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

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THE ILLNESS EXPERIENCE OF PATIENTS FOLLOWING A MYOCARDIAL INFARCTION: IMPLICATIONS FOR PATIENT EDUCATION  By  DAWNA NADINE DeADDER B.N., Dalhousie U n i v e r s i t y , 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 t h e s i s as conforming to the r e q u i r e d  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 department or by  his or her  representatives.  be granted by the head of  It is understood that copying or  publication of this thesis for financial gain shall not be allowed without my permission.  Department of The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  hetemLui /S  /Wo  my  written  Abstract THE  ILLNESS EXPERIENCE OF PATIENTS FOLLOWING A MYOCARDIAL INFARCTION: IMPLICATIONS FOR PATIENT EDUCATION  T h i s study used the r e s e a r c h method of phenomenology t o elicit  the p a t i e n t ' s p e r s p e c t i v e of the i l l n e s s  f o l l o w i n g a myocardial i n f a r c t i o n s t u d y i n g t h i s experience was i t meant t o men  I t was  The purpose  and women to have a MI, what the  proposed  of  to g a i n an understanding of what  needs were f o l l o w i n g a MI, and how met.  (MI).  experience  learning  these l e a r n i n g needs were  t h a t p a t i e n t s would view the  illness  experience d i f f e r e n t l y from h e a l t h p r o f e s s i o n a l s , thus the p a t i e n t s would i d e n t i f y d i f f e r e n t (1985)  was  l e a r n i n g needs.  Anderson's  a d a p t a t i o n of Klelnman's h e a l t h care system  framework  used t o c o n c e p t u a l i z e t h i s problem. Three males and two  years, p a r t i c i p a t e d  females, ranging i n age  i n the study.  11 in-depth i n t e r v i e w s . s i g n i f i c a n t statements  from 42 to 77  Data were c o l l e c t e d  through  From a n a l y s i s of t h i s data  were e x t r a c t e d to provide a d e s c r i p t i o n  of the phenomenon under study. The  f i n d i n g s of t h i s study suggest that h e a l t h  p r o f e s s i o n a l s and p a t i e n t s do view the MI experience different perspectives.  from  The emphasis of the p a t i e n t s on  understanding the MI experience from the r e a l i t y of t h e i r world  is reflected  i n t h e i r attempts  to r a t i o n a l i z e  the  occurrence of the MI and t h e i r d e s i r e s to know more about  their  own MI, p r o g n o s i s , and treatment.  In order to p l a n  p a t i e n t e d u c a t i o n t h a t w i l l a s s i s t post-MI p a t i e n t s i n t h e i r r e c o v e r y h e a l t h p r o f e s s i o n a l s must assess p a t i e n t s individually  for their:  (1) b e l i e f s r e g a r d i n g r i s k f a c t o r s and  causes of MI; (2) d e s i r e f o r Information;  (3) preference f o r  method of i n s t r u c t i o n ; and, (4) preference f o r t i m i n g of education.  iv Table of Contents Page Abstract  1i  Table of Contents  iv  Acknowledgements  vi  chapter 1: INTRODUCTION Background t o the Problem C o n c e p t u a l i z a t i o n of the Problem Problem Statement and Purpose D e f i n i t i o n of Terms Assumptions Limitations Summary  1 5 7 8 8 9 9  Chapter 2s REVIEW OF THE LITERATURE Introduction Outcomes F o l l o w i n g a MI L e a r n i n g & I n f o r m a t i o n Needs Causal E x p l a n a t i o n s D i f f e r i n g P e r s p e c t i v e s of P a t i e n t s , Nurses, & Physicians Summary  11 11 19 24 26 29  Chapter 3: METHODOLOGY Introduction Methodology. V a l i d i t y and R e l i a b i l i t y Sample S e l e c t i o n & S e l e c t i o n C r i t e r i a S e l e c t i o n Procedure Patient Education Protocol Data C o l l e c t i o n Procedures E t h i c a l Considerations Data A n a l y s i s Summary  30 30 32 32 34 36 37 39 40 41  V  Chapter  4: THE PARTICIPANTS' ACCOUNTS  Introduction C h a r a c t e r i s t i c s of P a r t i c i p a n t s MI Event Causes of MI Adjustments Concerns About Damage, P r o g n o s i s , & Treatment C a r d i a c Education Education from h e a l t h p r o f e s s i o n a l s . S e l f education Summary Chapter  42 42 45 56 58 71 73 74 82 89  5: DISCUSSION OF THE FINDINGS  Introduction Meaning of the Ml L e a r n i n g Needs Meeting L e a r n i n g Needs R e l a t i o n of F i n d i n g s t o Conceptual Framework Summary of F i n d i n g s Conclusions I m p l i c a t i o n s f o r Nursing P r a c t i c e I m p l i c a t i o n s f o r Nursing Education I m p l i c a t i o n s f o r Nursing Research Summary  91 92 98 101 105 106 107 109 110 I l l 112  References  113  Appendix A  119  Appendix B  121  Appendix C  123  Appendix D  124  Vi  Acknowledgements  I would Professors  l i k e t o thank the members of my t h e s i s  Carol J i l l i n q s  ( c h a i r ) and Helen N i s k a l a ,  support and guidance through the r e s e a r c h  process.  committee, for their Special  thanks are extended to my f a m i l y and f r i e n d s f o r t h e i r and encouragement throughout t h i s endeavor.  As w e l l , I would  l i k e to acknowledge the time and e f f o r t of the f i v e whose p a r t i c i p a t i o n made t h i s p r o j e c t  love  possible.  subjects  1 Chapter  1  Introduction  Background to the Problem "Chronic  illness  (Dimond, 1983,  i s a t w e n t i e t h - c e n t u r y phenomenon"  p.636).  Heart d i s e a s e i s one  commonly o c c u r r i n g c h r o n i c i l l n e s s e s . four deaths i n 1982 1983  over  was  caused  In Canada, one  by heart d i s e a s e and  250,000 p a t i e n t s were discharged  being t r e a t e d f o r heart d i s e a s e S e r v i c e s , 1987).  Included  of the most of every  in  1982-  from h o s p i t a l  ( M i n i s t e r of Supply  after  &  i n the growing number of  people  being t r e a t e d for heart d i s e a s e are the s u r v i v o r s of myocardial The  infarctions  occurrence  (Mis).  of a MI  r e c o g n i t i o n of the presence  o f t e n marks the sudden of coronary a r t e r y d i s e a s e .  Coronary a r t e r y d i s e a s e , l i k e  other c h r o n i c  illnesses,  r e q u i r e s i n d i v i d u a l s to make l i f e s t y l e changes i n order to adapt.  According  to Dimond (1983) there are four major  f a c t o r s to c o n s i d e r when l o o k i n g at s o c i a l a d a p t a t i o n of the chronically i l l : d e f i n i t i o n s and  "(1)  [the] nature of the i l l n e s s ;  the meaning of the i l l n e s s ;  responses  to c h r o n i c i l l n e s s ;  illness"  (p.637).  The meaning of an i l l n e s s i s o f t e n overlooked  and  (3)  (2)  [the]  (4) the environment  to a p a t i e n t i s one  by h e a l t h p r o f e s s i o n a l s .  (the]  and  factor that  Dimond  (1983)  2  contends that of  illness  "most o f t h e  [ f o r the  s o c i o c u l t u r a l world other  ill  f a c t o r s t h a t determine the  person] are  of the  ill  r e l a t e d i n some way  person"  (p.641).  to  Nurses,  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 n terms of the normal, rather This  ill  ill  perspective  physicians  and  p r o f e s s i o n a l s have d e v e l o p e d  i n an  lifestyle  patients.  'Cardiac  changes i n c a r d i a c  information  a n a t o m y and  the  given  physiology  prevention  attempt to  programs  health promote  Most of the  current  s t r u c t u r e d around  of c o r o n a r y a r t e r y  of t h e  heart;  (2) r i s k  (3) s i g n s and  (4) a c t i v i t y r e s t r i c t i o n s and  cardiac diet  ill  to patients u s u a l l y includes:  coronary artery disease; attack;  other  P a t i e n t E d u c a t i o n Programs' are  p a t h o p h y s i o l o g y and  from  of t h e  t y p e of p a t i e n t e d u c a t i o n  that nurses, d i e t i c i a n s ,  instruction;  and  like  person's s o c i o c u l t u r a l world.  l a c k of a t t e n t i o n t o the i n the  the  illness  person's p h y s i o l o g i c a l d e v i a t i o n s  than from the  person i s evident  The  meaning  (6) use  disease.  (1)  factors  symptoms o f  the  for  heart  rehabilitation; of m e d i c a t i o n s  (5) (Wenger,  1979 ) . A multitude  o f s t u d i e s have b e e n done t o e v a l u a t e  patient education  programs w i t h a m a j o r i t y  having found t h a t c a r d i a c education an  increase  1988;  i n p a t i e n t s ' knowledge  G r e g o r , 1981;  H e n t i n e n , 1986;  Barnes, R o d e l l , & Terry,  1985;  of t h e s e  p r o g r a m s do (Garding,  cardiac  studies  contribute  Kerr,  &  to  Bay,  L i n d e & J a n z , 1979;  Mills,  Owens, McCann, & H u t e l m y e r ,  "  3 1978;  Pozen,  Raleigh  S t e c h m i l l e r , H a r r i s , Smith, F r i e d , & Voigt,  & O d t o k a n , 1987;  Steele  & R u z i c k i , 1987).  s t u d i e s have shown p a t i e n t s ' k n o w l e d g e g a i n (Scalzi,  Burke,  & Greenland,  Kempf, M a n s f i e l d , 1980).  The  attributed  & B r u c e , 1983;  l i m i t e d gain  The  and  readiness content,  (Scalzi  f o r new there  and  patients' health behavior  their  only  learning  patient's  Pfisterer, Rudy, 1980) factors:  1975)  and  limited effectiveness.  e v i d e n c e t h a t p a t i e n t s and cardiac  teaching  patients'  a b i l i t y to  learn  influences  Sivarajan et a l .  ( 1 9 8 3 ) f o u n d t h a t , when o v e r a l l b e h a v i o r a l  demonstrated  cardiac  illness.  (Runions, 1988).  risk-factor  the  patients with  r e s u l t s have d e m o n s t r a t e d  information  to  not t o e v a l u a t e  i s no e v i d e n c e t h a t t h i s  examined, t h e i r  e t a l . , 1980;  f o c u s o f t h e s e s t u d i e s was  l i v e with their  Although research  partially  i l l n e s s a f f e c t i n g the  of t h a t knowledge i n h e l p i n g  define  Albanese,  o f t h e s e s t u d i e s was  k n o w l e d g e g a i n , h o w e v e r , and  usefulness disease  S i v a r a j a n , Newton, Almes,  to l e a r n a t t h a t time  et a l . , 1980).  evaluate  i n two  few  t o be l i m i t e d  W h i t e , Lemon, &  t o the s t r e s s of a c u t e  patients' a b i l i t y White  1980;  A  c h a n g e s were  counseling  program  As w e l l , t h e r e  h e a l t h p r o f e s s i o n a l s view  the c a u s a l  of c a r d i a c d i s e a s e  and  1987;  a t t r i b u t e s ( F i e l d i n g , 1987; differently.  (1) t h e l a c k o f e v i d e n c e t h a t  patients' health behaviors;  is  the  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 , and  1977;  Given these  l e a r n i n g does  the f a c t that  (2) t h e  two  influence  4  patient's perspective professional,  leads  may  one  differ to ask,  f r o m t h a t of as d i d R u n i o n s  n u r s e s r e s p o n d i n g t o l e a r n i n g n e e d s and or p r o j e c t i n g t h e i r  own  the (1988):  desires  l e a r n i n g i n t e r e s t s on  [of  the  "Are  patients]  patients?"  (p.261). The  r e s p o n s e of n u r s e s t o p a t i e n t s ' l e a r n i n g needs i s  significant  because n u r s i n g  plays  rehabilitation.  One  a n a l y s i s of  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  "the  of the  a major r o l e i n c a r d i a c  m e a n i n g , i m p a c t , and i n d i v i d u a l s to situational, definitions result"  f o c u s e s of c a r d i a c  e f f e c t on  s o c i o c u l t u r a l ) s h a p i n g the of  i l l n e s s and  (Jillings,  understand cardiac  The  b a s i c needs; the  i t s impact; i n d i v i d u a l v a r i a b l e s  1988,  is  responses  and  c h a n g e s , l o s s e s , or g a i n s  p.46).  I t becomes i m p e r a t i v e  illnesses,  e n a b l e them t o  s u c h as MI,  of  (maturational,  perceptions  that w i l l  the  illness: its  the  that nurses undertake research  of t h e i r  nursing  from the  that  then better  perspective  patients. impetus f o r t h i s s t u d y arose from the  present cardiac  patient education  e x p e r i e n c e o f h a v i n g a MI Anderson's  f r a m e w o r k was  patient's  used t o c o n c e p t u a l i z e  from d i f f e r e n t  the  the  perspective.  problem i n t h i s  t h a t p a t i e n t s and  perspectives.  that  address  of K l e i n m a n ' s h e a l t h c a r e  because i n I t Kleinman r e c o g n i z e s view i l l n e s s  programs d i d not  from the  (1985) a d a p t a t i o n  concern  system study  nurses  may  5  C o n c e p t u a l i z a t i o n of the Problem Klelnman (1978) views medical systems as both s o c i a l c u l t u r a l systems. illness,  and  developed  In an attempt  to understand  health,  h e a l i n g i n s o c i e t y as a c u l t u r a l system he  the Health Care System Framework.  In t h i s framework  the h e a l t h care system c o n s i s t s of three s o c i a l popular, p r o f e s s i o n a l , and  folk.  The  arenas:  popular arena views  s i c k n e s s and care i n the context of the f a m i l y , the network, and  the community.  s p e c i a l i s t s comprise arena  The  professionalized  the f o l k arena, while the  professional  medicine  and  the  indigenous h e a l i n g t r a d i t i o n s .  Each arena of the h e a l t h care system has e x p l a n a t o r y model.  i t s own  E x p l a n a t o r y models " c o n t a i n e x p l a n a t i o n s  of any or a l l of the f i v e pathophysiology;  social  non-professional healing  includes professional s c i e n t i f i c  r o l e ) ; and  and  i s s u e s : e t i o l o g y ; onset of symptoms;  course of s i c k n e s s ( s e v e r i t y and  treatment"  (Kleinman,  1978,  pp.87-88).  type of s i c k Kleinman  propounds t h a t h e a l t h care r e l a t i o n s h i p s , such as the p a t i e n t p r a c t i t i o n e r r e l a t i o n s h i p , can be s t u d i e d and compared as t r a n s a c t i o n s between d i f f e r e n t e x p l a n a t o r y models. In examining  the experience of s i c k n e s s , Kleinman (1978)  denotes a d i f f e r e n c e between the terms ' d i s e a s e ' and 'illness'.  Disease  i s viewed as the m a l f u n c t i o n i n g or  maladaptation  of b i o l o g i c a l and/or p s y c h o l o g i c a l processes,  while  i s viewed as the a c t u a l experience of the  illness  6  disease.  Because of t h i s d i s t i n c t i o n the e x p l a n a t o r y models  of p r o f e s s i o n a l p r a c t i t i o n e r s are f r e q u e n t l y l i n k e d  with  d i s e a s e and i t s t h e o r i e s of c a u s a t i o n , much l i k e the b i o m e d i c a l model.  The popular arena's  more commonly l i n k e d with the concept  e x p l a n a t o r y models are of i l l n e s s  "where  s i c k n e s s i s most f r e q u e n t l y a r t i c u l a t e d  i n a highly personal,  n o n - t e c h n i c a l , concrete  with the l i f e  that r e s u l t  idiom concerned  problems  from s i c k n e s s " ( p . 8 8 ) .  Anderson (1985)  adapts  framework and develops  Kleinman's h e a l t h care system  a theoretical  framework f o r use i n  n u r s i n g p r a c t i c e and r e s e a r c h . Within t h i s framework the n u r s i n g p r o f e s s i o n i s viewed as a s o c i o c u l t u r a l system t h a t possesses  i t s own knowledge,  b e l i e f s , and values which may be d i s c r e p a n t from those of the c l i e n t .  I n t e r a c t i o n s between the nurse and c l i e n t  are t r a n s a c t i o n s between e x p l a n a t o r y models which d i f f e r i n c o g n i t i v e content, e x p e c t a t i o n s and g o a l s . 1985, Her  (Anderson,  p.238)  framework can be used by nurses  s o c i o c u l t u r a l context  f o r i n v e s t i g a t i o n of the  i n which the p a t i e n t ' s h e a l t h and  i l l n e s s experiences are c o n s t r u c t e d . Nurse-patient  i n t e r a c t i o n s , such as those t h a t occur  with  p a t i e n t e d u c a t i o n , are r e l e v a n t t o p i c s t o be i n v e s t i g a t e d u s i n g Anderson's framework.  The nurse and p a t i e n t possess  d i f f e r i n g e x p l a n a t o r y 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 e x p l a n a t o r y models w i l l  a f f e c t what the nurse I d e n t i f i e s as being important  learning  needs f o r the p a t i e n t , and what l e a r n i n g needs the p a t i e n t 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 t o a p a t i e n t and e f f e c t i v e l y i d e n t i f y the l e a r n i n g needs of the p a t i e n t .  Problem  Statement  In a d j u s t i n g  and Purpose to the c h r o n i c  p a t i e n t s are r e q u i r e d  i l l n e s s of heart d i s e a s e MI  t o make l i f e s t y l e changes.  h e a l t h care p r o f e s s i o n a l s , are o f t e n  involved  Nurses, as  in cardiac  p a t i e n t e d u c a t i o n programs that are designed t o address patient  l e a r n i n g needs and to promote these l i f e s t y l e  The nurse, as a p r o f e s s i o n a l , may d e f i n e the i l l n e s s d i f f e r e n t way from the p a t i e n t , thus i d e n t i f y i n g needs that are d i f f e r e n t  change in a  learning  from those i d e n t i f i e d by p a t i e n t s .  In order to be e f f e c t i v e , however, p a t i e n t e d u c a t i o n must address the l e a r n i n g needs of the p a t i e n t . The purpose  of t h i s study was to e l i c i t  p e r c e p t i o n s of t h e i r (1) To determine  patients'  i l l n e s s experience f o l l o w i n g a MI: what i t meant to p a t i e n t s  to have had  MI. (2) To determine what p a t i e n t s needs f o l l o w i n g a MI.  i d e n t i f i e d as l e a r n i n g  8  (3) To determine  Definition  how p a t i e n t s met these l e a r n i n g needs.  o f Terms  For the purpose of t h i s study the f o l l o w i n g 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 i n the heart muscle, due to i n t e r r u p t i o n of the blood supply to the a r e a " ( M i l l e r & Keane, 1972, p.618). d i a g n o s i s determined  by the p a t i e n t ' s p h y s i c i a n .  (2) L e a r n i n g n e e d ( s ) - the concern(s) expressed  T h i s was a medical  i d e n t i f i e d and  by the p a t i e n t , f o r which the p a t i e n t r e q u i r e d  i n f o r m a t i o n i n order to manage on a day-to-day b a s i s f o l l o w i n g a MI. (3) C a r d i a c e d u c a t i o n - the formal or Informal g i v e n to p a t i e n t s and t h e i r  f a m i l i e s to help them  instruction understand  the p a t i e n t ' s i l l n e s s and manage i l l n e s s problems t h a t arose i n day-to-day  living.  Assumptions In t h i s study the f o l l o w i n g assumptions were made: (1) a p a t i e n t , having experienced a MI, would be able to speak to t h a t experience; the f i r s t  (2) a p a t i e n t , having experienced a MI f o r  time, would have l e a r n i n g needs; and (3) the  r e s e a r c h e r would bracket a l l preconceived  ideas r e g a r d i n g the  l e a r n i n g needs of p a t i e n t s who had had a MI.  9 Limitations The  f o l l o w i n g were l i m i t a t i o n s  participation  i n t h i s study was  of t h i s study:  restricted  l i v e d w i t h i n Vancouver proper i n order a c c e s s i b l e to the r e s e a r c h e r ; participation  was  i n E n g l i s h ; and time and  to p a t i e n t s  t h a t they would  who be  (2) f o r communication purposes  also r e s t r i c t e d  to p a t i e n t s who  (3) the number of s u b j e c t s  resources  (1)  of the student  was  were f l u e n t  limited  by  the  researcher.  Summary  T h i s chapter has addressed  introduced  i n t h i s study.  the problem and  I t i s evident  reviewed on c a r d i a c p a t i e n t education only one  aspect  perspectives the  of p a t i e n t education.  