned to driv i n g shortly after discharge from h o s p i t a l . The married man had not returned to dri v i n g even after the six week mark and stated he did not see the need to since his wife was able to drive. The remaining subject was anxious to be able to drive because her husband was a non-driver, yet she was apprehensive about d r i v i n g even after waiting s i x weeks. A l l subjects had made an e f f o r t to follow a d a i l y exercise routine of walking and for most t h i s was the f i r s t organized exercise they had done in years. The married subjects were often accompanied by the i r spouses when they went for the i r walks. The subjects maintained th e i r walking schedules throughout the time they were followed for t h i s study. Only two subjects were working at the time of the i r MI. One man did not have sick benefits and therefore returned to work on a part-time basis three weeks after discharge from ho s p i t a l . He was then l a i d off from his job because of a slump In business but later returned to f u l l time employment in a new job. However, t h i s subject viewed his MI as being an impetus to change his career, subsequently went through career counseling, and was planning to s t a r t night courses at a community college. ... of course i t ' s come down to r e a l i t y , the studying and a l l the rest of i t but no, I d e f i n i t e l y uhm s t i l l want to change ah some things in my l i f e and I'm going to do i t , and that's for sure, hah. 70 The other subject, at his i n i t i a l interview, stated he had not been t o l d when he would be able to return to work. Although finding out when he could go back to work appeared to be his foremost concern, i t did not create a f i n a n c i a l worry for him because he had sick benefits. At the time of the f i r s t interview he was awaiting the results of a thallium stress test to determine i f an angioplasty would benefit him. This subject did undergo angioplasty but he was hesitant to go back to work even when told he could do so by a c a r d i o l o g i s t . He expressed concern about his job being s t r e s s f u l , e s p e c i a l l y over the summer with people on holidays, and he wanted to take the summer o f f . ... I know that going to September ah i s stretching i t but ah the only other, other alternative would be to have me go back to work to some other job u n t i l September ah which is ah p o s s i b i l i t y ... Approximately three months following his MI the subject did in fact return to work in another position part-time, but only for two weeks. The subject reported he found i t t i r i n g and for every half day he worked he was being deducted a half a day in sick time so he decided to take the rest of the summer of f . His family physician did not fee l t h i s was necessary and the subject was informed that he would have to make his own arrangements with the occupational health doctor at his place of employment. The occurrence of a Ml required the subjects to make adjustments in their l i f e s t y l e s which Included changing their d i e t , managing episodes of chest pain, incorporating medications into a d a l l y routine, adjusting the running of the i r households, adding a walking routine, and for two subjects the cessation of smoking. Although the senior subjects appeared to have made some adjustments in t h e i r l i f e s t y l e s prior to having a MI their return to s o c i a l and recreational a c t i v i t i e s was slower than the younger subjects in t h i s study. For the women In the study having a MI made It easier for them to say "no" in situations where they did not want to do some a c t i v i t i e s . Returning to work was not a smooth t r a n s i t i o n for either of the men employed at the time of their MI. Concerns About Damage, Prognosis and Treatment Only one subject was aware of the amount of damage to his heart because while in hospital recuperating from his MI he had undergone an angiogram and the results of t h i s had been explained to him. The other subjects in the study expressed concern over not knowing the extent of the damage and It was something they had asked or planned to ask the i r c a r d i o l o g i s t about. 72 I, I want to know exactly, well I don't know how precise they can be about t h i s , but I want to know how he [cardiologist] knows what part of my heart is damaged. I want to know how much i s damaged. I want to know the exact r e s u l t s of the thallium t e s t . I want to know what they found, was there any r e s t r i c t i o n s . Uh, I just want to know a l o t more about what happened to me and where exactly I stand. ... I don't even know the extent of the damage. ... Ya, she [cardiologist] said, you had a damn big heart attack and that's a l l and not gas. So, well but no, I didn't get any ah answers on.., I don't think they know unless they ah put you through some kind of ah, a dye deal. ... I don't remember having any idea of how much damage there was ... I don't know, I hope to know more about i t r e a l l y . I don't know whether i t ' s , some doctors are not crazy about giving too much information away but I would l i k e to know. In r e l a t i o n to t h i s concern damage most of the subjects also to expect in the future and what about the extent of the expressed anxiety over what in fact was the i r prognosis. ... what can I expect for the future ya know, based reasonably on what he [cardiologist] saw and the res u l t s of a l l these tests they took. ... I would've preferred to have known what the prognosis was, O.K.. Now, very early on they said that, that I would return to a normal l i f e eventually, reasonably normal l i f e i s what they said. Uhmm, that doesn't conjure up any pa r t i c u l a r r e s t r i c t i o n s in my pa r t i c u l a r area because I don't think I, I ah want to do anything in a physical nature that, that was r e a l l y out of the ordinary ... 73 Well ah, I guess how serious i t was and was I going to get better, was I going to be an i n v a l i d ... Uhm, I suppose in the back o£ my mind there's s t i l l a b i t of a concern that I ' l l get back to the way I'd l i k e to f e e l . I mean ah sometimes I f e e l that there's no doubt about i t and other times I'm a l i t t l e b i t uhm wary, ya know. Concerns regarding treatment were also raised, e s p e c i a l l y by the subjects undergoing invasive procedures such as angiogram and angioplasty. Although these concerns related to the s p e c i f i c procedure being performed they often included things such as ri s k factors and what to expect during the procedure. In summary, the subjects were interested in knowing about the damage caused by their Mis and the e f f e c t It would have on the i r a b i l i t i e s in the future. For those undergoing further treatments and procedures there was also an amount of concern expressed about these procedures. cardiac Education Both the formal and informal aspects of cardiac education received by the subjects following their MI w i l l be presented in t h i s section. The focus of t h i s study was to obtain the subjects' perspectives of their experience, therefore no 74 attempt was made by the researcher to test the subjects' knowledge l e v e l or to judge the qu a l i t y of the teaching received. To f a c i l i t a t e presentation of these data, the section has been subdivided into education from health professionals, and s e l f education. Education from health professionals. During their stays in hospital a l l fiv e subjects had received the MI book The heart talk series heart attack used by the i n s t i t u t i o n for cardiac patient education. The fi v e subjects reported having read the book and a majority used i t as a guide or reference throughout the recovery period. Oh ya, they gave me ah literature on, I guess i t ' s from the heart foundation, ... e s s e n t i a l l y what had happened to me, and uhmm how to get over i t , ya know, that i t ' l l applies to d i f f e r e n t age groups ya know, but how to st a r t your exercise schedule and what to look f o r . ... That's what I was doing ya, was l i k e trying to st i c k roughly to that book ya know ... They gave me a book which I've read through a couple of times ... that's a very good book ... Ya, well ah, I've read i t [MI book] more then a couple of times. I keep checking on, i t . . i t ' s ah l i k e a guide now, because I know where to look for what I want to find out. So, I read i t when I got Into the cardiac ward, from cover to cover, and in fact I read i t also and look at i t , I mean I refer to i t a l i t t l e b i t now, just to give me an idea of perhaps where I might be at t h i s stage. The cardiac education protocol at t h i s i n s t i t u t i o n Included the d i s t r i b u t i o n of the MI book with supplementary instruction from the nursing s t a f f . Only two subjects in thi s study report receiving i n s t r u c t i o n from their nurses. ... a c t u a l l y before I l e f t she [nurse] ah sat down with ah, sat down with me and ah, and ah brought t h i s l i t t l e p l a s t i c heart thing that ah folded and whatever and ah explained ya know what happened and, and ah ya know what angina Is and she wrote that [hand written note on the use of nitroglycerine] and we had ah I, I would Imagine that i t would've taken her at least half an hour so I f e l t f a i r l y comfortable ah as to ya know what had happened and, and ah what could happen i f i t ever happens again that sort of s t u f f and why and a l l that sort of s t u f f . The nurses came in and talked to me and asked me a few questions about the book [MI book] and