p a t i e n t education gained  from the  and  the  literature  that knowledge gain i s The  of h e a l t h p r o f e s s i o n a l s and  i l l n e s s experience and  purposes  differing  patients  i t s meaning may  also  influence  i n c o r p o r a t i o n of the knowledge  i n t o day-to-day l i f e .  Anderson's (1985) a d a p t a t i o n  Kleinman'n h e a l t h care system framework supports e x p l o r a t i o n of these d i f f e r i n g p e r s p e c t i v e s nursings illness The  of  the  to f u r t h e r  understanding of the p a t i e n t ' s s u b j e c t i v e h e a l t h  and  experience. remainder of t h i s t h e s i s i s organized  f o l l o w i n g manner. the  regarding  In Chapter Two  i n the  a more extensive  l i t e r a t u r e on s p e c i f i c aspects of c a r d i a c  review of  patient  education i s d i s c u s s e d .  Chapter Three  includes a d e s c r i p t i o n  of the methodology of phenomenology, the t h e 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  f i n d i n g s are d e s c r i b e d  i n Chapter  Four, with a d i s c u s s i o n of these f i n d i n g s presented In Chapter Five.  Chapter F i v e concludes with the study summary and  p r e s e n t a t i o n of the i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , e d u c a t i o n , and r e s e a r c h .  11 Chapter 2  Review of the L i t e r a t u r e  Introduction Although there have been numerous s t u d i e s done e v a l u a t i n g the e f f e c t i v e n e s s of c a r d i a c education  programs i n i n c r e a s i n g  p a t i e n t s ' knowledge about c a r d i a c disease research  a v a i l a b l e on the meaning of the  p a t i e n t and needs.  how  outcomes of c a r d i a c d i s e a s e ; of t h e i r  f o r MI;  the d i f f e r i n g p e r s p e c t i v e s  and be  physicians  l e a r n i n g needs and  on the  learning  the  cardiac  causal  the  patients'  explanations  of p a t i e n t s , nurses,  l e a r n i n g needs of post-MI p a t i e n t s  will  reviewed.  Outcomes F o l l o w i n g  a  MI  E a r l y s t u d i e s of MI  patients  i n v e s t i g a t e d the  of post-MI p a t i e n t s to the work f o r c e Picton-Roblnson, 1971; low  I l l n e s s to  l i t e r a t u r e on  perceptions and  is limited  t h i s a f f e c t s the c a r d i a c p a t i e n t ' s  In t h i s chapter s u p p o r t i v e  psychosocial  there  low  return  (Nagle, Gangola, &  Wishnie, Hackett, & Cassem, 1971).  r a t e of r e t u r n to work was  i n s t r u c t i o n patients received  a t t r i b u t e d to the  lack of  (Nagle et a l . , 1971)  and  The  the  emotional problems they experienced, post-MI, which a f f e c t e d their rehabilitation  (wishnie  et a l . , 1971).  Nagle et a l . (1971) surveyed 115 s u f f e r e d a MI  and  found that only 49.5%  They s t a t e that c a r d i a c damage and and  social  male p a t i e n t s who had  returned  non-cardiac  f a c t o r s , such as a n x i e t y and  had  to work.  psychological  depression,  were  almost e q u a l l y common as causes of i n v a l i d i s m post-MI. Wishnie et a l . (1971) interviewed from Mis and anxiety,  24 p a t i e n t s  convalescing  found that most of the p a t i e n t s s u f f e r e d  depression,  p h y s i c a l weakness, insomnia, and  Both Nagle et a l . and  wishnie et a l . contend that  from boredom.  the  psychosocial  problems experienced by MI  recovery  these problems need to be addressed through  and  patients affect  their  education. Salonen and  Puska (1980) reported  the  f i n d i n g s of a  community based program f o r r e h a b i l i t a t i o n and  secondary  prevention  initiated  f o r p a t i e n t s with acute MI  North K a r e l i a  i n 1972  control cardiovascular  t h a t was  as part of a comprehensive program to diseases  i n that r e g i o n of  The  program i n c l u d e d h e a l t h education,  and  psychosocial  p a t i e n t s entered it  counseling  during 1308  the  part  f i v e year p e r i o d  515  vocational  visited  counseling,  as w e l l as medical treatment.  b a s i s f o r one  patients that survived  acute MI,  Finland.  the program while i n h o s p i t a l and  on a o u t p a t i e n t  in  year.  continued  Data were c o l l e c t e d  from 1973  to 1977.  the  s i x months a f t e r  first  the o u t p a t i e n t  i n the r e h a b i l i t a t i o n groups.  The  MI One  Out  c l i n i c and  of  575  the their took  of the main o b j e c t i v e s  of the program was to improve the r a t e of r e t u r n t o work of p a t i e n t s a f t e r an acute Ml.  Although the r e s u l t s could not be  a t t r i b u t e d t o 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% i n the r a t e of new pensions  among the male p a t i e n t s and a s i g n i f i c a n t r e d u c t i o n  of 77%  among the females. Mayou, Williamson, and F o s t e r  (1976, 1978) s t u d i e d the  a t t i t u d e s and outcomes of p a t i e n t s f o l l o w i n g Mis. 1976  study they interviewed  40 p a t i e n t s and t h e i r  They found that p a t i e n t s and t h e i r understanding of medical advice  In t h e i r relatives.  f a m i l i e s had a lack of  and i n f o r m a t i o n  which o f t e n  was not r e a l i z e d u n t i l they t r i e d to cope a t home. cited  One reason  f o r the low understanding the p a t i e n t s and f a m i l i e s 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 p a t i e n t s . which they interviewed  In t h e i r  1978 study, i n  100 MI p a t i e n t s , they found a wide  v a r i a t i o n i n d i s a b i l i t y among the p a t i e n t s which was u n r e l a t e d to t h e i r c a r d i a c s t a t e . of medical advice p a t i e n t s and t h e i r  The p a t i e n t ' s lack of understanding  and the c a u t i o u s  expectations  of the  f a m i l i e s were f e l t to c o n t r i b u t e  to t h i s  disability. Stern, Pascale,  and Ackerman (1977) followed  for one year to study t h e i r p s y c h o s o c i a l S p e c i f i c areas explored activities.  68 p a t i e n t s  adjustments post-MI.  were work, f a m i l y , sexual  and s o c i a l  The p a t i e n t s were assessed using a v a r i e t y of  s c a l e s f o r d e p r e s s i o n and  a n x i e t y , before l e a v i n g the  hospital  and again a t s i x weeks, three months, s i x months, and year.  Subjects were found  d e p r e s s i v e s , d e n i e r s , and  to f i t i n t o three c a t e g o r i e s ; general non-depressives.  p a t i e n t s were i d e n t i f i e d as depressed continued to be depressed  at one year.  group were considered poor responders.  and  78% of  higher readmission  r a t e to h o s p i t a l .  to  they a l s o had a  In t h i s study d e n i e r s  continued to f u n c t i o n as good responders,  as d i d the g e n e r a l  R e h a b i l i t a t i o n outcomes were  s p e c i f i c a l l y poor f o r the 13 female s u b j e c t s who readmission  rates.  f i n d i n g s the r e s e a r c h e r s concluded  had  both  As w e l l , 80% of the  women showed s i g n s of d e p r e s s i o n and a n x i e t y .  From these  that the p o p u l a t i o n a t r i s k  f o r poor r e h a b i l i t a t i o n outcomes c o u l d be post-hospital  those  They o f t e n f a i l e d  sexual f u n c t i o n i n g , and  high m o r t a l i t y and  Nine  The d e p r e s s i v e s as a  r e t u r n to work and  non-depressed p o p u l a t i o n .  one  identified early in  recovery.  j. Ott et a l . (1983) measured the i l l n e s s - r e l a t e d b e h a v i o r a l d y s f u n c t i o n of 258 MI  patients using a questionnaire.  The  q u e s t i o n n a i r e measured d y s f u n c t i o n on both p h y s i c a l and p s y c h o l o g i c a l dimensions. i n t o three groups.  The  s u b j e c t s were randomly assigned  Group A, the c o n t r o l group, r e c e i v e d  c o n v e n t i o n a l medical and  n u r s i n g treatment,  group B l r e c e i v e d  an a d d i t i o n a l three month e x e r c i s e program, and  group  B2  r e c e i v e d the e x e r c i s e program plus a t e a c h i n g - c o u n s e l i n g  15 program about r i s k  f a c t o r s and  f o l l o w up e v a l u a t i o n s discharge  emotional adjustments.  were done three and  from h o s p i t a l .  The  researchers  i n the s i c k n e s s - r e l a t e d b e h a v i o r a l and  B l but  categories  s i x months a f t e r found no  dysfunction  differences  between group A  there were d i f f e r e n c e s found between group B2  both groups A and significant  The  Bl.  The  d i f f e r e n c e was  i n the p s y c h o s o c i a l such as s o c i a l  communication, and  statistically  dimension which  included  i n t e r a c t i o n , a l e r t n e s s behavior,  emotional behavior.  The  differences in  t h i s study were a t t r i b u t e d to the t e a c h i n g - c o u n s e l i n g and  not  the e x e r c i s e program however, because there  no d i f f e r e n c e s between group A and Burgess and beliefs attack  immediate and 180  Bl  (p.569).  had  been  critical  f e e l i n g s ) surround the  determine I t s meaning to the  future l i f e "  program  identified.  Hartman (1986) "hypothesized that  (e.g., thoughts and I t s e l f and  and  heart  person's  They randomly  assigned  p a t i e n t s to e i t h e r an experimental or c o n t r o l group.  experimental group r e c e i v e d n u r s i n g i d e n t i f i e d the  Interventions  i n d i v i d u a l ' s b e l i e f s and  would l i m i t or promote recovery.  The  The  that  expectations  that  s p e c i a l l y t r a i n e d nurses  helped c o r r e c t p a t i e n t ' s b e l i e f s t h a t 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 w e l l , s u b j e c t s were surveyed using a  v a r i e t y of instruments to o b t a i n p a t i e n t c h a r a c t e r i s t i c s and d i f f e r e n c e s between the two the p a t i e n t s reported  groups.  In t h e i r  f i n d i n g s 90%  job s t r e s s , with 33% blaming t h e i r  of  jobs  for t h e i r MI. and  The s u b j e c t s  viewed the heart a t t a c k  as s e r i o u s  expressed f e e l i n g s of s u s c e p t i b i l i t y t o heart a t t a c k and  relapse.  The p a t i e n t s  i n the experimental group a t the three  month f o l l o w 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 f a m i l y . Boogaard psychosocial and  (1984) compared r e t u r n t o p h y s i c a l aspects,  and f a m i l y i n t e r r e l a t i o n s h i p s of 10 male  10 female post-MI p a t i e n t s .  semi-structured  activity,  interviews  Data were c o l l e c t e d through  and r e v e a l e d  problem areas f o r women r e c u p e r a t i n g to resume household a c t i v i t i e s  several potential  from MI: (1) women tended  Immediately a f t e r  discharge  from h o s p i t a l ; (2) women delayed r e t u r n i n g t o work and sexual activity;  (3) women d i d not seem t o enter  structured  cardiac  r e h a b i l i t a t i o n programs; and, (4) women tended t o express f e e l i n g s of g u i l t as a r e s u l t of not being able t o resume normal household a c t i v i t i e s .  Boogaard s t r e s s e d the importance  of s t r u c t u r i n g c a r d i a c r e h a b i l i t a t i o n t o the i n d i v i d u a l needs of the p a t i e n t , whether male or female, and t h a t more work i s reguired  i n 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, G a r r e t t , and R i n g e l  (1986)  s t u d i e d the adherence of 112 post-MI p a t i e n t s t o p r e s c r i b e d medical regimens i n four l i f e  s i t u a t i o n s ; home, work, s p o r t s /  r e c r e a t i o n , and s o c i a l a c t i v i t y . while i n h o s p i t a l as t o t h e i r medical regimen.  The s u b j e c t s were surveyed  i n t e n t t o f o l l o w the p r e s c r i b e d  A f o l l o w up survey completed s i x t o nine  months post  i n f a r c t i o n , by both s u b j e c t s and f a m i l y members,  measured the s u b j e c t s a c t u a l adherence t o the p r e s c r i b e d regimen.  T h e i r f i n d i n g s showed t h a t although MI p a t i e n t s had  s t r o n g i n t e n t i o n s to f o l l o w the p r e s c r i b e d regimen while i n h o s p i t a l 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 d e c l i n e i n adherence behaviors measured s i x t o nine months l a t e r . f a m i l y r e p o r t s of adherence were not s i g n i f i c a n t l y  The  different  from the s u b j e c t s . These r e s e a r c h e r s a l s o hypothesized  t h a t the e x p e c t a t i o n s  of s i g n i f i c a n t others to the p r e s c r i b e d medical i n f l u e n c e s u b j e c t ' s adherence.  regimen would  T h e r e f o r e , data were c o l l e c t e d  on the s u b j e c t s ' p e r c e p t i o n s of the e x p e c t a t i o n s h e l d by s i g n i f i c a n t others. found  Adherence i n s p e c i f i c l i f e  s i t u a t i o n s was  to be r e l a t e d to the s u b j e c t ' s b e l i e f s about what others  thought  they should be doing s i x t o nine months a f t e r  d i s c h a r g e from h o s p i t a l .  These f i n d i n g s suggest  that the  a c t u a l adherence t o regimens once home may be more d i f f i c u l t than a n t i c i p a t e d and t h a t the b e l i e f s held by p a t i e n t s as to the e x p e c t a t i o n s of others should be assessed. The  e f f e c t of a Ml on a p a t i e n t ' s f a m i l y has a l s o been  investigated.  Hilgenberg and Crowley (1987) interviewed 25  p a t i e n t s and t h e i r f a m i l i e s a t two to three months, and again at f i v e t o s i x months a f t e r the p a t i e n t ' s d i s c h a r g e hospital.  from  T h i s study focused on changes i n f a m i l y 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  e x e r c i s e ; p r o t e c t l v e n e s s ; as w e l l a s , f i n a n c i a l and emotional changes.  Changes were noted by both p a t i e n t s and f a m i l y  members i n a l l areas  Investigated.  The r e s e a r c h e r s  "a general d e c l i n e i n s o c i a l a c t i v i t i e s , together in r o l e e x p e c t a t i o n s (p.32).  reported  with changes  and d i s r u p t i o n of f a m i l i a r r o u t i n e s "  These changes were a l s o a s s o c i a t e d with  distress,  s i n c e many of them had not been a n t i c i p a t e d by the p a t i e n t or the family., The  y  e f f e c t of u n c e r t a i n t y on coping and d i s t r e s s  f o l l o w i n g a MI has a l s o been r e p o r t e d  i n 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 l o n g i t u d i n a l e x p l o r a t o r y design t o study patients.  They examined the Influence of u n c e r t a i n t y i n  i l l n e s s and use of coping methods on emotional recovery  f o l l o w i n g MI.  v a r i e t y of instruments discharge  60 Ml  d i s t r e s s and  The p a t i e n t s were evaluated  using a  a t three d i f f e r e n t times a f t e r  from h o s p i t a l .  The a n a l y s i s of the data showed  "high l e v e l s of u n c e r t a i n t y were d i r e c t l y r e l a t e d to high l e v e l s of emotional  d i s t r e s s d u r i n g the t r a n s i t i o n  h o s p i t a l t o home and r e t u r n to s e l f - c a r e f o l l o w i n g infarction"  from myocardial  (p.80).  Webster and Christman  (1988) used a d e s c r i p t i v e survey t o  examine the r e l a t i o n s h i p s between p e r c e i v e d u n c e r t a i n t y , use of a f f e c t i v e or emotion-oriented methods, and emotional  and problem-oriented  coping  d i s t r e s s i n 20 p a t i e n t s r e c o v e r i n g  from  19 a MI.  Although u n c e r t a i n t y was not s i g n i f i c a n t l y r e l a t e d to  e i t h e r type  of coping method, increased Xeyels of u n c e r t a i n t y  were s i g n i f i c a n t l y r e l a t e d to both a n x i e t y and d e p r e s s i o n . " P e r c e p t i o n of one's i l l n e s s as vague or u n c l e a r , exposure t o v a r i e d cues about one's i l l n e s s and i t s treatment, and the p e r c e p t i o n of i n s u f f i c i e n t  i n f o r m a t i o n about one's d i a g n o s i s  were a s s o c i a t e d with g r e a t e r emotional  distress"  (p.389).  These r e s e a r c h e r s suggest t h a t p r o v i d i n g Information  about a  p a t i e n t ' s I l l n e s s and i t s treatment might reduce u n c e r t a i n t y and  thereby decrease the a s s o c i a t e d emotional  distress.  As t h i s l i t e r a t u r e demonstrates r e s e a r c h e r s i d e n t i f i e d many areas recovery post-MI.  have  of concern i n p a t i e n t s ' p s y c h o s o c i a l  The focus of present  programs on the p h y s i c a l aspect  cardiac r e h a b i l i t a t i o n  of c a r d i a c d i s e a s e may not be  meeting the needs of these p a t i e n t s .  Learning and information Needs E a r l y work done on p a t i e n t l e a r n i n g needs i d e n t i f i e d p a t i e n t s had a d e s i r e f o r more i n f o r m a t i o n about t h e i r and  i t s future e f f e c t s  surveying  (Dodge, 1969; Llnehan,  1966).  116 p a t i e n t s using a v e r b a l l y administered  ended i n t e r v i e w technique  Dodge (1969) concluded  that  illness After  open-  "patients  were p a r t i c u l a r l y concerned with r e c e i v i n g the kinds of i n f o r m a t i o n which would enable them to plan r e a l i s t i c a l l y f o r their  Immediate and long-range l i v e s "  (p.509).  Differences  between p a t i e n t s * c o g n i t i v e needs were i d e n t i f i e d when the v a r i a b l e s of sex, age, e d u c a t i o n , nature of involvement, term of involvement were examined.  Nature of  and  involvement  d i f f e r e n t i a t e d the p a t i e n t s as e i t h e r medical or s u r g i c a l term of involvement denoted a time frame of s h o r t term,  and  less  than a month, or long term, a month or more. Dodge (1969) found s u r g i c a l p a t i e n t s wanted to know about t h e i r s u r g e r y and were more concerned about t o t a l  time  involvement, whereas, medical p a t i e n t s emphasized  knowledge  r e g a r d i n g t h e i r medications and s e l f - c a r e . of involvement  i t was  In examining  again noted that long term p a t i e n t s  more q u e s t i o n s r e g a r d i n g t h e i r r o l e  i n s e l f - c a r e and  e f f e c t s of medications, while s h o r t term p a t i e n t s the r e s u l t s of d i a g n o s t i c and s u r g i c a l c a r e . wanted to know how  term had  the  emphasized  Male p a t i e n t s  t h e i r c o n d i t i o n would e f f e c t t h e i r  ability  to work and earn a l i v i n g , while female p a t i e n t s seemed more concerned health.  with t h e i r r o l e as the p r o t e c t o r of the  family  Age e f f e c t e d the c o g n i t i v e needs a c c o r d i n g to where  the p a t i e n t f i t i n the stages of adulthood, i e . , e a r l y , middle, or l a t e . p a t i e n t was  As w e l l , the l e v e l of education of the  viewed  i n t h i s study to e f f e c t the type of  i n f o r m a t i o n sought by the p a t i e n t , with p o o r l y educated p a t i e n t s wanting  n o n - t e c h n i c a l i n f o r m a t i o n , to h i g h l y  p a t i e n t s wanting  i n f o r m a t i o n t h a t would a s s i s t them i n  decision-making.  educated  These e a r l y f i n d i n g s suggest that the  21 i n d i v i d u a l c h a r a c t e r i s t i c s of both p a t i e n t and the c o g n i t i v e needs of the  patient.  Moynlhan (1984) examined the s p e c i f i c post-MI p a t i e n t s  l e a r n i n g needs of  i n a s m a l l , q u a n t i t a t i v e study.  p a t i e n t s responded to a mailed q u e s t i o n n a i r e . questionnaire subjects'  was  f e l t was  important  information  i n a range of t o p i c s  Information would be most b e n e f i c i a l to them.  r e h a b i l i t a t i o n process i n t o three time from t r a n s f e r from CCU (3) time from discharge  previous  wished t h a t  phases: (1) time i n CCU;  (2)  from h o s p i t a l ;  u n t i l p a t i e n t returned  information  t o p i c s as  to  important  and  could be r e i n f o r c e d i n a l l three  patients perceived  In phase one  important  i n the d i f f e r e n t  p a t i e n t s were concerned about the  explanations  information  as  was  of procedures.  In phase two  educational  more  t o p i c s of importance were  r e l a t e d to a c t i v i t i e s , emotional response, and Although the study was  CCU  d e s i r e d about d i e t , medications, r i s k  f a c t o r s , e t c . , while i n phase three  perceived  the  cardiac  u n t i l discharge  r a t e d a l l education  environment and specific  For  However, d i f f e r e n c e s were noted i n what types of  information phases.  felt  lifestyle.  Subjects  phases.  considered  when s u b j e c t s '  purposes of the study Moynihan d i v i d e d the  and,  Seventeen  The  designed to e s t a b l i s h what  important to c a r d i a c r e h a b i l i t a t i o n , and this  illness effect  follow-up.  viewed as d e l i n e a t i n g p a t i e n t s ' needs the education  self-  t o p i c s were those  22 considered  by the researcher  t o be c u r r e n t and recommended  components i n a c a r d i a c r e h a b i l i t a t i o n program. Nicklin  (1986) s t u d i e d postdischarge  p a t i e n t s as presented  v i a a telephone  concerns of c a r d i a c  c a l l b a c k system.  The  p a t i e n t s had had e i t h e r a MI or c a r d i a c surgery, and a l l had been exposed t o p a t i e n t e d u c a t i o n .  T h i s education  included:  " b a s i c anatomy and p h y s i o l o g y of the h e a r t , a t h e r o s c l e r o s i s , angina,  MI, r i s k  f a c t o r s of heart d i s e a s e ,  g u i d e l i n e s , and d i e t  information"  (p.268).  activity The p a t i e n t s were  encouraged t o c a l l the on-duty n u r s i n g c o o r d i n a t o r arose  post d i s c h a r g e .  217 telephone concerns arose  i f problems  In a p e r i o d of l e s s than f i v e months  c a l l s were r e c e i v e d . F o r t y percent  of the  w i t h i n the p a t i e n t s * f i r s t week a t home.  N i c k l i n concluded  t h a t p a t i e n t s and f a m i l i e s appeared t o need  more, or d i f f e r e n t ,  i n f o r m a t i o n d u r i n g the r e h a b i l i t a t i o n  phase of a MI or c a r d i a c  surgery.  Liddy and Crowley (1987) s t u d i e d 11 post-MI p a t i e n t s and t h e i r spouses t o see I f MI p a t i e n t s had the i n f o r m a t i o n needed f o r the recovery phase a t home.  T h e i r study  they  focused on  s p e c i f i c c a t e g o r i e s of i n f o r m a t i o n such as p h y s i o l o g y , p e r m i s s i b l e a c t i v i t i e s , d i e t , medications,  smoking,  p s y c h o s o c i a l f a c t o r s , and unanswered q u e s t i o n s .  Data were  c o l l e c t e d by i n t e r v i e w s from both the p a t i e n t s and t h e i r spouses two t o three months f o l l o w i n g the p a t i e n t ' s MI. and  Liddy  Crowley found t h a t both groups of respondents were not  w e l l Informed i n any  of the designated  categories.  The  respondents f e l t they would have b e n e f i t e d  from more  information  to i n t e g r a t e  and  s p e c i f i c g u i d e l i n e s on how  demands i n t o t h e i r d a i l y r o u t i n e s .  T h i s study was  designed to determine the reasons f o r the inadequate knowledge and information  only examined the  needs i n s p e c i f i c  new  not  respondents patients'  categories.  Phenomenological s t u d i e s done with c a r d i a c p a t i e n t s have shown that p a t i e n t s have i n f o r m a t i o n met  (Dubyts, 1988;  These s t u d i e s  Dunn, 1985;  focused  needs that are o f t e n  Kent, 1985;  Yamada, 1984).  on p a t i e n t s ' experiences with  angina, and  coronary a r t e r y bypass g r a f t surgery.  their  was  focus  depicted  MI, Although  not on p a t i e n t s l e a r n i n g needs areas of  concern were d i s c u s s e d perceived  not  in their  f i n d i n g s , such as the  problems  by the p a t i e n t s were o f t e n not the same as i n p a t i e n t education  s o l v e t h i s problem one  them cope with c a r d i a c  manuals (Yamada, 1984).  researcher  a c t i v e l y sought i n f o r m a t i o n  those  reports patients  from books and  i l l n e s s and  To  often  the media to  help  i t s management (Dubyts,  1988). P a t i e n t c h a r a c t e r i s t i c s , such as age, and  illness  f a c t o r s , such as type and  sex,  spouses have acknowledged the d e s i r e f o r more i n the recovery  education,  d u r a t i o n , have been  shown to i n f l u e n c e p a t i e n t s ' l e a r n i n g needs.  specifically  and  Patients  and  Information,  phase at home, when c a r d i a c  24 p a t i e n t s l e a r n i n g needs have been s t u d i e d .  Causal  Explanations  In 1980 Rudy s t u d i e d p a t i e n t s ' and spouses' explanations  of a MI.  MI p a t i e n t s and t h e i r  Her sample c o n s i s t e d  of 50 f i r s t - t i m e  50 spouses or s i g n i f i c a n t  During the acute phase, and again d u r i n g  causal  others.  the convalescent  phase of the i l l n e s s , data were c o l l e c t e d by i n t e r v i e w s a structured questionnaire. p a t i e n t s and spouses reported frequent general  At both phases of the study, both t h a t t e n s i o n was the most  cause of the p a t i e n t ' s MI.  Rudy noted that i n  p a t i e n t s who had an i d e n t i f i a b l e medical r i s k  d i d not name, nor d i d t h e i r spouses name, that r i s k an e x p l a n a t i o n therefore  using  f o r the p a t i e n t ' s heart a t t a c k .  factor  f a c t o r as  It is  I n t e r e s t i n g to note t h a t a high percentage of  p a t i e n t s changed t h e i r smoking, d i e t , and e x e r c i s e even when they d i d not consider t h e i r heart  behavior  these f a c t o r s as having caused  attack.  Fielding  (1987) s t u d i e d 102 MI p a t i e n t s and argued that  poor outcomes f o l l o w i n g Mis occur because 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 c a u s a l a t t r i b u t e s of MI d i f f e r e n t l y . h i s study, the most f r e q u e n t l y c i t e d c a u s a t i v e  factors  by p a t i e n t s were overwork, smoking, and worry, while physicians  emphasized smoking, hypertension,  cholesterol.  and serum  H i s study l e d him t o conclude t h a t the  In listed  biological  focus of c a r d i a c 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 h e l d by MI p a t i e n t s . Murray (1989) Interviewed 25 MI p a t i e n t s , the day of or the day before d i s c h a r g e from h o s p i t a l , t o assess the p a t i e n t s ' p e r c e p t i o n s of the causes of t h e i r MI and t h e i r knowledge r e g a r d i n g r i s k  f a c t o r s of coronary heart d i s e a s e .  P a t i e n t s g e n e r a l l y r e p o r t e d that they f e l t w e l l prepared to go home but as one p a t i e n t r e p o r t e d , not having been home how would they know i f they had had enough i n f o r m a t i o n . study s t r e s s , worry, and overwork comprised  In t h i s  68% of the  c i t a t i o n s as to the cause of MI, while standard r i s k  factors  such as smoking, h y p e r t e n s i o n , c h o l e s t e r o l , e t c . were c i t e d o n l y 60%. risk  T h i r t y - s i x percent of the p a t i e n t s c i t e d  f a c t o r s as the most important cause  48% c i t e d s t r e s s , worry, and overwork.  standard  of t h e i r MI, while As r e p o r t e d by Murray  these f i n d i n g s are b r o a d l y i n l i n e with the f i n d i n g s of Fielding  (1987).  These s t u d i e s have shown t h a t p a t i e n t s emphasize the p s y c h o s o c i a l aspects of t h e i r for  t h e i r MI.  post-MI,  lifestyle  as c a u s a l e x p l a n a t i o n s  Poor outcomes, i n r i s k f a c t o r m o d i f i c a t i o n  may be the r e s u l t  i f 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 hold c o n f l i c t i n g views as t o the cause of a p a t i e n t ' s MI.  26 D i f f e r i n g Perspectives In a 1975 and  of P a t i e n t s . Nurses, and  study P f i s t e r e r examined how  nurses p e r c e i v e d  the  patients,  from h o s p i t a l .  p a t i e n t s ' c a r d i a c diagnoses v a r i e d from MI Using open-ended q u e s t i o n n a i r e s the p a t i e n t s , the d o c t o r s ,  and  The  to valve  information  was  stenosis.  obtained  from  the nurses when the p a t i e n t  on the  exception  f i f t h day  at home.  Pfisterer  agreement among d o c t o r s ,  found  nurses,  that  and  p a t i e n t s about the p a t i e n t ' s l e a r n i n g needs never exceeded and  t h a t four out of the seven p a t i e n t s had  information,  was  As w e l l , each p a t i e n t completed a second  questionnaire with one  doctors,  l e a r n i n g needs of a small sample of  c a r d i a c p a t i e n t s being discharged  discharged.  Physicians  i n the p r e s e n t a t i o n  of the  50%  unmet needs f o r  findings Pfisterer  not e x p l i c i t as to what l e a r n i n g needs the p a t i e n t s ,  Is  doctors,  or nurses i d e n t i f i e d or what needs the p a t i e n t s ' f e l t went unmet. Casey, O'Connell, and nurses', MI  p a t i e n t s ' , and  Price  c a r d i o l o g i s t s ' perceptions  p a t i e n t s need to know post-MI. and  Twelve p h y s i c i a n s ,  30 p a t i e n t s completed a q u e s t i o n n a i r e  asked to r a t e the  '"knowing the s i g n s and  program.  33  nurses,  i n which they were  names, dosages, and  taught  A l l three groups r a t e d :  symptoms of a heart a t t a c k ' ;  to modify or change personal  care  of what  importance of 21 t o p i c s that might be  in a post-MI education  how  (1984) s t u d i e d coronary  risk  'knowing  f a c t o r s ' ; 'knowing the  s i d e e f f e c t s of medications';  and,  27 'knowing p e r s o n a l r i s k f a c t o r s ' "  (p.77) as  important.  Although the three groups were b a s i c a l l y congruent t o p i c s r a t e d as being most important there were  with the  statistically  s i g n i f i c a n t d i f f e r e n c e s among the groups i n 10 of the items.  P a t i e n t s were asked to complete  while i n h o s p i t a l , t h e r e f o r e , how  21  the q u e s t i o n n a i r e  b e n e f i c i a l t o p i c s were to  t h e i r r e h a b i l i t a t i o n a t home c o u l d not be a s s e s s e d . K a r l i k and Yarcheskl (1987) d i d a comparative  study of  nurses' views of c a r d i a c p a t i e n t s ' l e a r n i n g needs and p a t i e n t s ' views of t h e i r own  l e a r n i n g needs.  cardiac  They a l s o  s t u d i e d nurse educators to i d e n t i f y a p o s s i b l e source of p r a c t i c i n g nurses' b e l i e f s r e g a r d i n g the l e a r n i n g needs of these p a t i e n t s .  The sample c o n s i s t e d of 24 male and s i x  female p a t i e n t s and  30 nurses: 15 post-coronary care  nurses and 15 nurse e d u c a t o r s . through q u e s t i o n n a i r e s .  The data were c o l l e c t e d  They found nurses ranked the  needs d i f f e r e n t l y than the p a t i e n t s d i d . i n f o r m a t i o n c a t e g o r i e s the CCU knowledge as the number one  learning  Out of e i g h t  nurses ranked  medication  p a t i e n t l e a r n i n g need, while the  p a t i e n t s ranked the c a t e g o r y of r i s k number one.  (CCU)  f a c t o r knowledge as  I t i s i n t e r e s t i n g to note t h a t nurse  educators  a l s o ranked the category of medication knowledge as the most important p a t i e n t l e a r n i n g need. The members of the h e a l t h care team p e r c e i v e as a support to the p a t i e n t who  themselves  has to make l i f e s t y l e  changes  28  or adjustments  post-MI.  p a t i e n t , however.  T h i s may  not be the p e r c e p t i o n o£ the  A content a n a l y s i s 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, G a r r e t t , and R i n g e l (1989) examined the i s s u e of who  MI p a t i e n t s viewed as being  persons d u r i n g r e c o v e r y .  F i f t y nurse/patient Interactions  were analyzed t o i d e n t i f y support persons judge  or groups,  the q u a l i t y of the communication as being  n e g a t i v e , or ambiguous. themselves  I t was  and  found t h a t p a t i e n t s viewed spouses,  other r e l a t i v e s viewed as p r o v i d i n g both  t a n g i b l e and emotional support of a p o s i t i v e nature. the h e a l t h team ranked was  to  positive,  as t h e i r g r e a t e s t p o s i t i v e support, with  c h i l d r e n , and  support  second  as support persons  Although  their  support  o f t e n p e r c e i v e d as negative or ambiguous with almost a  t o t a l absence of emotional r e s e a r c h e r s to conclude  support.  T h i s l e d these  t h a t " i f the h e a l t h team, as the major  p r o v i d e r of i n f o r m a t i o n , i s going to f a c i l i t a t e p a t i e n t and f a m i l y adjustment identified  post i n f a r c t i o n , reasons need to be  f o r negative q u a l i t y of support, u n c l e a r messages,  and absence of emotional support"  (p.566).  D i f f e r i n g p e r c e p t i o n s , as t o the l e a r n i n g needs of p a t i e n t s post-MI and the r o l e of h e a l t h p r o f e s s i o n a l s i n 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 . make p a t i e n t education more b e n e f i c i a l these d i f f e r i n g p e r c e p t i o n s must be  In order to  f o r post-MI p a t i e n t s  clarified.  Summary A review following the  a cardiac  patients*  patients' presence  of the l i t e r a t u r e event  perception  recognition  viewed d i f f e r e n t l y  of the cause  home. there of  learning  e f f e c t e d by  n e e d s , and t h e  Learning  by n u r s e s and p a t i e n t s , As w e l l ,  needs a r e o f t e n  w h i c h may c a u s e  patients  may n o t  needs u n t i l t h e y t r y t o manage t h e i r  Although these areas has been l i m i t e d  the i l l n e s s experience  undertaken t o explore methodology used  o f c o n c e r n have been  research  this  issue  i s presented  a MI.  This  illness at  perceptions s t u d y was  and a d e s c r i p t i o n  i n the next  recognize  identified  on t h e p a t i e n t s '  following  outcomes  of the i l l n e s s , the  learning  problems.  t h e s e needs t o go unmet. their  patient  s u c h a s a MI a r e o f t e n  of t h e i r  of psychosocial  suggests that  chapter.  of the  30 Chapter  3  Methodology  Introduction The q u a l i t a t i v e methodology of phenomenology was to guide t h i s study.  selected  In t h i s chapter a d e s c r i p t i o n of  phenomenology and the c o r r e l a t i o n between t h i s methodology and the methods of p a r t i c i p a n t s e l e c t i o n , data c o l l e c t i o n , data a n a l y s i s are d i s c u s s e d . process and  A d e s c r i p t i o n of the  the data c o l l e c t i o n procedure  w i l l also  and  selection be  presented.  Methodology The q u a l i t a t i v e r e s e a r c h method of phenomenology was  used  i n t h i s study to r e s e a r c h the meaning of the MI experience the a f f e c t t h a t experience had p a t i e n t s and  their  on the day-to-day l i v e s of  l e a r n i n g needs.  "The  aim of phenomenology  i s t o d e s c r i b e experience as i t i s l i v e d by people" 1986,  p.70),  thus  and  (Oiler,  i t i s a method which allows the r e s e a r c h e r  to focus on the p e r s p e c t i v e of the p a t i e n t (popular arena) r a t h e r than the p e r s p e c t i v e of the nurse Glorgi  (1975) o u t l i n e d e i g h t c h a r a c t e r i s t i c s of the  phenomenological it  is lived"  (professional arena).  approach:  (1) " f i d e l i t y to the phenomenon as  (p.99), the phenomenon i s s t u d i e d i n the context  of the one l i v i n g through  the s i t u a t i o n .  Therefore,  e v e r y t h i n g the s u b j e c t f e e l s i s worth mentioning i n the data.;  (2) "primacy  of the l i f e - w o r l d "  i s included  (p.99), a l l o w s  the emphasis t o remain on the everyday world as i t i s l i v e d Instead of e x p l a n a t i o n s or t h e o r e t i c a l (3) " d e s c r i p t i v e approach" communicated through  I n t e r p r e t a t i o n s of I t ;  (p.100), the phenomenon i s  language thus d e s c r i p t i o n i s the main  technique of t h i s approach;  (4) " e x p r e s s i o n of s i t u a t i o n  from  viewpoint of s u b j e c t " (p.100), the data c o l l e c t e d are s t r i c t l y the s u b j e c t ' s viewpoint;  (5) " s i t u a t i o n as u n i t of r e s e a r c h  i m p l i e s s t r u c t u r a l approach"  (p.100), the r e s e a r c h s i t u a t i o n  c r e a t e s a l i v e d experience with meaning f o r both the s u b j e c t and the r e s e a r c h e r ; (6) " [ b i o g r a p h i c a l ] emphases"  (p.101),  with the use of human s u b j e c t s the data c o l l e c t e d are b i o g r a p h i c a l and p e r s o n a l ; (7) "engaged r e s e a r c h e r s "  (p.101),  the r e s e a r c h e r p l a y s an a c t i v e r o l e i n the c o n s t i t u t i o n of the data t h e r e f o r e , a l l p r e s u p p o s i t i o n s t h a t e x i s t must be made as e x p l i c i t as p o s s i b l e ; and (8) "search f o r meaning"  (p.101),  with t h i s approach the measurement of the phenomenon i s i t s meaning. The phenomenological  approach p r o v i d e s the r e s e a r c h e r  with a method of i n v e s t i g a t i n g a l i v e d experience p e r s p e c t i v e of the s u b j e c t . phenomenological  from the  In t h i s study the  approach was used t o e l i c i t  the meaning of the i l l n e s s experience  from the s u b j e c t s  f o l l o w i n g a MI.  V a l i d i t y and R e l i a b i l i t y The  i s s u e of v a l i d i t y  or c r e d i b i l i t y  in qualitative  r e s e a r c h r e s t s with how f a i t h f u l the r e s e a r c h e r ' s d e s c r i p t i o n and  i n t e r p r e t a t i o n of the experience  actual lived Sandelowskl  experience  i s t o the s u b j e c t ' s  (Sandelowsk1, 1986).  (1986) c r e d i b i l i t y  According to  i s represented when  having t h a t experience would immediately  "people  recognize i t from  those d e s c r i p t i o n s or i n t e r p r e t a t i o n s as t h e i r own" (p. 30), and when "other r e s e a r c h e r s or readers can r e c o g n i z e the experience when c o n f r o n t e d with i t a f t e r having o n l y read about i t i n a study"  (p. 30).  U n l i k e q u a n t i t a t i v e r e s e a r c h where r e p e a t a b i l i t y of the data  Is d e s i r e d , the aim of q u a l i t a t i v e r e s e a r c h Is to remain  t r u e t o the unique  experience of the i n d i v i d u a l  1986). Thus, r e l i a b i l i t y  (Sandelowskl,  In q u a l i t a t i v e s t u d i e s Is not  measured by the a b i l i t y t o r e p l i c a t e the f i n d i n g s but on the a b i l i t y of others t o f o l l o w the " d e c i s i o n t r a i l s " of the r e s e a r c h e r and t o a r r i v e a t the same or comparable c o n c l u s i o n s (Sandelowskl,  1986).  