that. I, I guess they'd figured I read i t . They were checking I guess, more or le s s , cause I pretty well had the answers. For one of these subjects the circumstances under which he had received his in s t r u c t i o n had concerned him. He f e l t i t had only been done because he personally knew the nurse who did i t . The thing that concerned me about that was that, was almost an afte r thought I mean i f It hadn't been her i t probably wouldn't have been done ... i f she hadn't been on s h i f t even I don't think that would've been done ... This same subject also f e l t that teaching sessions, such as the one he had received, should be something done more often by nurses. That's the type of thing ya know that I, that I think nurses should do, I ah don't think that they should be making beds ... Three subjects reported that they did not receive instruction from their nurses. However, the nurses were often viewed by these subjects as being supportive and kind. ... I was r e a l l y impressed by the nurses, and uh maybe because I'm single i t made a difference ya know because maybe they related to me a l i t t l e better I don't know. But uhm, I just found them r e a l l y good ya know i t made such a difference to me but uh just the way they were ya know r e a l l y nice, and professional, not l i k e p r ofessionally aloof, they were f r i e n d l y as well ... ... but once I was into the cardiac ward some of the nurses that I knew more because of the s i t u a t i o n , where they were there in the daytime or whenever i t was, were ah very nice and very h e l p f u l . Although the nurses had not reviewed the MI book with these subjects, nurses were viewed as a source of information by at least one of the subjects who reported asking questions of the nurses. The c a r d i o l o g i s t s , and to a certa i n degree family physicians, were viewed as sources of information as well. A c t i v i t y r e s t r i c t i o n s or guidelines appeared to be the focus of the information received or the questions asked of the physicians. The information varied from s p e c i f i c instructions as to when the subjects could go back to work, or drive cars, to more general instructions on a c t i v i t i e s permitted. Uhm, just to go back [to work], possibly i f I could part-time, which I'm doing and uhm, no heavy l i f t i n g and uhm l i k e strenuous movements, which I don't do normally anyways, but uhm other than that just to do i t as relaxed as I can and to just build up to i t slowly. Oh ya, she [cardiologist] t o l d me what to do and ah I wasn't to drive the car for six weeks, and ah we're not to go down across the l i n e for three weeks [to cottage] She [cardiologist] said to just, she said no big meals, no big walks, and ah t i r e d , rest when you're t i r e d . The type of questions the subjects asked or were planning to ask r e f l e c t the subjects' desire to know information s p e c i f i c to them. Ya, ya I asked him [cardiologist] l i k e how much I should exercise, uhmm what sort of heart, heart rate I should be getting up to when I'm exercising and how long I should do i t for, and uhm how long before I can do t h i s and before I can go back to work and drive and t h i s sort of stu f f ya know. I asked him about the tablets, how long w i l l I be on them, and what the long term e f f e c t s . 78 Well, there's, there's the work and the car thing, that's f a i r l y Important to me because that goes with the independence thing, ah I would l i k e to know whether I'm going to t r a v e l , I would l i k e to know what the r e s t r i c t i o n s are. Once home, subjects often contacted their family physicians when they had questions regarding their medications or physical symptoms that were not, in their opinion, connected to their heart problem. Some subjects f e l t that concerns about their heart should be directed to their c a r d i o l o g i s t s . . . . uh he's [family physician] t o l d me on a number of occasions he r e a l l y doesn't know what ah they're t a l k i n g about in terms of heart ... I don't think that he would know what the eff e c t s of various things are and, and that sort of st u f f so, which didn't cause me any discomfort i t ' s just you know uhmm i f I wanted to talk to somebody about a heart I guess I would talk to, to X or Z [cardiologists] I guess. ... maybe i t should have been a question to Dr. X [cardiologist] rather than my own family physician but anyway we'll see. Although the subjects used th e i r physicians as resources many also expressed that sometimes their physicians were in a rush and t h i s affected the information they were able to obtain. Four of the subjects did report making l i s t s of 79 questions for their physicians and to some extent t h i s had been b e n e f i c i a l . ... well because I guess ya know l i k e doctors and ya know they're in a rush ya know a l o t of the time ... Uhmm, the doctors ah, ya know they, ah Dr. ah X [card i o l o g i s t ] he ah, he gave me as much time as I ah probably ah needed ha, ha. Ah, i t ' s one of those things where you always think of questions after they've l e f t ya know and ah ac t u a l l y I've started to write down questions so that ah ... I can ask these things ... ... and of course when you go to see people [physicians], even when you make a l i s t , you can't stay there a l l day, they haven't got that kind of time uhm so a l l my questions are, are not answered ya know ... The subjects reported the d i e t i c i a n s , whether seen while in hospital or on an outpatient basis, as another source for information that was f e l t to be b e n e f i c i a l . The d i e t i c i a n s helped the subjects to i d e n t i f y areas In their d i e t that they f e l t required adjusting. ... the same mistakes I guess that I made only to a less degree before my heart, I was s t i l l getting suckered Into things l i k e muffins ... no matter what you c a l l i t ya know a sunflower o i l or whatever, that fat is f a t . That's the bottom l i n e , so now I understand a l o t better then I did . .. Low chole s t e r o l , low f a t , low, low sugar ... yes the g i r l [ d i e t i c i a n ] that came to v i s i t and gave us a l i s t of 80 things. The one f a u l t I guess I have is the number of, of eggs and cheese that I have during the week. It's quite astounding ah ... ya, well she's [ d i e t i c i a n ] t a l k i n g about three eggs a week and I'm talking about three eggs a s i t t i n g ... This one [diet] you gotta watch the s a l t s and the fats The readiness of subjects for teaching or educational materials varied among the three subjects who had expressed opinions in that area. One of the two subjects, who had received teaching in the hospital from a nurse, f e l t that the teaching could have been done e a r l i e r in his hospital stay. This was the only subject who had undergone angiography during his admission and who knew the s p e c i f i c s of the damage done to his heart. For him, receiving teaching at the time of discharge was disconcerting. ... I think i t should have been done e a r l i e r rather than ya know her fee l i n g that ah she's keeping me from going ... I was already discharged and she said wait u n t i l I come back so I had my ride and everything there and, and ah ya know we went over i t . And I, I thought i t was, i t was ya know a good presentation and a l o t of good stu f f but I think i t should have been done ah a few days e a r l i e r . ... I had that ah thing on the heart anyway ... the sheet where they, they t o l d me where the actual blockage was ... 81 Another subject i n i t i a l l y expressed surprise at receiving the MI book while she was s t i l l in the intensive care unit instead of being given i t the day she came home. For thi s subject other things took p r i o r i t y during the time in the intensive care unit. I mean I, i t seemed l i k e a good idea to me I just was surprised, cause I thought that, i t would be the kind of thing they'd give you the day you came home. Uhm, but of course they gave i t to me then persumably and everybody else, so that's the time when you get out of ICU, [ICU] is not the time that you want to st a r t looking at i t perhaps too much else i s going on, but once I was on the cardiac wards c e r t a i n l y was the time that I read i t from cover to cover. Uhm, so you're prepared for what's going on when you get home which I, so in retrospect It seemed l i k e a good idea. One subject whose cardiac education had consisted of reading the MI book and a discussion with his c a r d i o l o g i s t did not fe e l ready for that information while in ho s p i t a l . This subject expressed Interest In p a r t i c i p a t i n g in a cardiac follow-up group after his discharge. Uhmm, no I don't think so, I think that, that time [while in hospital] uhm that's I think when I f e l t I most needed somebody to talk to about what had happened to me and ah somebody to spend a b i t more time with me ... The only other health professional mentioned In the context of giving information to the subjects was a 82 pharmacist. One subject reported receiving information sheets from his pharmacist when he f i l l e d his prescriptions. Four of the five subjects asked questions of the researcher during the course of the interviews. The questions varied from wanting v a l i d a t i o n or c l a r i f i c a t i o n of Information already received, to requests for further information. One subject was p a r t i c u l a r l y Interested in knowing how her experience compared to the experience of other subjects in the study. For the subjects in t h i s study the physicians, s p e c i f i c a l l y the c a r d i o l o g i s t s , were used as a p r i n c i p a l source of information even though the time spent with their physicians had been limited. Also, those subjects receiving i n s t r u c t i o n from other health professionals, such as d i e t i c i a n s and nurses, f e l t t h i s Information to be b e n e f i c i a l . During the course of the interviews the researcher was viewed by most of the subjects as a source of information as well. Timing of teaching a c t i v i t i e s was a concern for three subjects. Four of the five subjects viewed the written material received while in hospital as useful as a guide and reference during recovery at home. Self education. A l l f i v e subjects reported having discussions with family or friends about their MI. Topics of these discussions ranged from changes in their d i e t , to comparing the course of the i r 83 i l l n e s s and recovery to that of others. One subject did not view these discussions as very b e n e f i c i a l . Well, everybody's a doctor, I got more damn advice then ya can shake a stic k at, I just l e t i t go in one ear and out the other. While for another subject t a l k i n g to a person who had been through the experience was thought to be h e l p f u l . ... ah i t ' s better to talk to somebody that's had i t and to find out exactly what ya know, what they do to you and how he [friend] f e l t ... The extent to which subjects f e l t comfortable t a l k i n g to people about th e i r MI varied as well. One woman who reported having interesting conversations with both her family and friends, many of whom were physicians, was s t i l l cautious about discussing i t too much. ... No, I don't know whether i t ' s wise to talk too much to people, they get t i r e d of l i s t e n i n g to other people's, at least that's my theory, that your i l l n e s s e s , that's why you have a doctor to talk i t over with ... Another subject, who described herself as someone who craved information, did not view everyone she talked to regarding her MI as an appropriate source of information. 84 ... in fact I sort of almost crave i t [information] and i f anybody has anything to t e l l me, l i k e you [interviewer], ah I don't mean the people next door, much as I l i k e them very much indeed because they're not into that. Ah, but i f people have anything interesting to t e l l me, I, or to t e l l me what books to read about i t I'm very much interested. As well, for another subject cert a i n aspects of the experience had to be dealt with on his own, s p e c i f i c a l l y in r e l a t i o n to his feelings of being down following his MI. Uhmm, no I usually t r y and resolve i t myself ya know and ah just think about why I'm down and what I can do about i t ya know I mean i t ' s more, cause I figure well to a point that I've talked enough about i t to other people ya know and ya know other people have asked me about i t and not that i t bothers me but ah I just figure i t ' s something that I have to come to terms with and uhm, It's me that's going to do i t and nobody else ya know, so. Two subjects, both of whom reported being inadequate readers or poor retainers of information that was read, stated they preferred the one-on-one instruction received from the nursing s t a f f to reading independently as a method of receiving information. ... I think that people learn much better by being taught than by reading ah ... l e t ' s put i t t h i s way I had no problem gaining the information from the book but I'd c e r t a i n l y rather because I don't personally read that well, so i f , i f I'm going to be taught ah I would c e r t a i n l y i f I had my druthers be taught in person rather than by being handed a book. It also should be noted that these subjects were the only two that received one-on-one in s t r u c t i o n from the nursing s t a f f . Both of the subjects who did not prefer reading had read only the information received in the hospital regarding their Mis. Other than the questions they asked of their physicians, and of th i s researcher during the interview process, neither of these subjects had reported a c t i v e l y seeking other information during the recovery period and both had expressed s a t i s f a c t i o n with the Information they had received. ... generally speaking I'm s a t i s f i e d with the information that I got. No, I'm just going by that book [Ml book] I got. I figure that's, about covers i t ... The three subjects who preferred reading did not express d i s s a t i s f a c t i o n with the information received, however they a c t i v e l y sought information from other sources. The methods most often used to obtain t h i s information were discussing i t with family or friends, doing further reading, and watching t e l e v i s i o n shows. The amount of extra reading varied among these three subjects with one having only made plans to read her husband's medical journals and another having already done extensive reading about the heart attack experience from a variety of sources. The topics of the books and a r t i c l e s read varied with each subjects individual tastes and often r e f l e c t e d areas of interest held by those subjects before their Mis. The two subjects who were the most active in obtaining other information following their Mis were also the same two subjects who perceived the impact of the MI as an impetus for change in their l i v e s . Both of these subjects had already made changes that would e f f e c t t h e i r futures such as undergoing career counseling and deciding not to resume cer t a i n a c t i v i t i e s such as choral singing. As well, they were the only two subjects that had expressed feelings of being down or blue following t h e i r Mis which may r e f l e c t somewhat the Impact the MI had had on them. For one of these two subjects viewing a t e l e v i s i o n talk show, featuring three guests who had survived their heart attacks, encouraged him to f e e l he could survive i t too. ... I think that seeing that made me r e a l i z e ... that you can survive i t [heart attack] and you can go on and l i v e a normal l i f e ya know. This subject was also the only person in the study to express Interest in p a r t i c i p a t i n g in a support group following his MI and he had written the l o c a l heart foundation for further information. As well, he had volunteered to participate in another research study investigating the effects of a new drug 87 on cholesterol levels but was dropped from the study when he did not meet a l l the sel e c t i o n c r i t e r i a . The other subject who had read extensively before her MI continued to do so following her MI. She had read books prior to her MI about other persons' battles with major Illnesses but found aft e r her own MI some parts of these books were too close to her own s i t u a t i o n to read. ... I don't know whether you know the name of a man ca l l e d Norman Cousins ... he wrote a book c a l l e d The  anatomy of an Illness which I read many, many years ago and he subsequently wrote another book c a l l e d The healing  heart. Now, I read i t many, when i t f i r s t came out many, many years ago and I thought i t was a fascinating, interesting book, and he's a fascinating and Interesting man. So, when I came home, two or three days after I'd been home, I thought I'd reread i t and ya know that I couldn't read some of i t . Ah, It was to close to me and ah the, e s p e c i a l l y the part where he had his major heart Although t h i s subject continued to read other things regarding the heart she t r i e d not to focus only on i l l n e s s and also began to read things that were on the li g h t e r side. ... and I l i k e to read other things too but ah I don't want to just sort of focus on health and ya know i l l health because I just don't want to do that. I think that's not an absolutely good thing. This subject also practiced techniques such as meditation and scattered imagery and believed these techniques could have a positive e f f e c t in her recovery. She did not necessarily view advanced medical and s u r g i c a l techniques as wrong, but she was taking into account a l l that she had read before making a decision to have the angiogram that was requested by her c a r d i o l o g i s t . ... but It is c e r t a i n l y making me think, think a b i t more about i t ya know because i f I can lead a reasonably inte r e s t i n g l i f e , which i s important to me and, and cope with ah ya know things and l i s . . , and then learn to l i s t e n to my body more, at least not l i s t e n to i t but do what my body says uh cause I've told you I meditated ya know and I s t i l l do, I, I think somehow that I should be able to make my own bypass, whether I w i l l or not is another story, so we'll see. It became evident as the interviews progressed that for these f i v e subjects t h e i r individual preferred method of learning influenced the extent to which they participated in the education process. The two subjects who acknowledged they had inadequate reading a b i l i t i e s preferred to receive information on an one-on-one basis and only minimally sought any further information about MI after discharge from h o s p i t a l . The three subjects who preferred reading were the subjects who took a more active role In obtaining information about Mis from other sources such as books, t e l e v i s i o n shows, and friends. In addition, for one subject b e l i e f s and opinions held prior to the MI about alternative health care techniques were also observed to influence