Sample S e l e c t i o n and S e l e c t i o n In t h e o r e t i c a l sampling  Criteria  the p a r t i c i p a n t s are s e l e c t e d by  the r e s e a r c h e r a c c o r d i n g t o the t h e o r e t i c a l needs and the d i r e c t i o n of the r e s e a r c h (Morse, 1986).  T h i s study r e q u i r e d  i n d i v i d u a l s who would be able t o speak to the experience of  having had was  a MI  t h e r e f o r e , a t h e o r e t i c a l sampling technique  used to o b t a i n the sample.  not predetermined. to f i v e , due  The  sample s i z e i n t h i s study was  to a lower than normal census of MI  the p a r t i c i p a t i n g agency and a student r e s e a r c h e r .  The  recruitment sample was  to be modified  stage i n order  and  i t was  be able to speak to t h i s problem. admitted f o r MI  r e s t r i c t i o n was  lifted.  p a t i e n t s of any  age  to be  interviewed, (2) The  following  65,  who  The had  criteria:  (Nagle et a l . ,  r a t e of  1971;  hoped that p a r t i c i p a n t s would However, the m a j o r i t y  were over 65,  thus,  the p h y s i c a l and  i e . no hearing  p a r t i c i p a n t s had  mental  of  this  c r i t e r i a then changed to  include  capacity  deficits.  to understand and  speak E n g l i s h  through  p a r t i c i p a n t s had  to be e x p e r i e n c i n g  their  T h i s excluded p a t i e n t s whose l e a r n i n g needs may  Influenced  those of  which were conducted i n E n g l i s h .  (3) The MI.  sample.  i s a low  as the data were c o l l e c t e d by t h i s researcher interviews  the  to Involve  have shown that there  r e t u r n to work i n post-MI p a t i e n t s  p a t i e n t s being  by  proposed that the p a r t i c i p a n t s  were to be between the ages of 30 and  Wishnie et a l . , 1971)  p a t i e n t s at  during  to o b t a i n the  s e l e c t e d using the  Studies  limited  As w e l l , c r i t e r i a e s t a b l i s h e d f o r  (1) O r i g i n a l l y , i t was  working age.  was  the time r e s t r a i n t experienced  s e l e c t i o n of p a r t i c i p a n t s had subject  A d e f i n i t i v e sample s i z e  by t h e i r previous  first  have been  experience of the phenomenon  34 being  studied. (4)  unit  The  of  a  willing  hospital  to  following (5)  be  The  be  was  or  female,  an  differences  and/or  respond to  breadth  Plrie, it  to  had  Is  Folsora,  a  coronary  Vancouver  homes two  live  the  this  and  to  care  they  four  were  weeks  within  study a  genders  of  all  patients,  for  the  first  participation  In  how  these  differences  have  there  perceive  (Melnlnger, & Gillum,  not  that  Individuals  Jacobs,  time  was  acknowledges  experience  that  city  that  Ml  researcher  Luepker,  the  researcher.  therefore  Illness  believed  the  to  for  This  between an  of  experienced  needs,  by g e n d e r .  may b e  However,  had  city  from  hospital.  assumption of who  patients  their  the  accessible  learning  restricted  Sorensen,  from  in  participants  to  have  the  interviewed  It  would  were  within  discharge  Vancouver  male  participants  1986; 1985). added  data.  Selection Procedure Subjects  were  hospital  within  from  four  the  approach  their  Appendix  A).  time Due  of to  the  obtained city  of  from  a  coronary  Vancouver.  cardiologists covering patients Three  initial  of  contact  for the and  a  of  the  coronary in  this  a  sought  care  unit  study  lack  recruitment of  MI  commenced.  admissions  to  (see  c a r d i o l o g i s t s consented at  subject  a d e c r e a s e d c e n s u s and  unit  P e r m i s s i o n was  participation four  care  under  the  these c a r d i o l o g i s t s only two s u b j e c t s were obtained f o l l o w i n g three month p e r i o d .  i n the  T h e r e f o r e , the f o u r t h  c a r d i o l o g i s t was again approached and with t h i s added a s s i s t a n c e three more s u b j e c t s were obtained. recruitment The  phase continued  The s u b j e c t  f o r a t o t a l of f i v e months.  names of p o t e n t i a l p a r t i c i p a n t s were passed on t o the  researcher by the c a r d i o l o g i s t s themselves, or by the head nurses  of the u n i t s i n v o l v e d .  The head nurses  o f t e n 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 . researcher's  initial  The  c o n t a c t with the MI p a t i e n t d i d not occur  u n t i l the c a r d i o l o g i s t e i t h e r  Introduced  the researcher to the  p a t i e n t , or gave v e r b a l permission t o the r e s e a r c h e r t o approach the p a t i e n t . P a t i e n t s were approached p r i o r t o t h e i r d i s c h a r g e  from  h o s p i t a l and a t t h a t time the study was e x p l a i n e d and w r i t t e n consent  obtained  contacted  (see Appendix B ) .  the s u b j e c t s by telephone  post d i s c h a r g e t o arrange The positive. six  The r e s e a r c h e r approximately  f o r the f i r s t  then two weeks  interviews.  p a t i e n t s ' response t o the study was g e n e r a l l y Seven p a t i e n t s were approached and of these  consented.  The one p a t i e n t not wishing  seven,  to p a r t i c i p a t e  c i t e d a p e r s o n a l d i s l i k e of r e s e a r c h as the reason f o r nonparticlpation. discharge The  One of the remaining  s i x moved f o l l o w i n g  from h o s p i t a l and d i d not c o n t a c t the r e s e a r c h e r .  sample s i z e remained a t f i v e throughout the data  36 c o l l e c t i o n phase.  P a t i e n t Education T h i s study experience  Protocol  focused  on each i n d i v i d u a l  subject's  and because i t followed the phenomenological  paradigm there was no e f f o r t made to c o n t r o l what each s u b j e c t r e c e i v e d i n the area of p a t i e n t education. s u b j e c t s were obtained  However, s i n c e a l l  through the same I n s t i t u t i o n  i t was  thought t h a t the i n f o r m a t i o n given t o the p a t i e n t s would be r e l a t i v e l y consistent. The  participating  i n s t i t u t i o n d i d i n f a c t have an  e s t a b l i s h e d p r o t o c o l f o r the t e a c h i n g of MI p a t i e n t s .  A l l MI  p a t i e n t s were t o r e c e i v e the p u b l i c a t i o n The heart t a l k s e r i e s heart a t t a c k  (1988).  T h i s w r i t t e n i n f o r m a t i o n was t o be  complimented by i n d i v i d u a l and  i n s t r u c t i o n from the n u r s i n g  r e f e r r a l t o a d i e t i c i a n where a p p l i c a b l e .  The n u r s i n g  s t a f f were r e q u i r e d t o complete a c h a r t form e n t i t l e d P a t i e n t Teaching  "Cardiac  C h e c k l i s t " which o u t l i n e d the b a s i c steps i n  the t e a c h i n g process and  staff  i n c h e c k l i s t format on the f r o n t s i d e ,  s u p p l i e d the nurse with an overview of what m a t e r i a l t o  cover  on the reverse s i d e .  was i n c o r p o r a t e d  The use of these t e a c h i n g t o o l s  i n t o the o r i e n t a t i o n program attended  by a l l  of the n u r s i n g s t a f f working i n the i n t e n s i v e care and the medical  u n i t where a l l f i v e s u b j e c t s  patients.  i n t h i s study were  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 i n t h i s study i n v o l v e d in-depth, taped Interviews with p a r t i c i p a n t s  i n t h e i r homes.  At the f i r s t  i n t e r v i e w demographic data were c o l l e c t e d on each (see of  Appendix C ) .  The i n i t i a l  participant  i n t e r v i e w s were guided by a s e t  t r i g g e r q u e s t i o n s (see Appendix D).  Subsequent i n t e r v i e w s  with each p a r t i c i p a n t were guided by the a n a l y s i s of the f i r s t Interview and by q u e s t i o n s that arose d u r i n g the a c t u a l process of i n t e r v i e w i n g . The p a r t i c i p a n t s ' accounts were c o n s t r u c t e d through a s e r i e s of e l e v e n taped and two telephone  i n t e r v i e w s , one c o i n c i d e n t a l  follow-ups.  meeting,  A l l f i v e p a r t i c i p a n t s were  interviewed twice and one p a r t i c i p a n t 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 d i s c o u r a g e d , t h e r e f o r e one p a r t i c i p a n t ' s spouse a c t i v e l y took p a r t i n two i n t e r v i e w s . s u b j e c t r e c r u i t m e n t phase both second i n t e r v i e w were conducted  Due t o the extended i n t e r v i e w s and one t h i r d  with the f i r s t  two s u b j e c t s before  the remaining three s u b j e c t s had had t h e i r A telephone subjects.  i n i t i a l interviews.  follow-up was a l s o done with the f i r s t  two  Data c o l l e c t i o n took p l a c e over a four and a h a l f  month p e r i o d . The time spent a t p a r t i c i p a n t s ' homes d u r i n g the I n t e r v i e w i n g process ranged q u a r t e r hours.  from 4 5 minutes t o two and a  A t o t a l of nine hours was audiotaped  with  38 r e c o r d i n g times of  ranging  from 20 t o 60 minutes.  The presence  the tape r e c o r d e r d i d not appear t o a f f e c t the  participants. stopped  At no time d i d any p a r t i c i p a n t request the tape  or erasure  of any of the r e c o r d i n g .  One p a r t i c i p a n t  asked that the tape not be r e p l a y e d i n h i s presence because he did  not wish t o hear himself t a l k i n g .  Often p a r t i c i p a n t s  ended the r e c o r d i n g s e s s i o n but then proceeded t o c a r r y on f u r t h e r c o n v e r s a t i o n s with the r e s e a r c h e r .  Notes were made of  these c o n v e r s a t i o n s as soon as p o s s i b l e f o l l o w i n g departure from the p a r t i c i p a n t ' s home. All  first  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 f i v e were done d u r i n g week three a t home. subject's f i r s t readmission  i n t e r v i e w was delayed  to h o s p i t a l f o r treatment  One  i n t o week four due to of chest p a i n .  Second  i n t e r v i e w s ranged from f i v e weeks, s i x days t o 14 weeks, three days post d i s c h a r g e .  Three were done around the s i x week  mark, one a t e i g h t weeks, and one s u b j e c t was delayed  Into  week 15 because he was away on a t r i p . A c o i n c i d e n t a l meeting with one p a r t i c i p a n t was the impetus f o r a t h i r d  interview.  At the time of the chance  meeting i t appeared t h a t the s u b j e c t wished an o p p o r t u n i t y t o t a l k about h i s recent h o s p i t a l i z a t i o n f o r a n g i o p l a s t y . third  Interview was done a t approximately Telephone follow-ups  A  the nine week mark.  were done with the f i r s t two  39  s u b j e c t s a t 21 weeks, two days and Although  16 weeks, four days.  the r e s e a r c h e r used t h i s o p p o r t u n i t y to address  management of l i f e s t y l e changes with each p a r t i c i p a n t , p r i n c i p a l reason  f o r the follow-up was  on t h e i r r e t u r n to work. In the study who  to gather  the  the  information  These p a r t i c i p a n t s were the only  two  were i n the work f o r c e at the time of t h e i r  MI.  Ethical  Considerations  Before data c o l l e c t i o n began the r e s e a r c h e r approval to conduct  obtained  t h i s study from the U n i v e r s i t y of  Columbia B e h a v i o r a l Sciences Screening Committee and p a r t i c i p a t i n g h o s p i t a l ' s Research Committee. p a r t i c i p a n t s were informed study was  The  British the  potential  that t h e i r p a r t i c i p a t i o n in t h i s  s t r i c t l y v o l u n t a r y and  t h a t there would not be  any  e f f e c t on the care they r e c e i v e d i f they d i d not wish to participate.  They were a l s o informed  participating  i n the study c o u l d not be p r e d i c t e d ; however, by  s h a r i n g t h e i r experience understand  that the e f f e c t s of  they would help nurses  to b e t t e r  t h i s experience which c o u l d Improve care f o r MI  p a t i e n t s In the f u t u r e . W r i t t e n consent all  was  obtained  from a l l p a r t i c i p a n t s  p a r t i c i p a n t s r e c e i v e d a copy of the  letter  (see Appendix B).  information-consent  They were informed  withdraw from the study a t any time.  The  and  t h a t they c o u l d  p a r t i c i p a n t s were  aware that data would be coded  to p r o t e c t t h e i r anonymity and  the audiotapes would be destroyed f o l l o w i n g completion of the thesis.  The p a r t i c i p a n t s were a l s o n o t i f i e d of the i n t e n t i o n  to p u b l i s h the f i n d i n g s of t h i s study and that they would not be i d e n t i f i e d  i n any p u b l i c a t i o n .  Data A n a l y s i s The audiotapes were t r a n s c r i b e d verbatim by the researcher.  The d a t a , comprised  notes, were reviewed process proceeded. b e f o r e second  of both t r a n s c r i p t s and f i e l d  c o n t i n u o u s l y as the data The f i r s t  collection  i n t e r v i e w s were t r a n s c r i b e d  Interviews were conducted  with each  individual  p a r t i c i p a n t , a l l o w i n g the r e s e a r c h e r to v a l i d a t e the i n i t i a l a n a l y s i s with that  participant.  Following C o l a i z z l ' s  (Knaack, 1984) steps of data  a n a l y s i s s i g n i f i c a n t statements verbatim t r a n s c r i p t s .  were e x t r a c t e d from the  These statements  helped the r e s e a r c h e r  to formulate meanings that were c l u s t e r e d  i n t o themes which i n  t u r n provided a d e s c r i p t i o n of the phenomenon under study. The r e s e a r c h e r was unable t o v a l i d a t e the f i n a l a n a l y s i s with each p a r t i c i p a n t due to g e o g r a p h i c a l r e s t r a i n t s a t the time of analysis.  However, i n each s t e p of the a n a l y s i s process the  r e s e a r c h e r r e t u r n e d to the data to ensure that the meanings remained ignored.  f a i t h f u l t o the o r i g i n a l data and t h a t no data were  Summary Phenomenology was the q u a l i t a t i v e r e s e a r c h methodology chosen to guide t h i s study.  A t h e o r e t i c a l sample of f i v e  post-MI p a t i e n t s p a r t i c i p a t e d  i n the study.  Participant  accounts were c o n s t r u c t e d using data c o l l e c t e d depth  i n eleven i n -  i n t e r v i e w s , one c o i n c i d e n t a l meeting, and two  follow-ups.  The data Included f i e l d  t r a n s c r i p t s of the audiotapes. reviewed  telephone  notes and verbatim  The data were c o n t i n u o u s l y  d u r i n g the data c o l l e c t i o n and a n a l y s i s phases.  d e s c r i p t i o n s d e r i v e d from t h i s a n a l y s i s are presented i n Chapter  Four.  The  42 Chapter 4  The P a r t i c i p a n t s '  Accounts  Introduction The accounts of the I l l n e s s experience of f i v e MI p a t i e n t s w i l l be presented i n t h i s c h a p t e r .  Prior to  p r e s e n t i n g the accounts the c h a r a c t e r i s t i c s of the p a r t i c i p a n t s w i l l be d e s c r i b e d .  In the t e l l i n g of t h e i r  s t o r i e s the p a r t i c i p a n t s have recounted the experience from t h e i r own unique p e r s p e c t i v e s with common themes, as w e l l as o c c a s i o n a l c o n t r a s t s , having been I d e n t i f i e d .  These themes  and c o n t r a s t s were used as a framework to present the data In t h i s chapter.  To f a c i l i t a t e t h i s p r e s e n t a t i o n the i l l n e s s  experience accounts have been organized under the f o l l o w i n g headings: MI event; causes of MI; adjustments; concerns  about  damage, p r o g n o s i s , and treatment; and, c a r d i a c e d u c a t i o n , which i n c l u d e d t h a t done by both s e l f and h e a l t h professionals.  characteristics of participants Three males and two females, ranging i n age from 42 to 77 years, participated  i n the study.  The two p a r t i c i p a n t s i n  t h e i r e a r l y f o r t i e s were both male, one was d i v o r c e d and the other s e p a r a t e d , while the remaining three p a r t i c i p a n t s i n  43 their  seventies  language the  other All  grade  12  employed other  a  retired Both  three three and at  both  being  the  a  were  for  C).  had  few  very  study.  Only  problem, their and  Illness had  a  other listed  was  five  as  primary  British  with  the  born  a  and  male  for  supplies  the  was store.  trained  occupation.  working  and  subject  nurses,  for  close  having  men  policeman  hospital  other  two  two  professionally  their a  was  welding  and  the  Of  third  a  nursed  and  listed  problems one  to  many 25  The  years),  women  husband and  had  angina.  a  oral  by  one  were  the  under  demographic  at  previously  many the  time  the  subjects,  with  one  being  the  kidney  removed.  subjects  reported  younger  a  family  sheet  of  diagnosed  The male  the  problems,  of  hypoglycemics. of  little  listed  active  Two  diabetes  very  on t h e  subject  actually  subject  taking  at  age  subjects  had  the  retired.  were  was  being  10.  one  The  having  health  that  cancerous All  one  all  seventies,  the  50  Although  which  of  had  being  one  MI,  job  housewife  with  two  education,  grade  their  years  woman  other  Appendix  of  almost  husband  with  technician.  75  E n g l i s h was  school  having  management  listed  of  high  other time  married.  Canadian.  men h a d  Generally, heading  subjects,  the  married,  other's  five  neither  (one  both  all  hydraulic  women  years  all  from  although  and  o£  were  the  were  in  controlled  only  other  subjects  history  he  heart  who  diet  (see  of  major  who  had  cardiovascular disease f o l l o w i n g ; angina,  i n c l u d i n g one, or more, of the  s t r o k e , MI, or heart f a i l u r e .  The younger  male s u b j e c t s had s t r o n g f a m i l y h i s t o r i e s with both reported t h e i r  f a t h e r s having  f o r t i e s or e a r l y f i f t i e s .  had Mis i n e i t h e r t h e i r  the remaining  the o l d e r male s u b j e c t reported having a f t e r a 30 year  late  The younger male s u b j e c t s were a l s o  smokers a t the time of t h e i r M l . of  ago  having  subjects,  q u i t smoking 21 years  h i s t o r y of heavy smoking, while both women  r e p o r t e d 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 s u b j e c t s  r e p o r t e d t o the researcher  t h e i r p e r c e p t i o n s about the  i n f o r m a t i o n they had r e c e i v e d while  in hospital.  r e c e i v e d and taken home the p u b l i c a t i o n heart a t t a c k .  A l l f i v e had  The heart talk series  Three of the f i v e s t a t e d they had r e c e i v e d d i e t  i n s t r u c t i o n from a d i e t i c i a n while  in hospital.  Only two  s u b j e c t s r e l a t e d r e c e i v i n g any follow-up  from the n u r s i n g  s t a f f on the w r i t t e n m a t e r i a l r e c e i v e d .  A l l reported  having  d i s c u s s i o n s with t h e i r c a r d i o l o g i s t s r e g a r d i n g t h e i r MI, but there was a v a r i a t i o n  i n how i n f o r m a t i v e the s u b j e c t s  these d i s c u s s i o n s had been. subjects*  perceptions  received during t h e i r later  in this  chapter.  felt  Further d i s c u s s i o n of the  regarding  i n f o r m a t i o n r e q u i r e d and  i l l n e s s experience  w i l l be presented  MI Event o£ the f i v e p a r t i c i p a n t s only one had been diagnosed with a p r i o r c a r d i a c c o n d i t i o n , t h e r e f o r e when d e s c r i b i n g the a c t u a l MI event three s u b j e c t s something other  r e l a t e d how they thought  than a heart a t t a c k  was o c c u r r i n g .  ... I d i d n ' t recognize t h i s as being a heart a t t a c k . I thought ah when i t got r e a l l y bad that somehow I'd managed t o c o l l a p s e a lung because t h a t ' s what i t f e l t l i k e was that I was s h o r t of breath and my lungs were burning, ah that I had run a thousand m i l e s , and ah i t never even occurred t o me that i t was the h e a r t . . .  We were having a d r i n k and a p i z z a with our f r i e n d s who l i v e r i g h t near us and f i n e and dandy u n t i l about one o'clock i n the morning and that was when i t s t a r t e d , so I then walked around the house t r y i n g t o get r i d of t h e , what I thought was i n d i g e s t i o n and i t d i d n ' t go away, I t was j u s t as bad i n the morning so we phoned the doctor then.  I t was a t i g h t n e s s but I t was ah gas as f a r as I was concerned, that I couldn't get r i d o f . . .  Two p a r t i c i p a n t s r e l a t e d t h a t they knew they were having heart  attacks.  One s u b j e c t whose f a t h e r had had Mis s a i d he  knew what i t was and that he had t o get h e l p .  ... I knew what i t was ... I don't know why, i t ' s j u s t different. We a l l get headaches and t h i s and t h a t or whatever but there was j u s t something about t h a t , that ya know deep down i n s i d e that uh, you're not going t o be able t o make t h i s go away and ah, you got t o get help ...  46 Even the p a r t i c i p a n t who had p r e v i o u s l y been diagnosed  with  angina d i d not t h i n k a t f i r s t t h a t i t was a heart a t t a c k  until  her symptoms worsened.  ... I knew as soon as I s t a r t e d having the pain i n my arms, which got more, and more, and more, and the pain i n my chest got t i g h t e r , and t i g h t e r , and t i g h t e r , I knew p r e t t y w e l l . In f a c t I think I may even have v o i c e d those words t o my f r i e n d , uhm, so I, I was p r e t t y c e r t a i n that i t was a heart a t t a c k .  A l l s u b j e c t s r e l a t e d a degree of s u r p r i s e , a f t e r out t h a t what had occurred  was a MI.  finding  T h e i r r e a c t i o n s ranged  from s u r p r i s e t o d i s b e l i e f and these r e a c t i o n s were o f t e n shared  with t h e i r  f a m i l i e s and f r i e n d s .  For three of the  s u b j e c t s t h e i r s u r p r i s e was compounded by the f a c t t h a t felt  they  they had been t a k i n g good care of themselves.  ... ya i n terms of people I t h i n k they f i n d t h a t they're s u r p r i s e d ... I mean I'm not l i k e s u p e r b l y f i t or I wasn't before my a c e , my heart a t t a c k but I use t o t r y ya know and ah I guess you t h i n k God damn i t , ya know why me?  Ya, I t h i n k everybody i s ah s u r p r i s e d , not t h a t , I mean I was s u r p r i s e d too because I'm a reasonably a c t i v e person and uh f a i r l y young ...  ... I was i n very good h e a l t h and of course been r a t h e r slender and I think I do a l l the r i g h t t h i n g s and I e x e r c i s e and eat the r i g h t foods, I hope, and, and g e n e r a l l y have taken ah care of myself.  47  Oh w e l l , I was shocked of course and d i d n ' t f e e l w e l l  I d i d n ' t b e l i e v e them, no I d i d n ' t b e l i e v e them. I s a i d no I t h i n k i t ' s gas but they, they t o l d me In no u n c e r t a i n terms you have, I t i s not gas, you're having a heart a t t a c k . So, by t h a t time I guess I was going t o have one, whether I had I t or not.  In c o n j u n c t i o n with t h i s element of s u r p r i s e , four of the s u b j e c t s compared t h e i r s i t u a t i o n described feelings  t o t h a t of others and  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 a t f i r s t , ya know, I use t o think my God what i s t h i s ... t r u c k e r s , 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 I t t h i s way there are a l o t of people t h a t 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 i s one of them and ah he's three years o l d e r , s o .  Ah, the guy, a f r i e n d of mine, gosh he, he should've been underground 50 years ago f o r t h e , he a t e f a t s t r a i g h t out of the pan.  ... I s a i d t o a f r i e n d the other day t h e r e ' s no j u s t i c e , I've done a l l these t h i n g s , i n f a c t a v e r y dear f r i e n d of mine, ... she's f a r too heavy, and loves a l l the r i c h , r i c h , r i c h t h i n g s and she says you do a l l the r i g h t things . . .  48 The response  t o the emergency admission to h o s p i t a l  v a r i e d among the s u b j e c t s . s e c u r i t y and r e l i e f  Three s u b j e c t s f e l t a sense of  to be t h e r e .  P r e t t y s a f e a c t u a l l y , a l l In a l l , I f e l t as though I was i n good hands. And there were people that r e a l l y knew what they were doing ...  ... I d i d n ' t have much time t o worry about a n y t h i n g out there [ h o s p i t a l ] but ah I knew I was i n a p l a c e where I would get a t t e n t i o n .  I was very r e l i e v e d t o be there [ h o s p i t a l ] , to be i n somewhere, you know, t o have somebody around t h a t c o u l d make i t a l i t t l e b i t e a s i e r f o r me.  The  remaining two s u b j e c t s were bewildered by, or c o u l d n ' t  remember, what took place In the h o s p i t a l d u r i n g 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 a f t e r that ...  Being d i s c h a r g e d from h o s p i t a l a l s o evoked d i f f e r e n t responses  from the s u b j e c t s .  For some i t was a nervous  time  where the f e a r of having  another heart a t t a c k was p r e v a l e n t .  uhmm, oh i t was p r e t t y s c a r y a c t u a l l y ya know, uh l i k e t o be out of t h a t h o s p i t a l and t o be away ya know from a l l the equipment ... you t h i n k w e l l uhmm oh gees what i f anything happens ya know what am I going t o do ... j u s t 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 t a k i n g care o f , and you're suddenly s o r t of ah on your own and I t h i n k I was a l i t t l e b i t nervous t h a t , would I have another heart a t t a c k ... t h a t was with me q u i t e a b i t i n the beginning and i t ' s c e r t a i n l y i s n ' t anything l i k e , so much now ...  For others coming home h e l d no f e a r and they were g l a d t o be there.  ... I was comfortable i n as much as I d i d n ' t t h i n k I was going t o come home and d i e O.K., uh I would've been comfortable i f they'd r e l e a s e d me ah, a week e a r l i e r i n that regard ...  Well,  The  I was g l a d t o get home ...  impact the MI experience  had on the p e r s o n a l  l i v e s of  the s u b j e c t s 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 t o make changes i n h i s l i f e .  ... I j u s t f e e l r e a l l y l u c k y t h a t I've been given a warning and p o t e n t i a l l y t h a t i f I r e a l l y watch myself I ' l l be O.K.  ... I j u s t f e e l the urge now t h a t I want to change my l i f e a l o t , ya know I , i n terms of my j o b as w e l l , and ah j u s t get some t h i n g s done t h a t I haven't done ...  For two of the o l d e r s u b j e c t s the impact was minimal. T h i s might be a s e r i o u s problem, i t ' s hard t o say, but I don't r e a l l y think i t ' s t h a t s e r i o u s , but I'm not going to worry about i t ...  It hasn't r e a l l y thrown me t h a t much I don't t h i n k . t h i n k I ' l l come back a l l r i g h t ...  I  One man's response r e f l e c t e d somewhat h i s personal philosophy an  about l i f e .  He d i d not foresee the heart a t t a c k as  impetus f o r many changes i n h i s l i f e .  make some concessions  regarding  He was w i l l i n g to  h i s d i e t and e x e r c i s e but he  was not prepared t o be f a n a t i c a l about e i t h e r because as he saw  i t there would be no guarantees.  ... I have a reasonable amount of f a i t h t h a t ah ya know, t h a t ah t h i s i s going t o be something t h a t ah I go through and ah e v e n t u a l l y get b e t t e r and ah ya know i f He decides t h a t ah I , I'm coming home then o b v i o u s l y I'm going t o have to go but ah there's not much I can do about i t , one way, or another.  The  two s u b j e c t s who f e l t the MI had Impacted a great  d e a l on t h e i r  l i v e s a l s o r e l a t e d having  days where they were  down or b l u e . ... the odd day i t ' s s t i l l  s o r t of gets me down a l i t t l e .  51 ... I j u s t f i g u r e i t ' s something t h a t I have t o come t o terms with and uhm, i t ' s me t h a t ' s going t o do i t and nobody e l s e , ya know ...  ... I thought i t would be you j u s t , 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 b l u e r than others and the days t h a t I'm blue I n o t i c e are r e l a t e d t o my energy f e e l i n g s .  The  Mi's most s i g n i f i c a n t  p h y s i c a l nature,  impact appeared t o be of a  as a l l f i v e s u b j e c t s reported a notable  decrease i n t h e i r p h y s i c a l stamina.  I d i d n ' t have any stamina, ... ya t h a t ' s what I n o t i c e d , how q u i c k l y I l o s t a l l t h a t ...  ... but r i g h t now I don't seem t o be able t o 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 t h a t I have t o go and s i t down f o r awhile ...  lately  ... the f i r s t few days a t home, when I f e l t a b s o l u t e l y grim, ya know I j u s t wasn't up t o t h a t [ s t r e t c h i n g and walking] ...  These r e p o r t s of f e e l i n g p h y s i c a l l y l i m i t e d continued t o be expressed by most s u b j e c t s  I f e e l I guess l i m i t e d  i n subsequent  interviews.  ... 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 f a v o r i n g t h i n g s ya see, uh I'm not doing what I think i s beyond what I can do.  One woman f e l t her l i m i t a t i o n s r e f l e c t e d where she was i n her recovery  and t h a t with time she would f e e l  better.  I'm perhaps l i m i t e d but ah, a f t e r a l l i t ' s not even two months y e t ya know. So, I think t h a t ah another couple of months I'm, ya know, may f e e l d i f f e r e n t l y even.  The  MI event a l s o appeared t o have an impact on the  s u b j e c t s and t h e i r c o n t a c t  with f a m i l y members.  For some I t  was demonstrated In a d e s i r e t o see t h e i r f a m i l i e s , or i n their  f a m i l i e s d e s i r e to see them.  ... t h a t was the f i r s t t h i n g , w e l l ya know other than my own s e l f s u r v i v a l , uh t h a t was the, the f i r s t t h i n g that came t o mind t h a t , t h a t n i g h t was that I want t o see her [daughter] a g a i n , l i k e r i g h t now, and uh i t , when she came over then, i t was d i f f i c u l t f o r me, f o r me t o see her go o f f again ...  ... the f a m i l y a l l came to see me and I wasn't t o sure ah why they were a l l there except that I must be kind of seriously sick.  ... he [brother] s a i d , w e l l ya know I f we hadn't been coming on J u l y 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 s o .  One man with a younger f a m i l y delayed u n t i l he had been s t a b i l i z e d  seeing h i s c h i l d r e n  in hospital.  ... I made the d e c i s i o n , I d i d n ' t want them to see me when I was hooked up t o , ya know e v e r y t h i n g and I guess i t was the ah, the r i g h t t h i n g ... by the time she [daughter] saw me I, I t h i n k I j u s t had the one Intravenous i n uhm and I t h i n k ya know she r e l a x e d a l i t t l e b i t a f t e r t h a t ...  In g e n e r a l , a l l s u b j e c t s r e p o r t e d t h e i r f r i e n d s as being s u p p o r t i v e those  f a m i l i e s and  throughout the experience.  s u b j e c t s who were married  the support  For  of t h e i r spouses  was e v i d e n t .  Thank goodness we grow o l d together ... i f you're alone now t h a t would be a whole l o t d i f f e r e n t s t o r y ...  ... i t ' s a 50/50 p r o p o s i t i o n r i g h t down the c e n t e r , so there's t r u s t , and t h e r e ' s l o v e , and there's what have you ...  ... my husband's been tremendously h e l p f u l and my neighbors have ya know, been r e a l l y tremendous ...  There were two s u b j e c t s not married  a t the time of t h e i r Mis  One f e l t t h a t going through the experience  without  a spouse  made him f e e l the importance of a good r e l a t i o n s h i p .  . b u t  a c t u a l l y a t t h e time o£ the h e a r t a t t a c k t h a t ' s  when I f e l t gees I wish I was married, ya know ... I wish there was somebody t h a t was r i g h t there with me ...  The  other unmarried  s u b j e c t who d e s c r i b e d h i m s e l f as a loner  d i d not f e e l he lacked support even though he was  living  alone.  ... I guess uh everybody i s , i s ah p u l l e d together on t h i 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 s u b j e c t the f a m i l y pets were seen as being a positive  i n f l u e n c e and support  i n the p e r i o d f o l l o w i n g her MI.  i t ' s b e c a u s e a dog, i t d o e s n ' t t a l k back, they're your best f r i e n d , and v e r y t r u l y they a r e , ah so t o l e r a n t of you and they a l l o w you to pet them, they don't care what you do r e a l l y f o r them as long as you feed them.  Both women i n the study viewed t h e i r  f a m i l i e s as  s u p p o r t i v e but there a l s o appeared t o be e x p e c t a t i o n s placed upon them d u r i n g r e c o v e r y by t h e i r  families.  So, t h e y ' l l [sons and husband] a l l be watching me and they a l l walk and e x e r c i s e and swim and e v e r y t h i n g e l s e so they're not going t o l e t me s i t around too much without doing what I'm t o l d .  But he [husband] wants me t o do a l l the t h i n g s t h a t I'm supposed t o do of course, he doesn't want me s i t t i n g around i n the bed a l l day long and I don't want t o  55  either.  i n summary, the occurrence  of a MI f o r the s u b j e c t s i n  t h i s study was an u n a n t i c i p a t e d event which gave r i s e to a range of f e e l i n g s from s u r p r i s e t o d i s b e l i e f . the s u b j e c t s expressed MI. and  a degree of i n j u s t i c e a t having  Three of the s u b j e c t s considered safe place to be.  discharge  A m a j o r i t y of had a  the h o s p i t a l a secure  For two s u b j e c t s being a t home a f t e r  from h o s p i t a l was i n i t i a l l y a nervous time i n which  they feared having another MI. The  impact the MI had on the s u b j e c t s ' p e r s o n a l  depended on how they viewed the event.  lives  The s u b j e c t s '  responses v a r i e d from a minimal a f f e c t t o an impetus f o r change.  For two s u b j e c t s the MI had an e f f e c t on  psychological wellbelng, blue.  i n t h a t some days they f e l t down or  A decrease i n energy appeared t o be of s i g n i f i c a n c e In  the p h y s i c a l recovery  of the s u b j e c t s , with  l i m i t a t i o n s being expressed  f e e l i n g s of  by some s u b j e c t s weeks a f t e r the  MI. G e n e r a l l y , the s u b j e c t s viewed t h e i r as being s u p p o r t i v e being  of s i g n i f i c a n t  study.  throughout the MI experience, importance t o the married  with  spouses  s u b j e c t s In the  Both of the female s u b j e c t s p e r c e i v e d t h e i r f a m i l i e s  as having recovery  f a m i l i e s and f r i e n d s  c e r t a i n expectations period.  f o r the s u b j e c t d u r i n g the  56  Causes of MI The you  responses t o the q u e s t i o n  "what do you t h i n k caused  t o have a MI?" v a r i e d with each p a r t i c i p a n t .  The two  younger men i n the study acknowledged the f a m i l y tendency i n the course  of t h e i r  i n t e r v i e w s but n e i t h e r r e l a t e d i t as a  f a c t o r when asked the q u e s t i o n as above. were considered  Lifestyle practices  major c o n t r i b u t i n g f a c t o r s , with one man  c o n s i d e r i n g them as f a c t o r s but unsure as t o the extent of their influence.  Uhmm, j u s t my l i f e s t y l e . The way I uhm, j u s t not watching what I was doing ya know not, not watching what I was e a t i n g , smoking ... e x e r c i s e I think I was reasonably good a t but i t was j u s t too much of the other s t u f f ... I t h i n k t h a t was probably the two ah, two biggest things.  ... I've been t o l d what e f f e c t s t r e s s has but I don't know how long ah, or how much s t r e s s i t would take i n order t o c r e a t e the problem that I have. ... I don't know what p r o p o r t i o n of ah my smoking ah would do t o i t ... I mean o b v i o u s l y I can vary my d i e t ah which i s no problem, I can stop smoking t h a t doesn't appear t o be any problem, uhm s t r e s s i s going to be something e l s e . ... I f I can e l i m i n a t e the two out of the three ah or c u t them down, o b v i o u s l y I think t h a t I ' l l be b e t t e r o f f f o r i t ...  The  three o l d e r s u b j e c t s whose r i s k  diabetes, hypertension,  factors included  angina or being overweight gave other  reasons f o r t h e i r MI.  I guess I I n h e r i t e d a c e r t a i n amount of i t i f ah,  if  57  t h a t ' s p o s s i b l e from my, my mother ... I don't know why I had a heart attack r e a l l y unless t h a t c h r o n i c a ah, noise and, and whatever showed up on that cardiogram was something t o do with ah, from b i r t h . I don't know t h a t , no one ever suggested i t , I j u s t s o r t of thought about that a f t e r I had the a t t a c k ...  The only t h i n g t h a t I can think of ah t h a t c o n t r i b u t e d t o i t was p o s s i b l y s t r e s s that I d i d n ' t know I had and ah, maybe too much s a l t ...  The  t h i r d o l d e r s u b j e c t expressed disappointment  In h e r s e l f  because she f e l t pushing h e r s e l f t o hard may have caused her to have the MI.  I don't know what t o answer t o t h a t r e a l l y . I'm d i s g u s t e d with myself of course. ... I don't f e e l very happy with myself about i t . No, I'm not d i s g u s t e d with myself, t h a t ' s a b i t too s t r o n g , but I, I'm, I'm s o r r y i t happened. ... I j u s t d i d have a f e e l i n g t h a t I was pushing myself a b i t too much so, ya know, maybe t h a t ' s , maybe I j u s t d i d push too much.  Another l i f e s t y l e component o f t e n mentioned by the s u b j e c t s was s t r e s s .  For some s t r e s s was viewed as a d i r e c t  cause of t h e i r MI, as noted i n some of the previous while f o r the others their  quotes,  i t was viewed as a f a c t o r present i n  lives.  I think I , I handle i t [ s t r e s s ] r e a l l y w e l l but i t ' s j u s t that a t that p a r t i c u l a r time [going through d i v o r c e ] I d i d n ' t and uhm ya, and as I say ya know I got my c i g a r e t t e s way up there and I j u s t d i d n ' t b r i n g them down again.  58 ... I never r e l a x , never r e l a x ... I've always been t h a t way ever s i n c e I was very, very small ... t h a t ' s why i t doesn't s u r p r i s e me t h a t i t , t h i s may be s t r e s s , i t may not be d i e t a t a l l ...  ... you can't r a i s e a f a m i l y and run a great b i g house without some s t r e s s and I had i t ...  Ah, w e l l ya, s t r e s s i s not the g r e a t e s t t h i n g and I , you can have s t r e s s and not even know i t , and of course i n my work I , I guess I had q u i t e a b i t of s t r e s s a t t h a t , but you don't r e a l i z e ya got s t r e s s , a t l e a s t I d i d n ' t .  ... I'm sure i t [ s t r e s s ] comes Into almost everybody's l i f e i n some kind of way, whether i t r e s o r t s t o a heart a t t a c k I don't know, but uhm I'd l i k e t o say 'no' to t h a t but I'm sure t h a t , t h a t there probably i s an element of that ... In a s s o c i a t i o n with t h e i r d i s c u s s i o n s about s t r e s s i n t h e i r l i v e s three or  s u b j e c t s a l s o used terms such as ' p e r f e c t i o n i s t '  'worry wart' when d e s c r i b i n g themselves. In summary, the s u b j e c t s  i n t h i s study c i t e d such  things  as d i e t , smoking, s t r e s s , f a m i l y tendency, and pushing too hard as p o s s i b l e causes of t h e i r MI. subjects  s t r e s s was a l i f e s t y l e  c u r r e n t l y present,  As w e l l , f o r a l l  f a c t o r t h a t was e i t h e r  or had once been a p a r t of t h e i r  lives.  Adjustments In d e s c r i b i n g t h e i r day-to-day r o u t i n e s u b j e c t s  reported  59 adjustments they had made or were planning t o make i n t h e i r lifestyles.  Four of the f i v e s u b j e c t s s t a t e d they had used  the MI book The heart t a l k s e r i e s heart attack r e c e i v e d In h o s p i t a l as a guide i n making these adjustments.  As w e l l , a l l  s u b j e c t s r e p o r t e d r e c e i v i n g some i n s t r u c t i o n from t h e i r c a r d i o l o g i s t before make i n t h e i r  l e a v i n g h o s p i t a l on changes they were t o  lifestyles.  Four of the s u b j e c t s were making some changes i n t h e i r diet.  Three of the four were f o l l o w i n g d i r e c t i o n s they  r e c e i v e d from d i e t i c i a n s while  i n the h o s p i t a l .  The f o u r t h  s u b j e c t had been r e f e r r e d t o a d i e t i c i a n a f t e r d i s c h a r g e  from  h o s p i t a l when i t was found t h a t h i s c h o l e s t e r o l l e v e l was elevated.  T h i s was the only s u b j e c t aware of having  cholesterol level. cholesterol range.  a high  The only other s u b j e c t who knew what h i s  l e v e l was had been t o l d h i s was w i t h i n normal  Most of the s u b j e c t s p e r c e i v e d t h e i r d i e t changes as  amounting t o the d e l e t i o n of one or two t h i n g s from t h e i r diet.  ... ah s a l t ya I , I'm c u t t i n g out the s a l t ah ... and she's [wife] c u t down on the s a l t on the cooking a b i t  ... I w i l l c u t down and on the f a t and t h a t s o r t of s t u f f uh I don't know i f I can c u t down on s a l t s i n c e I don't use i t uhmm I suppose I c o u l d c u t down on the amount of taco c h i p s or whatever but t h a t s o r t of t h i n g , I'm not a b i g eater of t h a t s o r t of s t u f f anyway uh but ah when I went over my d i e t 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 d i e t i s ah v e r y low f a t , and low sugar, and low s a l t , you see ...  I'm c a r e f u l about v i s i b l e f a t ya know and I guess when I see s t u f f l i k e t h a t ya know I do back away from i t ... but I was s u c k e r i n g myself Into the, the hidden s t u f f ...  The s u b j e c t s q u a l i f i e d t h e i r d i e t changes somewhat with statements of l i m i t a t i o n e i t h e r of a p e r s o n a l nature, or of what they i n t e r p r e t e d from i n s t r u c t i o n  received.  ... I don't have to c u t out s a l t completely so when I've been making p o r r i d g e the l a s t two days I've put j u s t a l i t t l e dash of s a l t i n , t a s t e s a l o t b e t t e r ...  [ P a r t i c i p a n t ' s spouse] W e l l , Dr. X says she doesn't want him [husband who i s the s u b j e c t i n the study] t o change the ah ... change too much because she says sometimes i t does more harm than good ...  ... but the, the b i g t h i n g I t h i n k i s , I d i e t and ah I'm c e r t a i n l y prepared to go not ya know, i f I want a p i z z a and beer, happen t h a t o f t e n , but i f I want one I'm it.  t h i n k i s the h a l f way but I'm which doesn't going t o have  Two s u b j e c t s had been i n s t r u c t e d t o lose weight and d u r i n g the time of follow-up i n 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  o n l y s u b j e c t not making any d i e t changes viewed her d i e t  to be c o n s i s t e n t with what was suggested i n the MI book. The  s u b j e c t s follow-up  post Ml Included  scheduled  appointments with t h e i r a t t e n d i n g c a r d i o l o g i s t s , and v i s i t s or telephone dictated.  c a l l s to their  T h i s method of follow-up d i d not c r e a t e a problem  for four of the s u b j e c t s . scheduled  f a m i l y p h y s i c i a n as I n d i v i d u a l needs  However, f o r one man, who was  f o r an a n g i o p l a s t y a t 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 p h y s i c i a n s l e d t o s e v e r a l  misunderstandings e s p e c i a l l y i n the p r e s c r i b i n g of medications.  T h i s s u b j e c t was somewhat confused  should have been  over how t h i s  coordinated.  And I , I don't know ah who was suppose t o c o o r d i n a t e but there should be somebody I would t h i n k .  that  T h i s i n c i d e n t l e d the s u b j e c t t o c e r t a i n c o n c l u s i o n s about f u t u r e h e a l t h care s e r v i c e s .  ... I don't know what the answer i s but I ' l l t e l l you one t h i n g i s t h a t I probably would not want Dr. X t o do i t ... I t h i n k I ' l l be going t o X H o s p i t a l the next time i f there i s one. ... Well, I j u s t don't want something l i k e t h i s happening again t h a t ' s a l l , i t r e a l l y made me nervous ...  G e n e r a l l y , the s u b j e c t s s t a t e d they f e l t prepared with the p o s s i b l e recurrence  of chest p a i n .  Following  to deal  d i s c h a r g e from h o s p i t a l four of the s u b j e c t s experienced episodes of chest p a i n which d i d r e q u i r e them t o use t h e i r nitroglycerine.  The number of episodes f o r each s u b j e c t  v a r i e d , from one episode s i n c e being d i s c h a r g e d , t o one with almost every walk.  One s u b j e c t was readmitted t o h o s p i t a l  j u s t one week a f t e r h i s i n i t i a l d i s c h a r g e because of an episode of chest p a i n .  ... i t f e l t l i k e angina p a i n but, but t o be honest with you I can't be r e a l l y sure and uh I took a couple of n i t r o s and uhmm I don't know i f i t was panic or what, but I s t a r t e d t o get a steady p a i n i n my c h e s t . Uhmm, I guess I wasn't c o n f i d e n t enough t o j u s t s o r t of s i t i t out and I thought w e l l t a heck with i t I'm going back up there [ h o s p i t a l ] ...  T h i s same s u b j e c t , l a t e r  i n h i s r e c o v e r y , experienced  episode of chest p a i n which he s u c c e s s f u l l y t r e a t e d  another  with  n i t r o g l y c e r i n e a t home. The s u b j e c t s r e p o r t e d t h a t they c a r r i e d nitroglycerine p i l l s  their  or spray with them f o r the most p a r t .  One s u b j e c t , when he r e a l i z e d d u r i n g an o u t i n g t h a t he had left  h i s n i t r o g l c e r i n e p i l l s a t home, went to the d r u g s t o r e  and purchased  another  bottle.  I n c o r p o r a t i n g medications present a problem  i n t o the d a i l y r o u t i n e d i d not  f o r the s u b j e c t s g e n e r a l l y .  The one married  man i n the study r e p o r t e d t h a t he would not have remembered his  afternoon p i l l  i f not f o r h i s w i f e , a t which time she  informed the r e s e a r c h e r that she l a i d out h i s p i l l s every day and made sure he took them.  f o r him  One man was d i s c h a r g e d  on w a r f a r i n which i n i t i a l l y r e q u i r e d him to go f o r blood t e s t s twice a week, t h i s was l a t e r c u t down t o once a week and eventually discontinued.  The w a r f a r i n dose was a d j u s t e d by  the f a m i l y p h y s i c i a n based was  on the t e s t r e s u l t s .  The s u b j e c t  c o n t a c t e d by phone i f there was a change to be made In the  dosage.  Other adjustments  In medications were g e n e r a l l y made  by the a t t e n d i n g c a r d i o l o g i s t without d i f f i c u l t y , except f o r the s u b j e c t p r e v i o u s l y mentioned who had had a misunderstanding  with the medications p r e s c r i b e d because two  c a 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  i n his care.  Both men who had been smokers a t the time of t h e i r MI had q u i t smoking while i n h o s p i t a l .  Although n e i t h e r had resumed  smoking both r e p o r t e d having the o c c a s i o n a l urge which, so far,  they had been a b l e t o r e s i s t . C e r t a i n housekeeping  a c t i v i t i e s presented o b s t a c l e s f o r  some s u b j e c t s , thus r e q u i r i n g them t o make adjustments. of  the s i n g l e men i n i t i a l l y  found shopping  One  for groceries  tiring.  ... i t ' s never occurred t o me before because I guess ya know i t j u s t gets done so q u i c k l y was shopping a t the s t o r e , ... I n o t i c e d how q u i c k l y I became t i r e d and uh s t a r t e d t o f e e l l i g h t headed, uh t h i s was the f i r s t weekend I guess when I got out, and so t h a t I j u s t s a t the basket on the f l o o r and walked s l o w l y around and picked up s t u f f and put i t i n the basket ...  The other s i n g l e man, because he could not d r i v e h i s c a r , r e p o r t e d g r o c e r y shopping as an inconvenience and he found i t demeaning t o have t o depend on other people.  ... i t ' s a l i t t l e demeaning i n as much as I have t o b a s i c a l l y depend on other people ya know t o d r i v e me up there [ g r o c e r y s t o r e ] but ah i t hasn't r e a l l y been a major problem I j u s t don't l i k e t o depend on other people that's a l l .  N e i t h e r of the s i n g l e men r e p o r t e d any s p e c i f i c  concern  about doing housework or cooking but both a l s o appeared t o have r e t u r n e d t o other pre-MI a c t i v i t i e s more q u i c k l y than the other s u b j e c t s i n the study.  One man was a l r e a d y d r i v i n g h i s  car and had r e t u r n e d t o work p a r t - t i m e a t the time of h i s first  i n t e r v i e w , o n l y three weeks a f t e r d i s c h a r g e from  hospital.  The other man, who s t a t e d he was not f a n a t i c a l  about housework, r e p o r t e d f o l l o w i n g the g u i d e l i n e s f o r i t l a i d out i n the MI book. Both women i n the study r e p o r t e d t h e i r husbands a s s i s t i n g with some household chores such as the laundry and i n one s u b j e c t ' s case, her husband had taken over the cooking and shopping as w e l l .  These s u b j e c t s had domestic h e l p come t o do  t h e i r heavy housework p r i o r t o having t h e i r MI and they found t h i s t o be v e r y h e l p f u l t o them f o l l o w i n g t h e i r MI.  However,  f o r one woman the managing of the household and t h i n g s 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 d i d n ' t f e e l very w e l l p h 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 c l e a n i n g l a d y who's o n l y been coming once every two weeks but i n p o i n t of f a c t has come every week s i n c e , uhm s i n c e I've got home, which i s a great r e l i e f ... so, what I've been doing of course Is t a k i n g care of the meals and uhm a l i t t l e b i t of shopping, a l o t of my f r i e n d s and neighbors have helped me a g r e a t d e a l , some I've gone with the odd time, which I haven't enjoyed too much, ... i s almost too much f o r me ... I j u s t f i n d I t ah a f t e r being to the bank and going to there [ s t o r e ] f o r a few minutes I was r e a l l y g l a d t o be home.  T h i s s u b j e c t r e p o r t e d she accepted help o f f e r e d by her and by spreading the jobs out amongst them she had comfortable with a c c e p t i n g t h i s h e l p . second  friends  f e l t more  By the time of the  i n t e r v i e w both women r e p o r t e d doing more around the  house but s t i l l  expressed  g r a t i t u d e f o r having h i r e d  domestic  h e l p to do the heavy work. As p r e v i o u s l y mentioned the r e t u r n t o 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 r e c r e a t i o n a l , was s u b j e c t s i n t h i s study.  slower  For the younger s u b j e c t s t r i p s  outings d i d not present a problem, with one man a three week t r i p to England. t h e i r s e v e n t i e s appeared  f o r the o l d e r and  even going  on  However, those s u b j e c t s i n  c a u t i o u s In resuming some a c t i v i t i e s  even s i x to e i g h t weeks a f t e r d i s c h a r g e from  hospital.  ... I haven't been out anywhere e l s e . Although, I'm going t o a wedding on, t h i s Saturday, and ah but f o r a while I thought I wouldn't go but I've turned down e v e r y t h i n g e l s e . ..  66 We've been down [ t o t h e i r c o t t a g e ] f o r the day and back but ah t o check t h i n g s out but t h a t ' s ah, t h a t ' s the f i r s t time we stayed down.  ... I'm s t i l l a t the stage where I'm q u i t e happy to be uhm ya know l e a d i n g a q u i e t l i f e , f a i r l y q u i e t l i f e . But tomorrow i s , tomorrow i s ah our wedding a n n i v e r s a r y so my husband and I are going t o the f a c u l t y c l u b f o r dinner ... t h a t ' s s o r t of a major o u t i n g cause we haven't been out t o dinner ...  Two of the three o l d e r s u b j e c t s f e l t they had slowed down before  t h e i r Mis.  ... I'm slowed down anyway, before t h i s ever I was slowed down.  happened  ...my l i f e s t y l e wasn't ah such t h a t we were on the go a l l the time, even when we're down t o the Bay we s t i c k around p r e t t y w e l l . 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 s e n i o r s u b j e c t r e l a t e d t h a t she would have t o change  her busy l i f e  and had decided  t o stop some a c t i v i t i e s ,  c h o r a l s i n g i n g , but was not upset  like  about t h a t .  ... I'm q u i t e happy t o l i s t e n and ah ya know j u s t s o r t of cut back on t h i n g s a l i t t l e b i t , which doesn't mean t h a t I don't do i n t e r e s t i n g t h i n g s a t a l l , so. Oh, I t h i n k there comes a time i n everybody's l i f e when some t h i n g s have t o be g i v e n up, s o .  These s u b j e c t s appeared t o have considered examining adjustments t o t h e i r two  lifestyle  t h e i r age when  f o l l o w i n g MI and f o r  of them some adjustments had a l r e a d y been made.  ... those t h i n g s had t o change, we j u s t c o u l d n ' t , we knew we had p h y s i c a l l y t o stop some of t h a t c a r r y on, when you get t o be t h a t age you do.  ... the main reason was because when you get t o 77 ya g o t t a 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 t o have t h a t , and ah i f something happened t o me she'd have i t a l l t o do.  However, t a k i n g these s u b j e c t s '  life  three  not resumed what they  s e n i o r s u b j e c t s had s t i l l  considered  stages i n t o account the  t o be t h e i r normal s o c i a l and r e c r e a t i o n a l  a c t i v i t i e s s i x t o e i g h t weeks a f t e r  t h e i r Mis.  Another adjustment o n l y expressed by the three subjects,  older  In r e l a t i o n to the resumption of a c t i v i t i e s , was  t h e i r d e s i r e t o l i s t e n t o what t h e i r bodies t o l d them when i t came t o t h e i r p h y s i c a l  limitations.  ... In other words I'm t a k i n g care, c a r . , ah be, t r y i n g to be c a r e f u l of what I do and how long I do i t . She [doctor] s a i d t o go a c c o r d i n g t o what your body t e l l s ya and I've been t r y i n g t o do j u s t t h a t . ... you see i n 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 t o be s i c k your body warns you, then's your time t o 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 i n the study was d e v e l o p i n g the a b i l i t y t o say "no" t o a c t i v i t i e s they d i d not f e e l capable  of d o i n g .  T h i s appeared t o be a new  o p t i o n for them f o l l o w i n g t h e i r MI.  ... I don't think I want t o go t o e v e r y t h i n g , although I hate being a crybaby and s a y i n g I can't come, never have done t h a t , but ah you can't a l s o be a good ol'soak and say oh sure I ' l l be there whenever they say because t h a t i s what s t r e s s e s you out sometimes ...  ... i t has made me f e e l ah t h a t I can say 'no' t o t h i n g s and ah I don't want t o do t h a t , or I can't go, or whatever i t may be uhm before I d i d n ' t f e e l t h a t was uhm a t h i n g t h a t I wanted t o do.  Returning t o the a c t i v i t y of d r i v i n g a c a r was i n f l u e n c e d by each p a r t i c i p a n t ' s d e s i r e and the n e c e s s i t y of doing s o . Most s u b j e c t s were t o l d not t o d r i v e f o r a t l e a s t s i x weeks and  f o r one woman, who had g i v e n up her c a r the year  and whose husband s t i l l  before  drove, t h i s was not an adjustment.  For the two younger s u b j e c t s not being able t o d r i v e was inconvenient and one r e t u r n e d t o d r i v i n g s h o r t l y d i s c h a r g e from h o s p i t a l .  after  The married man had not returned t o  d r i v i n g even a f t e r the s i x week mark and s t a t e d he d i d not see  the need t o s i n c e h i s wife was a b l e to d r i v e . s u b j e c t was anxious  t o be able t o d r i v e because her husband  was a n o n - d r i v e r , y e t she was apprehensive after  The remaining  about d r i v i n g  even  w a i t i n g s i x weeks. All  s u b j e c t s had made an e f f o r t t o f o l l o w a d a i l y  e x e r c i s e r o u t i n e of walking and f o r most t h i s was the f i r s t organized e x e r c i s e they had done i n y e a r s .  The married  s u b j e c t s were o f t e n accompanied by t h e i r spouses when they went f o r t h e i r walks. schedules  throughout  The s u b j e c t s maintained  their  walking  the time they were f o l l o w e d f o r t h i s  study. Only two s u b j e c t s were working a t the time of t h e i r MI. One man d i d not have s i c k  b e n e f i t s and t h e r e f o r e returned t o  work on a part-time b a s i s three weeks a f t e r hospital.  He was then l a i d  discharge  o f f from h i s job because of a  slump In business but l a t e r returned t o f u l l in a new j o b .  from  time  employment  However, t h i s s u b j e c t viewed h i s MI as being an  impetus t o change h i s c a r e e r , subsequently  went through  career  c o u n s e l i n g , and was p l a n n i n g t o s t a r t n i g h t courses a t a community c o l l e g e .  ... of course i t ' s come down t o r e a l i t y , the s t u d y i n g and a l l the r e s t of i t but no, I d e f i n i t e l y uhm s t i l l want t o change ah some t h i n g s i n my l i f e and I'm going t o do i t , and t h a t ' s f o r sure, hah.  70 The had  other s u b j e c t , a t h i s i n i t i a l  i n t e r v i e w , s t a t e d he  not been t o l d when he would be able t o r e t u r n t o work.  Although f i n d i n g out when he c o u l d go back to work appeared to be h i s foremost concern, for  i t d i d not c r e a t e a f i n a n c i a l worry  him because he had s i c k b e n e f i t s .  