that subjects 89 choices during the recovery period. summary The occurrence of a MI was perceived by the participants in t h i s study as a s i g n i f i c a n t event that precipitated feelings of shock, d i s b e l i e f , and i n j u s t i c e . Although the MI was viewed as a motivating factor for change, the impact of the MI varied depending on how serious the event was perceived to be by each individual participant. The participants believed t h e i r Mis to have been caused by d i e t , smoking, stre s s , heredity, and overexertion. L i f e s t y l e adjustments made by the participants included changing th e i r d i e t , managing angina, incorporating medications, walking d a i l y , and/or quiting smoking. The concerns expressed by the participants were not unanimous but rather r e f l e c t e d each individual's s i t u a t i o n and experience. Their major concerns included: fearing another heart attack; adjusting to a decrease in physical stamina with continued feelings of l i m i t a t i o n ; eliminating stress as a l i f e s t y l e component; and, desiring more Information on the amount of damage caused by the Ml, prognosis, and treatment. The cardiac education received by the participants varied, but the information obtained from the MI book, physicians, d i e t i c i a n s , and nurses was viewed as b e n e f i c i a l . Those subjects who preferred reading as a method of i n s t r u c t i o n took a more active role in s e l f education and used other sources such as friends, books, and t e l e v i s i o n shows to learn more about the MI experience. In t h i s chapter a description of the i l l n e s s experience following a MI for the five participants in th i s study has been presented. In Chapter Five, these findings w i l l be discussed in r e l a t i o n to the purpose of the study, Anderson's framework, and the l i t e r a t u r e reviewed. Chapter 5 91 Discussion of the Findings introduction In t h i s chapter the findings of thi s study w i l l be discussed in r e l a t i o n to the purpose of the study, the framework used to conceptualize the problem, the l i t e r a t u r e reviewed in Chapter Two, and where necessary additional l i t e r a t u r e . The purpose of t h i s study was to examine patients* i l l n e s s experiences following a MI in order to determine what i t meant to patients to have a MI, what patients i d e n t i f i e d as learning needs following a MI, and how patients met these learning needs. To examine t h i s experience from the patients' perspectives the research method of phenomenology was used which produced an extensive amount of data. The data presented in Chapter Four Included a l l aspects of the i l l n e s s experience following a MI as described by the participants. It would be a formidable task to discuss a l l aspects of t h i s data, therefore the discussion in t h i s chapter w i l l be r e s t r i c t e d to the s p e c i f i c purposes of t h i s study and w i l l address the meaning of the MI, the learning needs i d e n t i f i e d , and how learning needs were met. 92 Meaning of the MI The meaning of the MI was determined by examining how the subjects viewed the occurrence and impact of the MI. For the subjects in t h i s study the extent of the Mi's impact, and their willingness to make adjustments post-Mi were Influenced by th e i r b e l i e f s as to the causes of their MI. The I n i t i a l reaction of the subjects to the Ml was that of surprise and d i s b e l i e f . Even the subject who had a fourteen year history of angina could not believe what was happening. One gentleman continued to deny that the event had been a MI and at his six week follow-up appointment again questioned the diagnosis with his c a r d i o l o g i s t . The feelings of Injustice expressed by a majority of the subjects r e f l e c t s their attempts to r a t i o n a l i z e to themselves the occurrence of the MI. For most i t was d i f f i c u l t for them to understand why they had had a MI when they knew many people who had worse habits or did not take care of themselves as well as the subjects f e l t they had. An examination of what these subjects considered to have been their r i s k factors for MI may explain somewhat the i r i n a b i l i t y to view themselves as candidates for MI. The written education material received and read by a l l the subjects i d e n t i f i e d nine r i s k factors: family history, being male, diabetes, high blood pressure, smoking, high blood ch o l e s t e r o l , overweight, lack of exercise, and stress (The heart talk series heart attack. 1988). The subjects were also aware, through t h i s l i t e r a t u r e , that their r i s k for MI increased with the number of r i s k factors. Certain factors have been i d e n t i f i e d which may have Increased your ri s k of having a heart attack or having another one. People with one of these factors are almost twice as l i k e l y to have a heart attack as those with none. Those with two of these factors may more than t r i p l e the r i s k . Those with three may multiply their r i s k of heart attack by ten, (p.10) However, even with their exposure to t h i s Information the subjects often overlooked a majority of their own r i s k factors. In the analysis of the data, i t was found that the subjects had a minimum of three and a maximum of six of the nine r i s k factors. Three subjects were unaware of what their cholesterol levels were, thus high cholesterol levels could have added another r i s k for those three subjects. Therefore, from the perspective of a health professional these subjects were in fact prime candidates for cardiac disease, yet the subjects did not view themselves as such. In regards to certain r i s k factors the subjects often compared themselves to people they knew. They acknowledged in a sense the presence of the r i s k factor, but f e l t they knew others for whom i t was even a greater r i s k . Comments such as 94 a person ate more fat, was more overweight, or had a more s t r e s s f u l job then they did were frequent. Instead of examining th e i r entire r i s k p r o f i l e s the subjects appeared to have concentrated on one or two of their r i s k factors. Therefore, i t was not surprising when the subjects were asked s p e c i f i c a l l y what they f e l t caused them to have a MI that most only named one or two ri s k factors or gave reasons other than r i s k factors as causes of the i r MI. The subjects in t h i s study Identified such things as d i e t , smoking, stress, too much s a l t , heredity, and overexertion as causes for their Mis. However, not every subject who had these factors i d e n t i f i e d them and other r i s k factors such as diabetes, high blood pressure, lack of exercise, and being overweight were never mentioned by the subjects for whom these were major ri s k factors. This finding supports previous research done on the patient's perspective as to the causes of MI. Rudy (1980) found in her study of patients' and spouses' causal explanations of a MI that tension was the most frequent cause given by both patients and spouses. She further states that " i n general, patients with an i d e n t i f i a b l e medical r i s k factor and their spouses did not name that r i s k factor as an explanation of the i r heart attack at either the acute or convalescent phase of their i l l n e s s " (p.355). F i e l d i n g (1987) and Murray (1989) also examined the patients' b e l i e f s regarding the causes of MI and found that psychosocial factors such as overwork, stress, and worry were most often c i t e d by patients. Although smoking was also found to be the most ci t e d physical cause, the percentage of smokers recognizing i t as a factor varied between the two studies. It should be noted that both smokers In thi s study had acknowledged their smoking as a factor. The emphasis placed by patients on psychosocial causes and by health professionals on the more standard r i s k factors concerned both F i e l d i n g (1987) and Murray (1989). They believed that what patients perceived as causes of their MI would influence the l i f e s t y l e adjustments made by patients, therefore possibly leading to poor compliance following a MI. Although t h i s study did not address adjustments and compliance s p e c i f i c a l l y the adjustments made by the participants following their Mis were noted to r e f l e c t somewhat the participants b e l i e f s as to the cause or causes of thei r MI. Thus, smokers quit smoking, and people who viewed die t as a factor made diet changes. Also, the subject who f e l t her Ml was caused by pushing herself too hard had made decisions to decrease her Involvement in certa i n a c t i v i t i e s . More than one subject had related stress as a cause of their MI but these subjects were unsure of how they would change that in their l i f e s t y l e s . Since the subjects who had diabetes and hypertension did not relate them as ris k factors It was 96 not surprising that keeping these i l l n e s s e s in control was not mentioned as being important following their Mis. It appears that the adjustments made, or not made, by participants in t h i s study were in fact influenced by the participants' perceptions, whether accurate or not, as to the cause of their Mis. As well, subjects were unsure as to how they could manage some factors such as stress. This lends support to Murray's (1989) contention "that account needs to be taken of the patients' b e l i e f s in t h i s area so that correction of misconceptions can form a part of the process of individually-planned r e h a b i l i t a t i o n " (p.691). The Impact