first  At the time of the  i n t e r v i e w he was a w a i t i n g the r e s u l t s of a t h a l l i u m  s t r e s s t e s t t o determine i f an a n g i o p l a s t y would b e n e f i t him. T h i s s u b j e c t d i d undergo a n g i o p l a s t y but he was h e s i t a n t t o go back t o work even when t o l d he c o u l d do so by a c a r d i o l o g i s t . He expressed  concern about h i s job being s t r e s s f u l ,  especially  over the summer with people on h o l i d a y s , and he wanted to take the summer o f f .  ... I know t h a t going t o September ah i s s t r e t c h i n g i t but ah the o n l y other, other a l t e r n a t i v e would be to have me go back t o work t o some other job u n t i l September ah which i s ah p o s s i b i l i t y ...  Approximately three months f o l l o w i n g h i s MI the s u b j e c t d i d i n f a c t r e t u r n t o work i n another p o s i t i o n p a r t - t i m e ,  but only  for  two weeks.  for  every h a l f day he worked he was being deducted a h a l f a  day  i n s i c k time so he decided  off.  The s u b j e c t r e p o r t e d he found i t t i r i n g and  t o take the r e s t of the summer  His f a m i l y p h y s i c i a n d i d not f e e l t h i s was necessary and  the s u b j e c t was informed  t h a t he would have to make h i s own  arrangements with the o c c u p a t i o n a l h e a l t h doctor a t h i s p l a c e  of employment. The o c c u r r e n c e of a Ml r e q u i r e d the s u b j e c t s t o 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 p a i n , i n c o r p o r a t i n g medications i n t o a d a l l y r o u t i n e , a d j u s t i n g the running of t h e i r households, adding a walking r o u t i n e , and f o r two s u b j e c t s the c e s s a t i o n of smoking. s u b j e c t s appeared  Although the s e n i o r  t o have made some adjustments  in their  l i f e s t y l e s p r i o r to having a MI t h e i r r e t u r n to s o c i a l and r e c r e a t i o n a l a c t i v i t i e s was slower than the younger s u b j e c t s i n t h i s study.  For the women In the study having a MI made I t  e a s i e r f o r them t o say "no" i n s i t u a t i o n s where they d i d not want to do some a c t i v i t i e s .  Returning t o work was not a  smooth t r a n s i t i o n f o r e i t h e r of the men employed a t the time of t h e i r MI.  Concerns About Damage, Prognosis and Treatment Only one s u b j e c t was aware of the amount of damage to h i s h e a r t because  while i n h o s p i t a l r e c u p e r a t i n g from h i s MI he  had undergone an angiogram e x p l a i n e d t o him.  and the r e s u l t s of t h i s had been  The other s u b j e c t s i n the study expressed  concern over not knowing the extent of the damage and I t was something about.  they had asked or planned t o ask t h e i r  cardiologist  72 I, I want t o know e x a c t l y , w e l l I don't know how p r e c i s e they can be about t h i s , but I want t o know how he [ c a r d i o l o g i s t ] knows what part of my heart i s damaged. I want t o know how much i s damaged. I want t o know the exact r e s u l t s of the t h a l l i u m t e s t . I want t o know what they found, was there any r e s t r i c t i o n s . Uh, I j u s t want to know a l o t more about what happened to me and where e x a c t l y I stand.  ... I don't even know the extent of the damage. ... Ya, she [ c a r d i o l o g i s t ] s a i d , you had a damn b i g heart a t t a c k and t h a t ' s a l l and not gas. So, w e l l but no, I d i d n ' t get any ah answers on.., I don't think they know unless they ah put you through some kind of ah, a dye d e a l .  ... I don't remember having any idea of how much damage there was ... I don't know, I hope t o know more about i t really. I don't know whether i t ' s , some d o c t o r s are not c r a z y about g i v i n g too much i n f o r m a t i o n away but I would l i k e to know.  In r e l a t i o n t o t h i s concern about the extent damage most of the s u b j e c t s  of the  a l s o expressed a n x i e t y over what  to expect i n the f u t u r e and what i n  f a c t was t h e i r  prognosis.  ... what can I expect f o r the future ya know, based reasonably on what he [ c a r d i o l o g i s t ] saw and the r e s u l t s of a l l these t e s t s they took.  ... I would've p r e f e r r e d to have known what the prognosis was, O.K.. Now, very e a r l y on they s a i d t h a t , t h a t I would r e t u r n t o a normal l i f e e v e n t u a l l y , reasonably normal l i f e i s what they s a i d . Uhmm, that doesn't conjure up any p a r t i c u l a r r e s t r i c t i o n s i n my p a r t i c u l a r area because I don't t h i n k I , I ah want t o do anything i n a p h y s i c a l nature t h a t , that was r e a l l y out of the o r d i n a r y ...  73  Well ah, I guess how s e r i o u s i t was and was I going t o get b e t t e r , was I going to be an i n v a l i d ...  Uhm, I suppose i n the back o£ my mind t h e r e ' 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 t o feel. I mean ah sometimes I f e e l t h a t t h e r e ' 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 r e g a r d i n g treatment were a l s o r a i s e d , by the s u b j e c t s undergoing angiogram and a n g i o p l a s t y .  i n v a s i v e procedures such as Although these concerns r e l a t e d t o  the s p e c i f i c procedure being performed t h i n g s such as r i s k  especially  they o f t e n  included  f a c t o r s and what to expect d u r i n g the  procedure. In summary, the s u b j e c t s were i n t e r e s t e d  i n knowing about  the damage caused by t h e i r Mis and the e f f e c t  I t would have on  their a b i l i t i e s  i n the f u t u r e .  For those undergoing  treatments and procedures there was  further  a l s o an amount of concern  expressed about these procedures.  cardiac Education Both the formal and  i n f o r m a l aspects of c a r d i a c e d u c a t i o n  r e c e i v e d by the s u b j e c t s f o l l o w i n g t h e i r MI w i l l be presented in this section.  The  focus of t h i s study was  t o o b t a i n the  s u b j e c t s ' p e r s p e c t i v e s of t h e i r e x p e r i e n c e , t h e r e f o r e no  74 attempt was made by the r e s e a r c h e r t o t e s t the s u b j e c t s ' knowledge l e v e l or t o judge the q u a l i t y of the t e a c h i n g received.  To f a c i l i t a t e p r e s e n t a t i o n of these data, the  s e c t i o n has been s u b d i v i d e d i n t o education from h e a l t h p r o f e s s i o n a l s , and s e l f Education  education.  from h e a l t h p r o f e s s i o n a l s .  During t h e i r s t a y s i n h o s p i t a l a l l f i v e s u b j e c t s had r e c e i v e d the MI book The heart t a l k s e r i e s heart a t t a c k used by the i n s t i t u t i o n  f o r cardiac patient education.  The f i v e  s u b j e c t s r e p o r t e d having read the book and a m a j o r i t y used i t as a guide  or r e f e r e n c e throughout  the r e c o v e r y p e r i o d .  Oh y a , 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 t o get over i t , ya know, t h a t i t ' l l a p p l i e s t o d i f f e r e n t age groups ya know, but how t o s t a r t your e x e r c i s e schedule and what t o look f o r . ... That's what I was doing ya, was l i k e t r y i n g t o s t i c k roughly t o t h a t book ya know ...  They gave me a book which I've read through a couple of times ... t h a t ' s a v e r y good book ...  Ya, w e l l 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 t o look f o r what I want t o f i n d out.  So, I cover it, I me an  read i t when I got Into the c a r d i a c ward, from t o cover, and i n f a c t I read i t a l s o and look a t mean I r e f e r t o i t a l i t t l e b i t now, j u s t t o g i v e idea of perhaps where I might be a t t h i s stage.  The c a r d i a c education p r o t o c o l a t t h i s  institution  Included the d i s t r i b u t i o n of the MI book with supplementary i n s t r u c t i o n from the n u r s i n g  staff.  Only two s u b j e c t s  study r e p o r t r e c e i v i n g i n s t r u c t i o n from t h e i r  in this  nurses.  ... a c t u a l l y before I l e f t she [nurse] ah s a t down with ah, s a t 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 t h i n g that ah f o l d e d and whatever and ah e x p l a i n e d ya know what happened and, and ah ya know what angina Is and she wrote t h a t [hand w r i t t e n note on the use of n i t r o g l y c e r i n e ] and we had ah I , I would Imagine t h a t i t would've taken her a t l e a s t h a l f an hour so I f e l t f a i r l y comfortable ah as t o ya know what had happened and, and ah what could happen i f i t ever happens again that s o r t of s t u f f and why and a l l that s o r t of stuff. The nurses came i n and t a l k e d to me and asked me a few q u e s t i o n s about the book [MI book] and t h a t . I , I guess they'd f i g u r e d I read i t . They were checking I guess, more or l e s s , cause I p r e t t y w e l l had the answers.  For  one of these s u b j e c t s  the circumstances under which he had  r e c e i v e d h i s i n 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 p e r s o n a l l y knew the nurse who d i d it.  The t h i n g t h a t concerned me about t h a t was t h a t , was almost an a f t e r thought I mean i f I t 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 t h a t would've been done ...  T h i s same s u b j e c t a l s o f e l t that t e a c h i n g s e s s i o n s , such as the one he had r e c e i v e d , should be something  done more o f t e n  by nurses.  That's the type of t h i n g ya know t h a t I , t h a t I t h i n k nurses should do, I ah don't think that they should be making beds ...  Three s u b j e c t s r e p o r t e d t h a t they d i d not r e c e i v e i n s t r u c t i o n from t h e i r nurses. viewed  However, the nurses were o f t e n  by these s u b j e c t s as being s u p p o r t i v e and k i n d .  ... I was r e a l l y impressed by the nurses, and uh maybe because I'm s i n g l e i t made a d i f f e r e n c e ya know because maybe they r e l a t e d t o me a l i t t l e b e t t e r I don't know. But uhm, I j u s t found them r e a l l y good ya know i t made such a d i f f e r e n c e to me but uh j u s t the way they were ya know r e a l l y n i c e , and p r o f e s s i o n a l , not l i k e p r o f e s s i o n a l l y a l o o f , they were f r i e n d l y as w e l l ...  ... but once I was i n t o the c a r d i a c ward some of the nurses t h a t I knew more because of the s i t u a t i o n , where they were there i n the daytime or whenever i t was, were ah v e r y n i c e and very h e l p f u l .  Although the nurses had not reviewed the MI book with these s u b j e c t s , nurses were viewed as a source of i n f o r m a t i o n by a t l e a s t one of the s u b j e c t s who r e p o r t e d a s k i n g q u e s t i o n s of the nurses.  The  c a r d i o l o g i s t s , and t o a c e r t a i n degree f a m i l y  p h y s i c i a n s , were viewed as sources  of i n f o r m a t i o n as w e l l .  A c t i v i t y r e s t r i c t i o n s or g u i d e l i n e s appeared to be the focus of the i n f o r m a t i o n r e c e i v e d or the questions physicians.  asked of the  The i n f o r m a t i o n v a r i e d from s p e c i f i c i n s t r u c t i o n s  as t o when the s u b j e c t s could go back t o work, or d r i v e c a r s , to more g e n e r a l  i n s t r u c t i o n s on a c t i v i t i e s  permitted.  Uhm, j u s t t o go back [ t o work], p o s s i b l y i f I c o u l d p a r t 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 t h a t j u s t t o do i t as r e l a x e d as I can and t o j u s t b u i l d up t o i t s l o w l y .  Oh ya, she [ c a r d i o l o g i s t ] t o l d me what t o do and ah I wasn't to d r i v e the c a r f o r s i x weeks, and ah we're not to go down a c r o s s the l i n e f o r three weeks [ t o c o t t a g e ] She [ c a r d i o l o g i s t ] s a i d t o j u s t , she s a i d no b i g meals, no b i g walks, and ah t i r e d , r e s t when you're t i r e d .  The  type of questions  the s u b j e c t s asked or were p l a n n i n g t o  ask  r e f l e c t the s u b j e c t s ' d e s i r e to know i n f o r m a t i o n  specific  to them.  Ya, ya I asked him [ c a r d i o l o g i s t ] l i k e how much I should e x e r c i s e , uhmm what s o r t of h e a r t , heart r a t e I should be g e t t i n g up t o when I'm e x e r c i s i n g and how long I should do i t f o r , and uhm how long before I can do t h i s and before I can go back t o work and d r i v e and t h i s s o r t of s t u f f ya know. I asked him about the t a b l e t s , how long w i l l I be on them, and what the long term e f f e c t s .  78 W e l l , t h e r e ' s , t h e r e ' s the work and the c a r t h i n g , t h a t ' s f a i r l y Important to me because t h a t goes with the independence t h i n g , ah I would l i k e t o know whether I'm going t o t r a v e l , I would l i k e t o know what the restrictions are.  Once home, s u b j e c t s o f t e n contacted p h y s i c i a n s when they had questions  their  regarding t h e i r  or p h y s i c a l symptoms t h a t were not, i n t h e i r connected to t h e i r heart problem.  family medications  opinion,  Some s u b j e c t s f e l t  that  concerns about t h e i r heart should be d i r e c t e d t o t h e i r cardiologists.  . . . uh he's [ f a m i l y 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 i n terms of heart ... I don't t h i n k t h a t he would know what the e f f e c t s of v a r i o u s t h i n g s a r e and, and t h a t s o r t of s t u f f so, which d i d n ' t cause me any d i s c o m f o r t i t ' s j u s t you know uhmm i f I wanted t o t a l k to somebody about a heart I guess I would t a l k t o , t o X or Z [ c a r d i o l o g i s t s ] I guess.  ... maybe i t should have been a q u e s t i o n t o Dr. X [ c a r d i o l o g i s t ] r a t h e r than my own f a m i l y p h y s i c i a n but anyway w e ' l l s e e .  Although the s u b j e c t s used t h e i r many a l s o expressed  p h y s i c i a n s as resources  t h a t sometimes t h e i r  p h y s i c i a n s were i n a  rush and t h i s a f f e c t e d the i n f o r m a t i o n they were able t o obtain.  Four of the s u b j e c t s d i d r e p o r t making l i s t s of  79  questions  f o r t h e i r p h y s i c i a n s and to some extent  t h i s had  been b e n e f i c i a l .  ... w e l l because I guess ya know l i k e d o c t o r s and ya know they're i n a rush ya know a l o t of the time ...  Uhmm, the d o c t o r s ah, ya know they, ah Dr. ah X [ c a r d 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 t h i n g s where you always t h i n k of questions a f t e r they've l e f t ya know and ah a c t u a l l y I've s t a r t e d to w r i t e down questions so t h a t ah ... I can ask these t h i n g s ...  ... and of course when you go t o see people [ p h y s i c i a n s ] , even when you make a l i s t , you can't s t a y there a l l day, they haven't got t h a t k i n d of time uhm so a l l my questions a r e , are not answered ya know ...  The  s u b j e c t s r e p o r t e d the d i e t i c i a n s , whether seen  while  i n h o s p i t a l or on an o u t p a t i e n t b a s i s , as another source f o r i n f o r m a t i o n t h a t was f e l t t o be b e n e f i c i a l . helped felt  the s u b j e c t s to i d e n t i f y areas  The d i e t i c i a n s  In t h e i r d i e t t h a t  they  required adjusting.  ... the same mistakes I degree before my h e a r t , t h i n g s l i k e muffins ... know a sunflower o i l or That's the bottom l i n e , then I d i d . ..  guess t h a t I made o n l y t o a l e s s I was s t i l l g e t t i n g suckered Into no matter what you c a l l i t ya whatever, t h a t f a t i s f a t . so now I understand a l o t b e t t e r  Low c h o l e 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 ] t h a t came t o 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 i s the number o f , of eggs and cheese t h a t I have d u r i n g the week. I t ' s q u i t e astounding ah ... ya, w e l l 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 t a l k i n g about three eggs a s i t t i n g ...  T h i s one [ d i e t ] you g o t t a watch the s a l t s and the f a t s  The r e a d i n e s s  of s u b j e c t s f o r t e a c h i n g or e d u c a t i o n a l  m a t e r i a l s v a r i e d among the three s u b j e c t s who had expressed opinions  i n that area.  received teaching  One of the two s u b j e c t s , who had  i n the h o s p i t a l from a nurse,  t e a c h i n g could have been done e a r l i e r  f e l t t h a t the  in his hospital  stay.  T h i s was the o n l y s u b j e c t who had undergone angiography d u r i n g h i s admission his heart.  and who knew the s p e c i f i c s of the damage done t o  For him, r e c e i v i n g t e a c h i n g a t the time of  d i s c h a r g e was d i s c o n c e r t i n g .  ... I t h i n k i t should have been done e a r l i e r r a t h e r than ya know her f e e l i n g t h a t ah she's keeping me from going ... I was a l r e a d y discharged and she s a i d wait u n t i l I come back so I had my r i d e and e v e r y t h i n g 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 p r e s e n t a t i o n and a l o t of good s t u f f but I t h i n k i t should have been done ah a few days e a r l i e r . ... I had t h a t ah t h i n g on the heart anyway ... the sheet where they, they t o l d me where the a c t u a l blockage was ...  81  Another s u b j e c t i n i t i a l l y expressed MI book while she was s t i l l of being g i v e n  s u r p r i s e a t r e c e i v i n g the  i n the i n t e n s i v e care u n i t i n s t e a d  i t the day she came home.  For t h i s  subject  other t h i n g s took p r i o r i t y d u r i n g the time i n the i n t e n s i v e care u n i t .  I mean I, i t seemed l i k e a good idea t o me I j u s t was s u r p r i s e d , cause I thought t h a t , i t would be the kind of t h i n g they'd g i v e you the day you came home. Uhm, but of course they gave i t t o me then persumably and everybody e l s e , so t h a t ' s the time when you get out of ICU, [ICU] i s not the time t h a t you want to s t a r t l o o k i n g a t i t perhaps too much e l s e i s going on, but once I was on the c a r d i a c wards c e r t a i n l y was the time t h a t I read i t from cover t o cover. Uhm, so you're prepared f o r what's going on when you get home which I, so i n r e t r o s p e c t I t seemed l i k e a good i d e a .  One s u b j e c t whose c a r d i a c education  had c o n s i s t e d of r e a d i n g  the MI book and a d i s c u s s i o n with h i s c a r d i o l o g i s t d i d not f e e l ready f o r t h a t i n f o r m a t i o n while s u b j e c t expressed follow-up  in hospital.  I n t e r e s t In p a r t i c i p a t i n g  This  i n a cardiac  group a f t e r h i s d i s c h a r g e .  Uhmm, no I don't think so, I think t h a t , t h a t time [while i n h o s p i t a l ] uhm t h a t ' s I think when I f e l t I most needed somebody t o t a l k to about what had happened to me and ah somebody t o spend a b i t more time with me ...  The context  o n l y other h e a l t h p r o f e s s i o n a l mentioned In the of g i v i n g i n f o r m a t i o n t o the s u b j e c t s was a  82 pharmacist.  One s u b j e c t r e p o r t e d r e c e i v i n g i n f o r m a t i o n  from h i s pharmacist when he f i l l e d  his prescriptions.  Four of the f i v e s u b j e c t s asked questions r e s e a r c h e r d u r i n g the course varied  of the i n t e r v i e w s .  of the The questions  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  a l r e a d y r e c e i v e d , t o requests s u b j e c t was p a r t i c u l a r l y experience  sheets  Information  f o r further information.  