of the Ml on the participants in t h i s study varied, with two subjects viewing i t as an lmptetus for change in t h e i r l i v e s , two r e l a t i n g i t as having minimal e f f e c t , and one believing i t was something he would get over and i f he did not there was not much he could do about i t one way or another. The most s i g n i f i c a n t Impact appeared to be one of a physical nature. A l l subjects reported fatigue and a decrease in their physical stamina. Fatique post-MI has been noted in other studies (Dunn, 1985; Hilgenberg, & Crowley, 1987; Mayou, Williamson, & Foster, 1978; Wishnie, Hackett, & Cassem, 1971). For the subjects in t h i s study fatique continued throughout the recovery period with most subjects reporting that they were not back to normal a c t i v i t i e s by the time of their second interview at least s i x weeks after discharge from h o s p i t a l . The i n i t i a l two subjects, who were followed longer, s t i l l had complaints of being t i r e d and not f e e l i n g "back to normal" 14 and 16 weeks post discharge. One subject related that the days she f e l t blue were the days she had less energy. The older three subjects also reported a slow return to s o c i a l and recreational a c t i v i t i e s . This finding was similar to that of Hilgenberg and Crowley (1987) who found one t h i r d of the 25 post-MI patients they interviewed reported going to fewer s o c i a l gatherings. Anxiety and depression have been reported in the l i t e r a t u r e as outcomes following MI (Hilgenberg, & Crowley, 1987; Nagle, & Gangola, 1971; Mayou, Williamson, & Foster, 1978; Wishnie, Hackett, & Cassem, 1971) Two subjects in t h i s study reported fe e l i n g down or blue post-MI and i t was the same two subjects who expressed fears of having another MI. These two subjects also viewed the MI as a catalyst for change in their l i v e s , thus the MI appeared to have impacted on them more than i t had on the others in t h i s study. For the others, viewing the MI as not serious and having a personal philosophy of "what w i l l be, w i l l be" may have helped them psychologically in their recovery post-MI. It i s evident that the occurrence of a MI did not hold the same meaning for a l l of the subjects in t h i s study. The attempt by each subject to r a t i o n a l i z e why they had had a MI and to focus only on certain r i s k factors r e f l e c t s an e f f o r t 98 by the subjects to understand what had occurred to them from the i r perspective. Their understanding of the causes of their MI and the seriousness of i t also appears to have influenced their adjustments and outcomes post-MI. Learning Needs In t h i s study a learning need was defined as a concern i d e n t i f i e d and expressed by the patient, for which the patient required information in order to manage on a day-to-day basis following a MI. The subjects found i t d i f f i c u l t to d i r e c t l y a r t i c u l a t e learning needs or areas where they lacked information but the researcher through the analysis of the interviews was able to Identify areas of concern. The t r a d i t i o n a l topics for cardiac patient education such as anatomy and physiology of the heart, r i s k factors for coronary artery disease, signs and symptoms of heart attack, cardiac diet i n s t r u c t i o n , and use of medications were not the type of areas acknowledged by the participants as causing them concern. It can either be assumed from t h i s that the information received by the subjects was perceived to be adequate in these areas or that these topics were not perceived by the subjects as a p r i o r i t y in the recovery period at home. The fact that most of the subjects were not aware of a l l their r i s k factors may lend credence to the idea the subjects did not perceive c e r t a i n topics as p r i o r i t i e s . However, th i s is not to say that the participants did not find information on such topics as d i e t , and medications, b e n e f i c i a l , only that they expressed s a t i s f a c t i o n In what they knew In these areas. The purpose of t h i s study was not to evaluate the subjects' l e v e l of knowledge in these areas, therefore i t i s impossible to state i f more information was required. The fact that the subjects put personal li m i t a t i o n s on such things as their d i e t adjustments suggests that the subjects were only w i l l i n g , regardless of the information given, to make certain changes in the i r l i f e s t y l e s . In the area of exercise, personal l i m i t a t i o n s were also noted as one subject related she was walking but wanted to do i t at her own pace and that she was not w i l l i n g to s t a r t something she did not f e e l she could continue. A c t i v i t y r e s t r i c t i o n s and resuming of a c t i v i t i e s appeared to be the only t r a d i t i o n a l area of cardiac patient education in which the subjects in t h i s study lacked Information. It was very Important for the subjects to know when they could resume d r i v i n g , working, t r a v e l i n g , and exercising. The general guidelines for a c t i v i t i e s l a i d out in the Ml book were viewed as helpful but most subjects v a r i f i e d with their individual c a r d i o l o g i s t s what the s p e c i f i c r e s t r i c t i o n s would be for them and when they could resume cert a i n a c t i v i t i e s . Some patients reported they had received Instructions from th e i r c a r d i o l o g i s t s regarding a c t i v i t i e s before leaving the 1 0 0 h o s p i t a l , yet once home they often wanted to v a r i f y again with the i r c a r d i o l o g i s t before try i n g some a c t i v i t i e s . This focus on the need for more information on a c t i v i t y r e s t r i c t i o n s and l i m i t a t i o n s in the recovery stage at home was also i d e n t i f i e d by Moynihan ( 1 9 8 4 ) in her study of the educational needs of post-MI patients. According to Moynihan Phase III of recovery, which begins at discharge and ends when the patient returns to previous productive l i f e s t y l e , was the time when patients i d e n t i f i e d their educational needs as reguiring instructions on s p e c i f i c hobbies, sexual a c t i v i t y , and other a c t i v i t y l i m i t a t i o n s . In her study she concluded that "patients expressed a need to have Instructions on items which would f a c i l i t a t e their resumption of a normal l i f e s t y l e " ( p . 4 4 5 ) . The fact that subjects in t h i s study appeared discouraged because they were s t i l l experiencing fatique and had not resumed f u l l y their normal a c t i v i t i e s shows that these subjects were also concerned with resuming a normal l i f e s t y l e . In conjunction with resuming a normal l i f e s t y l e the subjects in t h i s study were also quite concerned with finding out the s p e c i f i c s about the damage caused by t h e i r Mis, what thei r prognoses would be, given the amount of damage, and what treatments would be offered. It appeared that they were s t i l l searching for what the occurrence of a MI would ultimately mean to their futures and what type of r e s t r i c t i o n s they could expect, thereby placing the emphasis on the r e a l i t y of the s i t u a t i o n . Focusing on the r e a l i t y of an i l l n e s s and wanting to know Information that would help to plan for both immediate and long-range problems an i l l n e s s would Impose was also Identified by Dodge (1969) in her study of learning needs as the patient's main cognitive need. In the present study the subjects appeared s a t i s f i e d with the information they had received for the immediate recovery period but once home they were concerned with long-range plans. Generally, the subjects in t h i s study appeared s a t i s f i e d with the information given in the t r a d i t i o n a l areas of cardiac education. The concerns i d e n t i f i e d focus on the subjects desire to know more about th e i r individual situations regarding a c t i v i t y r e s t r i c t i o n s , damage done by MI, prognosis and treatments. It appeared that the subjects were concerned about the r e a l i t y of the s i t u a t i o n and were trying to put their MI in perspective by planning for the long-term. Meeting Learning Needs The patient education received by the subjects in t h i s study was not consistent, as described previously. However, other than the timing of the one-on-one ins t r u c t i o n received by one subject, the subjects appeared s a t i s f i e d with what they had received from health professionals. It was disconcerting to the researcher that only two subjects received any patient education from nurses. It was encouraging however, that the 102 two subjects who had received t h i s instruction found i t b e n e f i c i a l . Physicians, s p e c i f i c a l l y c a r d i o l o g i s t s , were viewed by the subjects in t h i s study as the p r i n c i p a l sources of information. The subjects often asked questions of the i r c a r d i o l o g i s t s while in hospital and a l l had prepared l i s t s of questions to take with them when they went for the i r follow-up v i s i t s l a t er in their recovery. Four of the five subjects had had contact with their family physicians during t h i s time as well. Patients' preference for teaching, regarding the s p e c i f i c s of their own heart condition, to come from physicians was also noted by T i l l e y , Gregor, and Thiessen (1987). In their study of the nurse's role in patient education these researchers found not only were there incongruencies between nurses and patients in who patients viewed as the preferred teacher, but when patients f e l t teaching should be done, and what teaching the patients desired from nurses. They concluded that nurses must stop making assumptions about patients' desires regarding patient education and that nurses need to validate patients' preferences i n : "(a) the educational approaches with which patients f e e l most comfortable (e.g. group or individual s t r a t e g i e s ) , (b) the timing of patient teaching, and (c) the type of information patients can accommodate during various 103 stages of t h e i r i l l n e s s and recovery" (pp. 299-300). The findings from the present study support the need for patients' preferences to be validated. Of the fiv e subjects in t h i s study, three preferred reading and two preferred one-on-one Instruction as methods of obtaining Information. As well, only one subject expressed Interest in p a r t i c i p a t i n g In a group education program with the other subjects r e l a t i n g that groups were not their s t y l e . Only three subjects commented on the timing of education received, and as previously described they were not in agreement as to when teaching should take place, which indicates timing of education was a personal preference. As previously discussed, the type of information patients wanted in the recovery period at home d i f f e r e d from the t r a d i t i o n a l topics of cardiac patient education suggesting that patients needs vary at d i f f e r e n t stages of t h e i r i l l n e s s . The degree to which the patients In t h i s study participated in s e l f education following their MI varied. There appeared to be a c o r r e l a t i o n between learning s t y l e s , impact of Ml and motivation for s e l f learning, with the two subjects who had f e l t the MI had impacted on their l i v e s the most, and who preferred reading, taking on the most active roles in s e l f education. These two subjects used a variety of sources to obtain further Information from magazine a r t i c l e s , to t e l e v i s i o n shows. The extent to which patients required 104 further information appeared to be a personal preference with the subject most active in s e l f education describing herself as a person who 'craves' information. Both subjects who reported inadequate reading a b i l i t y preferred the one-on-one method of Instruction and neither a c t i v e l y sought any further information except for questioning their physicians. This would suggest that nurses need to assess patients' preferences in i n s t r u c t i o n a l methods to ensure that patients receive information In a way that i s e a s i l y comprehended by them. Although not a l l subjects preferred reading, a l l fiv e subjects reported reading the MI book received in hospital and four continued to use i t as a reference at home. This Is encouraging for patient educators who spend time and e f f o r t in developing these written teaching aids. However, i t must be stressed that the presence of these aids does not re l i e v e the nurse of her r e s p o n s i b i l i t y in making sure patients are equiped with the information they need for their recovery at home. As discussed previously, patients may have needs for more s p e c i f i c information regarding their i l l n e s s and these needs cannot be dealt with in a general information book. The subjects in t h i s study used their physicians, s p e c i f i c a l l y their c a r d i o l o g i s t s , and the Ml book received In hospital as the i r p r i n c i p a l sources of information. The degree to which subjects participated in s e l f education varied, as did the amount of information desired by each part i c i p a n t . The subjects who preferred reading as a means of obtaining information took on a more active role in their own education. Relation of Findings to Conceptual Framework Anderson's (1985) adaptation of Kleinman's health care system framework was used to conceptualize the problem being investigated in t h i s study. According to Anderson "interactions between the nurse and c l i e n t are transactions between explanatory models which d i f f e r In cognitive content, expectations and goals" (p.238). Explanatory models "contain explanations of any or a l l of the fiv e issues: etiology; onset of symptoms; pathophysiology; course of sickness (severity and type of sick r o l e ) ; and treatment" (Kleinman, 1978, pp.87-88). Using the research method of phenomenology i t was hoped that a better uunderstandlng of the patient's explanatory model of the MI experience would be obtained. The findings from t h i s study have shown that patients perceive the etiology, the course of their i l l n e s s and the treatment for their MI from the perspective of their world. Regardless of the information the patients had on standard r i s k factors they analyzed their situations Individually by comparing themselves to others and i d e n t i f y i n g factors in their l i f e s t y l e s which they believed contributed to their 106 having a HI. Some adjustments were made according to these b e l i e f s , with the subjects applying personal l i m i t a t i o n s on these adjustments. The patients desire to know the amount of damage caused by their MI, their prognosis, and future treatments demonstrate that they were concerned with how thi s i l l n e s s would e f f e c t their l i v e s in the future. The goal of the subjects appeared to be a return to normal a c t i v i t i e s . Summary of Findings The i n i t i a l reaction to the Ml event, for these subjects, was that of surprise and d i s b e l i e f . The subjects attempted to r a t i o n a l i z e their Ml and expressed feelings of i n j u s t i c e because they considered the effects of their r i s k factors to be minor when compared to other people they knew. The subjects analyzed their r i s k factors from their own perspectives often focusing on one or two factors and not their r i s k p r o f i l e as a whole. Their b e l i e f s regarding the seriousness and causes of the MI appear to have influenced both their outcomes and adjustments following their MI. Thus, the impact of the MI varied from having minimal e f f e c t to being an Impetus for change. A decrease in stamina with feelings of l i m i t a t i o n appeared to be the most s i g n i f i c a n t physical outcome noted by these subjects. The t r a d i t i o n a l topics of cardiac patient education were not i d e n t i f i e d as causing concern for these subjects. The 107 learning needs of these subjects during the period of recovery at home related to knowing more about their own individual s i t u a t i o n regarding such things as a c t i v i t y r e s t r i c t i o n s , damage done by the MIf and their prognosis and treatment. The focus for these patients appeared to be obtaining information that would enable them to plan for the long-term. The cardiac patient education received by these subjects from health professionals was not consistent. Physicians, e s p e c i a l l y c a r d i o l o g i s t s , were viewed as p r i n c i p a l sources of information and those who had received information from nurses, and d i e t i c i a n s considered i t b e n e f i c i a l as well. The MI book, The heart talk series heart attack r was perceived by the subjects as being helpful and was often used as a reference by the subjects at home. The degree to which the subjects participated in s e l f education varied with the subjects who preferred reading, as a method of obtaining Information, taking the most active role in their own education. The amount of information sought appeared to be influenced by the subjects personal desire for Information and the impact the MI had had on the subject. Conclusions The subjects desire to r a t i o n a l i z e t h e i r MI by comparing themselves to others may have resulted in these subjects minimizing the magnitude of the i r own ris k factors. Risk factors that appeared obvious to t h i s health professional were overlooked by these subjects, such as diabetes, hypertension, and being overweight. This supports the supposition that subjects' b e l i e f s regarding the causes of the i r MI may d i f f e r from that of the professional. However, there appeared to be a willingness on the part of the subjects to make adjustments in areas they viewed as important. Thus, i t should be stressed that an assessment of the patient's perceptions regarding r i s k factors and causes of MI Is desired In order to promote and encourage ri s k factor modification on an individual basis. The information received by the subjects on the t r a d i t i o n a l topics of cardiac patient education were viewed as b e n e f i c i a l . However, the desire of the subjects to know more of the s p e c i f i c s about th e i r a c t i v i t y r e s t r i c t i o n s , damage caused by the MI, and the i r prognosis and treatment r e f l e c t the subjects' focus on the r e a l i t y of their own individual s i t u a t i o n . Thus, general information may be help f u l but in order to make long-term plans patients require that the information received be organized according to t h e i r individual needs. The information needs of these subjects varied, as did thei r desire and motivation to obtain Information. Personal preferences for the method of ins t r u c t i o n , timing of education, and type and amount of information received were 109 expressed by these subjects. The type of information requested in the recovery period at home re f l e c t e d the subjects' desire to understand the long-term e f f e c t s of their MI. Therefore, general information regarding MI and i t s treatment can be viewed as helpful to patients but they s t i l l require s p e c i f i c information about their own MI. Although the MI book was viewed as b e n e f i c i a l i t contained only general information, thus the desire for information s p e c i f i c to themselves may have been the Impetus for these subjects to use the i r physicians as p r i n c i p a l resources. The subjects appeared unclear as to the role of nurses in the education process, with only one of the three subjects not receiving instruction from nurses even commenting on i t s absence. In the next section the implications these findings have for nursing practice, education, and research w i l l be presented. implications for Nursing Practice Nurses in the practice setting must be cognizant of the fact that the patient's perspective of the MI experience may d i f f e r from that of the health professslonal. Nurses cannot assume that what is obvious to them, in regards to ris k factor modification and l i f e s t y l e adjustments post-MI, w i l l be obvious to the patient. In order to deliver patient education that w i l l be more 110 b e n e f i c i a l to the patient nurses must complete individual assessments which i d e n t i f y the patients: (1) b e l i e f s regarding ri s k factors and causes of MI; (2) desire for information; (3) preference for method of ins t r u c t i o n ; and, (4) preference for timing of education. This type of assessment w i l l help nurses in c l a r i f y i n g misconceptions that might influence adjustments made by patients and to i d e n t i f y the method and timing of instr u c t i o n desired by patients. The fact that only two of the five subjects in thi s study received patient education from nurses during the hospital stay leads one to question the p r i o r i t y given to patient education in the practice s e t t i n g . As well, the findings In th i s study demonstrate that patients do have information needs following their Mis but that they are unclear as to the role of nurses in f u l f i l l i n g these needs. Thus, nurses must be more active in delineating their role in patient education and ac t u a l l y functioning in that r o l e . Implications for Nursing Education The promotion of the nurse as a patient educator begins with each nurse's educational development. Students must be prepared to take on the role of patient educator and to be supplied with the tools necessary to teach t h e i r patients. It i s hoped that the p r i o r i t y given to patient education throughout the students educational experience w i l l be I l l transferred to the practice s e t t i n g . Nurse educators must also prepare their students to consider that the patient's perspective of an I l l n e s s experience may d i f f e r from that of the health professional. An awareness of these differences w i l l prompt the student to more f u l l y analyze the Illness experience by including the patient's perspective. Implications for Nursing Research The small sample size in t h i s study l i m i t s the amount of d i r e c t i o n that can be taken from the findings. However, the findings suggest that further study in t h i s area is required to better understand the i l l n e s s experience of patients post-MI and their education needs. Therefore, a r e p l i c a t i o n of t h i s study using a larger sample i s recommended. During the analysis of the data other areas of concern were raised that i n v i t e further research of the patient's MI experience. These areas include: (1) the Influence of patients' health b e l i e f s on l i f e s t y l e adjustments post-MI; (2) the maintaining of patients' l i f e s t y l e adjustments over the long-term; (3) the differences in perceptions of the experience in r e l a t i o n to patients' gender; (4) the differences in perceptions of the experience in r e l a t i o n to patients' age; and, (5) the influence of learning styles on patients' p a r t i c i p a t i o n in their own patient education. As 112 well, the findings In th i s study support the need for more research into the nurse's role In patient education from both the perspective of the nurse and the patient. summary In t h i s chapter the findings of t h i s study were discussed in r e l a t i o n to the purpose of the study, the conceptual framework, and the available l i t e r a t u r e . The findings were summarized and the conclusions presented. Lastly, the implications of these findings for nursing practice, education, and research were presented. In conclusion, the findings of t h i s study suggest that health professionals and patients do view the MI experience from d i f f e r e n t perspectives. The emphasis of the patients on understanding the MI experience from the r e a l i t y of their world i s re f l e c t e d in their attempts to r a t i o n a l i z e the occurrence of the MI and their desires to know more about the i r own MI, prognosis, and treatment. In order to plan patient education that w i l l a s s i s t post-MI patients in their recovery health professionals must assess patients i n d i v i d u a l l y for t h e i r : (1) b e l i e f s regarding r i s k factors and causes of MI; (2) desire for information; (3) preference for method of inst r u c t i o n ; and, ( 4 ) preference for timing of education. 113 References Anderson, J. M. (1985). The s o c i o c u l t u r a l context of health and i l l n e s s : A t h e o r e t i c a l framework. In M. Stewart (Ed.), Community health nursing in Canada (pp. 233-245). Toronto: Gage Education. Boogaard, M. A. K. (1984). Rehabilitation of the female patient after myocardial Infarction. Nursing C l i n i c s of North America, 19(3), 433-439. Burgess, A. W., & Hartman, c. R. (1986). Patients' perceptions of the cardiac c r i s i s . American Journal of Nursing,. 8_6_, 568-571. Casey, E., O'Connell, J. K., & Price, J. H. (1984). Perceptions of educational needs for patients after myocardial i n f a r c t i o n . Patient Education and Counseling, 6(2), 77-82. Christman, N. J., McConnell, E. A., P f e l f f e r , C , Webster, K. K., Schmitt, M., & Rles, J. (1988). Uncertainty, coping, and d i s t r e s s following myocardial i n f a r c t i o n : Transition from hospital to home. Research in Nursing and Health. 11(2), 71-82. Dimond, M. (1983). Social adaptation of the c h r o n i c a l l y i l l . In D. Mechanic (Ed.), Handbook of health, health care r and the health professions (pp. 636-654). New York: The Free Press. Dodge, J. S. (1969). Factors related to patients* perceptions of their cognitive needs. Nursing Research, 15.(6), 502-513. Dubyts, D. C. (1988). The experience of waiting for coronary artery bypass graft surgery. Unpublished master's thesis, The University of B r i t i s h Columbia, Vancouver, B.C. Dunn, P. C. (1985). Women's perceptions of th e i r Illness experience with myocardial Infarction. Unpublished master's thesis, The University of B r i t i s h Columbia, Vancouver, B.C. F i e l d i n g , R. (1987). Patient's b e l i e f s regarding the causes of myocardial Infarction: Implications for Information giving and compliance. Patient Education and Counseling, 9(2), 121-134. 114 Garding, B. S., Kerr, J. C , & Bay, K. (1988). Effectiveness of a program of information and support for myocardial patients recovering at home. Heart and Lung, 11(4), 355-361. G i o r g i , A. (1975). An application of phenomenological method. In A. Giorgi, C. Fischer, & E. Murray (Eds.), Duquesne studies in phenomenological psychology, Vol. I I , (pp. 82-103). Pittsburgh: Duquesne University Press. Gregor, F. M. (1981). Teaching the patient with Ischemic heart disease: A systematic approach to Instructional design. Patient Counselling and Health Education, 1-3, 57-62. Hilgenberg, C , & Crowley, C. (1987). Changes in family patterns after a myocardial i n f a r c t i o n . Home Healthcare  Nurse, 5.(3), 26-35. Hentinen, M. (1986). Teaching and adaptation of patients with myocardial i n f a r c t i o n . International Journal of Nursing Studies, 21(2), 125-138. J i l l l n g s , C. R. (1988). The nature of nursing in cardiac r e h a b i l i t a t i o n . In C. R. J i l l l n g s (Ed.), Cardiac  r e h a b i l i t a t i o n nursing (pp. 46-52). Rockville, MD: Aspen. Ka r l i k , B. A. & Yarcheski, A. (1987). Learning needs of cardiac patients: A p a r t i a l r e p l i c a t i o n study. Heart and  Lung, 16.(5), 544-551. Kent, M. A. (1985). Coping with angina pectoris following  diagnosis. Unpublished master's thesis, The University of B r i t i s h Columbia, Vancouver, B.C. Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as c u l t u r a l systems. Social Science and  Medicine, H(Pt.B), 85-93. Knaack, P. (1984). Phenomenological research. Western Journal  of Nursing Research. 6(1), 107-114. Liddy, K. G. & Crowley, C. (1987). Do MI patients have the information they need for the recovery phase at home? Home Healthcare NUKSE, 5.(3), 19-22, 24-25. Llnde, B. J. & Janz, N. M. (1979). E f f e c t of a teaching program on knowledge and compliance of cardiac patients. Nursing Research, 2J.(5), 282-286. 115 Linehan, D. T. (1966). What does the patient want to know? American Journal of Nursing, 6j6_(5), 1066-1071. Mayou, R., Williamson, B., & Foster, A. (1976). Attitudes and advice after myocardial i n f a r c t i o n . B r i t i s h Medical JJiiirjial, 1, 1577-1579. Mayou, R., Williamson, B., & Foster, A. (1978). Outcome two months after myocardial Infarction. Journal of Psychosomatic Research, 22, 439-445. McMahon, M., M i l l e r , P., Wlkoff, R,, Garett, M. J, , & Rlngel, K. (1986). L i f e s i t u a t i o n s , health b e l i e f s , and medical regimen adherence of patients with myocardial Infarction. Heart and hum, 15.(1), 82-86. Meinlnger, J. C. (1986). Sex differences In factors associated with use of medical care and alternative i l l n e s s behaviors. Social Science and Medicine. 12(3), 285-292. M i l l e r , B. F. & Keane, C. B. (1972). Encyclopedia and  dictionary of medicine and nursing. Philadelphia, PA: W.B.Saunders. M i l l e r , P., McMahon, M., Garett, M. J., & Ringel, K. (1989). A content analysis of l i f e adjustments post Infarction. Western Journal of Nursing Research, 11(5), 559-567. M i l l s , G., Barnes, R., Rodell, D., & Terry, L. (1985). An evaluation of an Inpatient cardiac patient/family education program. Heart and Lung, 14.(4), 400-406. Minister of Supply and Services. (1987). Canada year book 1988. Ottawa: Author. Morse, J. M. (1986). Quantitative and qu a l i t a t i v e research: Issues in sampling. In P.L. Chlnn (Ed.), Nursing research methodology Issues and implementation (pp.181-193). Rockville, MD: Aspen. Moynihan, M. (1984). Assessing the educational needs of post-myocardial Infarction patients. Nursing C l i n i c s of North  America. 19_(3), 441-447. Murray, P. J. (1989). Rehabilitation Information and health b e l i e f s in the post-coronary patient: Do we meet their information needs? Journal of Advanced Nursing, l i , 686-693. 116 Nagle, R., Gangola, R., & Plcton-Robinson, I. (1971). Factors influencing return to work after myocardial i n f a r c t i o n . The  Lancet, 2_, 454-456. N i c k l i n , W. M. (1986). Postdischarge concerns of cardiac patients as presented via a telephone callback system. Heart and Lunq r 15.(3), 268-272. O i l e r , C. J. (1986). Phenomenology: The method. In P.L. Munhaii, & c. J . o i l e r (Eds.), N u r s i n g r e s e a r c h a q u a l i t a t i v e perspective (pp. 69-84). Norwalk, CT: Appleton-Century-Crofts. Ott, C. R., Sivarajan, E. S., Newton, K. M., Almes, M. J., Bruce, R. A., Bergner, M., & Gilson, B. S. (1983). A controlled randomized study of early cardiac r e h a b i l i t a t i o n : The sickness Impact p r o f i l e as an assessment t o o l . Heart and Lung, 12.(2), 162-170. Owens, J. F., McCann, C. S., & Hutelmyer, C. M. (1978). Cardiac r e h a b i l i t a t i o n : A patient education program. Nursing Research, 21(3), 148-150. P f i s t e r e r , J. (1975). Learning needs of the cardiac patient being discharged from hospital as seen by the patient, his doctor, and his nurse. Nursing Papers, 1(2), 29-31. Pozen, M. W., Stechmiller, J. A., Harris, W., Smith, S., Fr i e d , D. D., & Voigt, G. C. (1977). A nurse r e h a b l l l t a t o r * s impact on patients with myocardial i n f a r c t i o n . Medical Care, 15.(10), 830-837. Raleigh, E. H., & Odtohan, B. C. (1987). The e f f e c t of a cardiac teaching program on patient r e h a b i l i t a t i o n . Heart and Lung, 16.(3), 311-317. Rudy, E. B. (1980). Patients' and spouses' causal explanations of a myocardial i n f a r c t i o n . Nursing Research, 22.(6), 352-356. Runions, J. (1988). Research in cardiac r e h a b i l i t a t i o n . In c. R. J i l l l n g s (Ed.), c a r d i a c r e h a b i l i t a t i o n n u r s i n g (pp. 255-270). Rockville, MD: Aspen. Salonen, J. T. & Puska, P. (1980). A community programme for r e h a b i l i t a t i o n and secondary prevention for patients with acute myocardial i n f a r c t i o n as part of a comprehensive community programme for control of cardiovascular diseases (North Karelia project). Scandinavian Journal of Rehabilitation Medicine 12, 33-42. 117 Sandelowski, M. (1986). The problem of rigor in q u a l i t a t i v e research. Advances in Nursing Science, 8_(3), 27-37. S c a l z i , C. C , Burke, L. E., & Greenland, S. (1980). Evaluation of an inpatient educational program for coronary patients and families. Heart and Luna, i ( 5 ) , 846-853. Sivarajan, E. S., Newton, K. M., Almes, M. J., Kempf, T. M., Mansfield, L. W., & Bruce, R. A. (1983). Limited effects of outpatient teaching and counseling after myocardial i n f a r c t i o n : A controlled study. Heart and Lung, 12.(1), 65-73. Sorenson, G., P i r i e , P., Folsom, A., Luepker, R., & Jacobs, D. (1985). Sex differences in the rela t i o n s h i p between work and health: the Minnesota heart survey. Journal of Health  and Social Behavior, 2£_, 379-395. Steele, J. M. & Ruzicki, D. (1987). An evaluation of the effectiveness of cardiac teaching during h o s p i t a l i z a t i o n . Heart and Lung, 16.(3), 306-311. Stern, M. J., Pascale, L., & Ackerman, A. (1977). L i f e adjustment postmyocardial i n f a r c t i o n . Archives of Internal  Medicine, 137, 1680-1685. The heart talk series heart attack. (1988). Manitoba: Heart and Stroke Foundation of Manitoba. T i l l e y , J. D., Gregor, F. M., & Thiessen, V. (1987). The nurse's role in patient education: Incongruent perceptions among nurses and patients. Journal of Advanced Nursing, 12., 291-301. Webster, K. K., & Christman, N. J. (1988). Perceived uncertainty and coping post myocardial Infarction. Western Journal of Nursing Research, IpJ 4), 384-400. Wenger, N. K. (1979). Rehabilitation of the patient after myocardial i n f a r c t i o n . In L. R. Zohman & A. A. Kattus (Eds.), cardiac rehabilitation for the practicing physician (pp. 1-13). New York: Stratton Intercontinental Medical Book. White, C. W., Lemon, D. K., & Albanese, M. A. (1980). E f f i c a c y of health education e f f o r t s in hospitalized patients with serious cardlvascular I l l n e s s : Can teaching succeed? Patient Counselling and Health Education, 1-3, 189-196. 118 Wishnie, H. A., Hackett, T. P., & Cassem, N. H. (1971). Psychological hazards of convalescence following myocardial i n f a r c t i o n . JAMA, 215,(8), 1292-1296. Yamada, P. K. (1984). The i l l n e s s experience of c l i e n t s undergoing s u r g i c a l intervention for coronary artery disease: C l i e n t s ' perceptions and concerns. Unpublished master's thesis, The University of B r i t i s h Columbia, Vancouver, B.C. 119 Appendix A Physician Information-Consent Letter My name i s Dawna DeAdder. I am a Registered Nurse and a student in the Master of Science in Nursing Program at the University of B r i t i s h Columbia. I am conducting a study e n t i t l e d "The I l l n e s s Experience of Patients Following a Myocardial Infarction: Implications for Patient Education". This study w i l l examine what i t means to patients to have had an MI and how having had an MI af f e c t s their day-to-day l i v e s . The focus of t h i s study i s to examine how these experiences relate to what patients Identify as their learning needs post MI and how they meet these needs. I would l i k e to Interview a sample of your patients regarding their i l l n e s s experience following an MI. The f i r s t , of two Interviews, with each participant w i l l be conducted two to four weeks following the participant's MI. Second interviews to validate and c l a r i f y data w i l l be conducted as data i s being analyzed. The Interviews w i l l be approximately one hour in length and w i l l be conducted in the par t i c i p a n t s ' homes. I would l i k e to commence interviewing as soon as possible. To participate in t h i s study an individual must be between the ages of 30 and 65, able to speak and understand English, experiencing his/her f i r s t MI, and l i v i n g within the c i t y of Vancouver. Eight to ten participants are required and w i l l be obtained from the University Hospital, UBC S i t e . The 121 Appendix B Participant Information-Consent Letter My name Is Dawna DeAdder. I am a Registered Nurse and a student in the Master of Science in Nursing Program at the University of B r i t i s h Columbia. I am Interested in learning about cardiac patients' i l l n e s s experience following a heart attack. My study is e n t i t l e d "The Il l n e s s Experience of Patients Following a Myocardial Infarction: Implications for Patient Education". I am i n v i t i n g you to partic i p a t e in t h i s study. P a r t i c i p a t i o n e n t a i l s being Interviewed on two occasions. If you wish to parti c i p a t e you w i l l be interviewed in your home in 2 to 4 weeks time. I w i l l conduct the interview which w i l l take approximately one hour and i t w i l l be tape recorded. To help c l a r i f y information obtained during the f i r s t interview i t w i l l be necessary to interview you again at a la t e r time. If at any time you wish to stop the interview, stop the recording, or have portions of the tape erased you may. Although your p a r t i c i p a t i o n in thi s study may not benefit you d i r e c t l y , the sharing of your experience w i l l help nurses better understand the i l l n e s s experience of patients following a heart attack which w i l l improve care for heart attack patients in the future. Your p a r t i c i p a t i o n in t h i s study i s s t r i c t l y voluntary and refusal to participate w i l l not a f f e c t your medical or nursing care. You may withdraw from the study at any time. Appendix C Demographic Data She (1) gender (2) age (3) ethnic o r i g i n (4) primary language (5) occupation (6) marital status (7) education l e v e l (8) other health problems Appendix D Interview Trigger Questions (1) T e l l me about your f i r s t few weeks at home following your heart attack. (2) How has having had a heart attack affected your day-to-day routine? (3) What information did you receive about your heart attack? and from whom? ( 4 ) Now that you are home, what Information do you f e e l i s helpful or would be helpful in managing your heart disease? 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0098543/manifest

Comment

Related Items