One  I n t e r e s t e d i n knowing how her  compared t o the experience  of other s u b j e c t s i n the  study. For the s u b j e c t s i n t h i s study the p h y s i c i a n s , 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 i n f o r m a t i o n even though the time spent with  p h y s i c i a n s had been l i m i t e d .  A l s o , those  their  subjects receiving  i n s t r u c t i o n from other h e a l t h p r o f e s s i o n a l s , such as d i e t i c i a n s and nurses, During  the course  felt this  Information  t o be b e n e f i c i a l .  of the i n t e r v i e w s the r e s e a r c h e r  by most of the s u b j e c t s as a source  was viewed  of i n f o r m a t i o n as w e l l .  Timing of t e a c h i n g a c t i v i t i e s was a concern f o r three subjects.  Four of the f i v e s u b j e c t s viewed the w r i t t e n  m a t e r i a l r e c e i v e d while  i n h o s p i t a l as u s e f u l as a guide and  r e f e r e n c e d u r i n g recovery a t home. Self All  education. f i v e s u b j e c t s r e p o r t e d having  or f r i e n d s about t h e i r MI.  d i s c u s s i o n s with  family  Topics of these d i s c u s s i o n s ranged  from changes i n t h e i r d i e t , t o comparing the course  of t h e i r  83  i l l n e s s and recovery t o t h a t of o t h e r s . view these d i s c u s s i o n s as very  One s u b j e c t d i d not  beneficial.  Well, everybody's a d o c t o r , I got more damn advice then ya can shake a s t i c k a t , I j u s t l e t i t go i n one ear and out the o t h e r .  While f o r another s u b j e c t t a l k i n g t o a person who had been through the experience  was thought t o be h e l p f u l .  ... ah i t ' s b e t t e r t o t a l k t o somebody t h a t ' s had i t and to f i n d out e x a c t l y what ya know, what they do t o you and how he [ f r i e n d ] f e l t ...  The  extent t o which s u b j e c t s f e l t comfortable  people about t h e i r MI v a r i e d as w e l l . having  i n t e r e s t i n g conversations  talking to  One woman who reported  with both her f a m i l y and  f r i e n d s , many of whom were p h y s i c i a n s , was s t i l l  cautious  about d i s c u s s i n g i t too much.  ... No, I don't know whether i t ' s wise to t a l k too much to people, they get t i r e d of l i s t e n i n g t o other people's, at l e a s t t h a t ' s my theory, t h a t your i l l n e s s e s , t h a t ' s why you have a doctor t o t a l k i t over with ...  Another s u b j e c t , who d e s c r i b e d h e r s e l f as someone who craved i n f o r m a t i o n , d i d not view everyone she t a l k e d t o r e g a r d i n g her MI  as an a p p r o p r i a t e  source  of i n f o r m a t i o n .  84 ... i n f a c t I s o r t of almost crave i t [ i n f o r m a t i o n ] and i f anybody has anything t o t e l l me, l i k e you [ i n t e r v i e w e r ] , ah I don't mean the people next door, much as I l i k e them very much indeed because they're not i n t o that. Ah, but i f people have anything i n t e r e s t i n g t o t e l l me, I , or t o t e l l me what books t o read about i t I'm very much i n t e r e s t e d .  As w e l l , f o r another  s u b j e c t c e r t a i n aspects of the experience  had t o be d e a l t with on h i s own, s p e c i f i c a l l y his  i n r e l a t i o n to  f e e l i n g s of being down f o l l o w i n g h i s MI.  Uhmm, no I u s u a l l y t r y and r e s o l v e i t myself ya know and ah j u s t t h i n k about why I'm down and what I can do about i t ya know I mean i t ' s more, cause I f i g u r e w e l l to a p o i n t t h a t I've t a l k e d enough about i t t o other people ya know and ya know other people have asked me about i t and not t h a t i t bothers me but ah I j u s t f i g u r e i t ' s something t h a t I have to come to terms with and uhm, I t ' s me t h a t ' s going t o do i t and nobody e l s e ya know, so.  Two s u b j e c t s , both of whom r e p o r t e d being  inadequate  readers or poor r e t a i n e r s of i n f o r m a t i o n t h a t was read, s t a t e d they p r e f e r r e d the one-on-one i n s t r u c t i o n r e c e i v e d from the n u r s i n g s t a f f t o r e a d i n g independently as a method of receiving information.  ... I t h i n k t h a t people l e a r n much b e t t e r by being taught than by r e a d i n g ah ... l e t ' s put i t t h i s way I had no problem g a i n i n g the i n f o r m a t i o n from the book but I'd c e r t a i n l y r a t h e r because I don't p e r s o n a l l y read t h a t w e l l , so i f , i f I'm going t o be taught ah I would c e r t a i n l y i f I had my d r u t h e r s be taught i n person r a t h e r than by being handed a book.  I t a l s o should be noted t h a t these s u b j e c t s were the o n l y two t h a t r e c e i v e d one-on-one i n s t r u c t i o n from the n u r s i n g  staff.  Both of the s u b j e c t s who d i d not p r e f e r reading had read o n l y the i n f o r m a t i o n r e c e i v e d i n the h o s p i t a l r e g a r d i n g Mis. and  Other than the questions  they asked of t h e i r  physicians,  of t h i s r e s e a r c h e r d u r i n g the i n t e r v i e w process,  of these s u b j e c t s had r e p o r t e d a c t i v e l y seeking  ... g e n e r a l l y speaking that I got.  neither  other  i n f o r m a t i o n d u r i n g the r e c o v e r y p e r i o d and both had s a t i s f a c t i o n with the Information  their  expressed  they had r e c e i v e d .  I'm s a t i s f i e d with the i n f o r m a t i o n  No, I'm j u s t going by t h a t book [Ml book] I g o t . f i g u r e t h a t ' s , about covers i t ...  I  The three s u b j e c t s who p r e f e r r e d reading d i d not express d i s s a t i s f a c t i o n with the i n f o r m a t i o n r e c e i v e d , however a c t i v e l y sought i n f o r m a t i o n from other s o u r c e s .  they  The methods  most o f t e n used t o o b t a i n t h i s i n f o r m a t i o n were d i s c u s s i n g i t with  f a m i l y or f r i e n d s , doing  television  f u r t h e r r e a d i n g , and watching  shows.  The amount of e x t r a reading v a r i e d among these s u b j e c t s with one having medical  three  o n l y made plans to read her husband's  j o u r n a l s and another having  a l r e a d y done  r e a d i n g about the heart a t t a c k experience  extensive  from a v a r i e t y of  sources.  The t o p i c s of the books and a r t i c l e s read v a r i e d  with each s u b j e c t s i n d i v i d u a l t a s t e s and o f t e n r e f l e c t e d of i n t e r e s t held by those The other  s u b j e c t s before  areas  t h e i r Mis.  two s u b j e c t s who were the most a c t i v e i n o b t a i n i n g  i n f o r m a t i o n f o l l o w i n g t h e i r Mis were a l s o the same two  s u b j e c t s who p e r c e i v e d the impact of the MI as an impetus f o r change i n t h e i r  lives.  Both of these s u b j e c t s had a l r e a d y  made changes t h a t would e f f e c t t h e i r f u t u r e s such as undergoing career c o u n s e l i n g and d e c i d i n g not to resume c e r t a i n a c t i v i t i e s such as c h o r a l s i n g i n g . the o n l y two s u b j e c t s t h a t had expressed down or blue the  As w e l l , they were  f e e l i n g s of being  f o l l o w i n g t h e i r Mis which may r e f l e c t  somewhat  Impact the MI had had on them. For one of these two s u b j e c t s viewing  show, f e a t u r i n g three guests  a television  who had s u r v i v e d t h e i r  talk  heart  a t t a c k s , encouraged him t o f e e l he could s u r v i v e i t t o o .  ... I think t h a t s e e i n g t h a t made me r e a l i z e ... t h a t you can s u r v i v e i t [heart a t t a c k ] and you can go on and l i v e a normal l i f e ya know. T h i s s u b j e c t was a l s o the o n l y person i n the study t o express Interest and  in participating  i n a support  group f o l l o w i n g h i s MI  he had w r i t t e n the l o c a l heart foundation  information.  As w e l l , he had v o l u n t e e r e d  another r e s e a r c h study  for further  to p a r t i c i p a t e i n  i n v e s t i g a t i n g the e f f e c t s of a new drug  87  on c h o l e s t e r o l l e v e l s but was dropped from the study when he d i d not meet a l l the s e l e c t i o n The  criteria.  other s u b j e c t who had read e x t e n s i v e l y before her MI  continued t o do so f o l l o w i n g her MI. to her MI about other persons'  She had read books p r i o r  b a t t l e s with major  Illnesses  but found a f t e r her own MI some p a r t s of these books were too c l o s e 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 c a l l e d Norman Cousins ... he wrote a book c a l l e d The anatomy of an I l l n e s s which I read many, many years ago and he subsequently wrote another book c a l l e d The h e a l i n g h e a r t . 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 f a s c i n a t i n g , i n t e r e s t i n g book, and he's a f a s c i n a t i n g and I n t e r e s t i n g man. So, when I came home, two or three days a f t e r I'd been home, I thought I'd reread i t and ya know t h a t I c o u l d n ' t read some of i t . Ah, I t was t o c l o s e t o me and ah the, e s p e c i a l l y the p a r t where he had h i s major heart  Although  t h i s s u b j e c t continued t o read other t h i n g s r e g a r d i n g  the heart she t r i e d  not to focus o n l y on i l l n e s s and a l s o  began t o read t h i n g s t h a t were on the l i g h t e r  side.  ... and I l i k e to read other t h i n g s too but ah I don't want t o j u s t s o r t of focus on h e a l t h and ya know i l l h e a l t h because I j u s t don't want t o do t h a t . I think t h a t ' s not an a b s o l u t e l y good t h i n g .  T h i s s u b j e c t a l s o p r a c t i c e d techniques and  such as m e d i t a t i o n  s c a t t e r e d imagery and b e l i e v e d these techniques  c o u l d have  a positive effect  i n her r e c o v e r y .  view advanced medical she was  and  She  d i d not n e c e s s a r i l y  s u r g i c a l techniques  t a k i n g i n t o account a l l t h a t she  had  as wrong, but read  making a d e c i s i o n to have the angiogram t h a t was her  before requested  by  cardiologist.  ... but I t i s c e r t a i n l y making me t h i n k , t h i n k a b i t more about i t ya know because i f I can lead a reasonably i n t e r e s t i n g l i f e , which i s important to me and, and cope with ah ya know t h i n g s and l i s . . , and then l e a r n to l i s t e n to my body more, at l e a s t not l i s t e n to i t but do what my body says uh cause I've t o l d you I meditated ya know and I s t i l l do, I, I t h i n k somehow t h a t I should be able to make my own bypass, whether I w i l l or not i s another s t o r y , so w e ' l l see.  I t became e v i d e n t as the these  f i v e subjects t h e i r  i n t e r v i e w s progressed  i n d i v i d u a l p r e f e r r e d method of  l e a r n i n g i n f l u e n c e d the extent the education had  process.  The  to which they p a r t i c i p a t e d i n  two  s u b j e c t s who  inadequate reading a b i l i t i e s  f u r t h e r i n f o r m a t i o n about MI  hospital.  The  s u b j e c t s who about Mis and  friends.  techniques  they  sought  from  p r e f e r r e d reading were the  took a more a c t i v e r o l e  In o b t a i n i n g  information  such as books, t e l e v i s i o n shows,  In a d d i t i o n , for one  o p i n i o n s held p r i o r to the MI  only m i n i m a l l y  a f t e r discharge  three s u b j e c t s who  from other sources  acknowledged  p r e f e r r e d to r e c e i v e  i n f o r m a t i o n on an one-on-one b a s i s and any  that for  subject b e l i e f s  and  about a l t e r n a t i v e h e a l t h care  were a l s o observed to i n f l u e n c e t h a t s u b j e c t s  89  c h o i c e s d u r i n g the  recovery  period.  summary The  occurrence of a MI  was  p e r c e i v e d by the  i n t h i s study as a s i g n i f i c a n t event that  precipitated  f e e l i n g s of shock, d i s b e l i e f , and  injustice.  was  for change, the  viewed as a m o t i v a t i n g f a c t o r  the MI to be  v a r i e d depending on how  serious  by each i n d i v i d u a l p a r t i c i p a n t .  believed  t h e i r Mis  stress, heredity, made by the  participants  Although the impact  the  event was  The  participants  MI  of  perceived  to have been caused by d i e t , smoking, and  overexertion.  participants  included  managing angina, i n c o r p o r a t i n g  L i f e s t y l e adjustments changing t h e i r d i e t ,  medications, walking d a i l y ,  and/or q u i t i n g smoking. The  concerns expressed by the  unanimous but experience.  rather Their  heart a t t a c k ;  p a r t i c i p a n t s were  r e f l e c t e d each i n d i v i d u a l ' s s i t u a t i o n  major concerns i n c l u d e d :  adjusting  fearing  to a decrease i n p h y s i c a l  continued f e e l i n g s of l i m i t a t i o n ; e l i m i n a t i n g l i f e s t y l e component; and,  varied,  cardiac but  physicians,  the  education received  by the  d i e t i c i a n s , and preferred  nurses was  a the  treatment.  participants  i n f o r m a t i o n obtained from the MI  Those s u b j e c t s who  stamina with  s t r e s s as  p r o g n o s i s , and  and  another  d e s i r i n g more Information on  amount of damage caused by the Ml, The  not  book,  viewed as b e n e f i c i a l .  r e a d i n g as a method of  i n s t r u c t i o n took a more a c t i v e  r o l e i n s e l f e d u c a t i o n and used  other sources such as f r i e n d s , books, and t e l e v i s i o n shows t o l e a r n more about  the MI e x p e r i e n c e .  In t h i s chapter a d e s c r i p t i o n following  a MI f o r the f i v e p a r t i c i p a n t s  been presented. discussed  of the i l l n e s s  experience  i n t h i s study has  In Chapter F i v e , these f i n d i n g s w i l l be  i n 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.  91 Chapter  5  D i s c u s s i o n of the F i n d i n g s  introduction In t h i s chapter the f i n d i n g s of t h i s study w i l l be discussed  in relation  t o the purpose of the study, the  framework used t o c o n c e p t u a l i z e the problem, the l i t e r a t u r e reviewed  i n Chapter  literature.  Two, and where necessary  additional  The purpose of t h i s study was t o examine  patients*  i l l n e s s experiences  f o l l o w i n g a MI i n order t o  determine  what i t meant t o p a t i e n t s t o have a MI, what  p a t i e n t s i d e n t i f i e d as l e a r n i n g needs f o l l o w i n g a MI, and how p a t i e n t s met these l e a r n i n g needs.  To examine t h i s  experience  from the p a t i e n t s ' p e r s p e c t i v e s the r e s e a r c h method of phenomenology was used which produced data.  The data presented  of the i l l n e s s experience participants.  i n Chapter  an e x t e n s i v e amount of Four  Included a l l aspects  f o l l o w i n g a MI as d e s c r i b e d by the  I t would be a formidable task to d i s c u s s a l l  a s p e c t s of t h i s data, t h e r e f o r e the d i s c u s s i o n i n t h i s will  be r e s t r i c t e d  to the s p e c i f i c purposes  chapter  of t h i s study and  w i l l address the meaning of the MI, the l e a r n i n g needs i d e n t i f i e d , and how l e a r n i n g needs were met.  92  Meaning of the MI The meaning of the MI was determined s u b j e c t s viewed  by examining  the occurrence and impact of the MI.  how the For the  s u b j e c t s i n t h i s study the extent of the Mi's impact, and t h e i r w i l l i n g n e s s to make adjustments  post-Mi were I n f l u e n c e d  by t h e i r b e l i e f s as t o the causes of t h e i r MI. The of  Initial  r e a c t i o n of the s u b j e c t s t o the Ml was t h a t  s u r p r i s e and d i s b e l i e f .  Even the s u b j e c t who had a  f o u r t e e n year h i s t o r y of angina c o u l d not b e l i e v e what was happening.  One gentleman continued t o deny t h a t the event had  been a MI and a t h i s s i x week follow-up appointment  again  questioned the d i a g n o s i s with h i s c a r d i o l o g i s t . The  f e e l i n g s of I n j u s t i c e expressed by a m a j o r i t y of the  s u b j e c t s r e f l e c t s t h e i r attempts t o r a t i o n a l i z e t o themselves the occurrence of the MI. to  For most i t was d i f f i c u l t  f o r them  understand why they had had a MI when they knew many people  who had worse h a b i t s or d i d not take care of themselves as w e l l as the s u b j e c t s f e l t they had. An examination of what these s u b j e c t s c o n s i d e r e d to have been t h e i r r i s k  f a c t o r s f o r MI may e x p l a i n somewhat t h e i r  i n a b i l i t y t o view themselves as c a n d i d a t e s f o r MI.  The  w r i t t e n education m a t e r i a l r e c e i v e d and read by a l l the s u b j e c t s i d e n t i f i e d nine r i s k  f a c t o r s : f a m i l y h i s t o r y , being  male, d i a b e t e s , high blood p r e s s u r e , smoking, high blood c h o l e s t e r o l , overweight,  lack of e x e r c i s e , and s t r e s s (The  heart t a l k s e r i e s heart a t t a c k . 1988).  The  s u b j e c t s were a l s o  aware, through t h i s l i t e r a t u r e , t h a t t h e i r r i s k increased with the number of r i s k  f o r MI  factors.  C e r t a i n f a c t o r s have been i d e n t i f i e d which may Increased another  have  your r i s k of having a heart a t t a c k or  one.  People with one  of these  having  f a c t o r s are almost  twice as l i k e l y to have a heart a t t a c k as those none.  Those with two  t r i p l e the r i s k .  of these  f a c t o r s may  Those with three may  r i s k of heart a t t a c k by t e n ,  more than  multiply their  (p.10)  However, even with t h e i r exposure to t h i s s u b j e c t s o f t e n overlooked  with  Information  a m a j o r i t y of t h e i r own  the  risk  factors. In the a n a l y s i s of the data,  i t was  found  t h a t the  s u b j e c t s had a minimum of three and a maximum of s i x of the nine r i s k  factors.  Three s u b j e c t s were unaware of what t h e i r  c h o l e s t e r o l l e v e l s were, thus high c h o l e s t e r o l l e v e l s could have added another  risk  f o r those three s u b j e c t s .  from the p e r s p e c t i v e of a h e a l t h p r o f e s s i o n a l these were i n f a c t prime candidates  to c e r t a i n r i s k  compared themselves to people  such.  f a c t o r s the s u b j e c t s o f t e n  they knew.  a sense the presence of the r i s k others f o r whom i t was  subjects  f o r c a r d i a c d i s e a s e , yet the  s u b j e c t s d i d not view themselves as In regards  Therefore,  They acknowledged i n  f a c t o r , but f e l t they knew  even a g r e a t e r r i s k .  Comments such as  94 a person ate more f a t , was more overweight, or had a more s t r e s s f u l job then they d i d were f r e q u e n t .  Instead of  examining t h e i r e n t i r e r i s k p r o f i l e s the s u b j e c t s appeared to have concentrated Therefore,  on one or two of t h e i r r i s k f a c t o r s .  i t was not s u r p r i s i n g when the s u b j e c t s were asked  s p e c i f i c a l l y what they f e l t caused them t o have a MI t h a t most o n l y named one or two r i s k risk  f a c t o r s or gave reasons other  than  f a c t o r s as causes of t h e i r  MI.  The  I d e n t i f i e d such t h i n g s as  s u b j e c t s i n t h i s study  d i e t , smoking, s t r e s s , too much s a l t , h e r e d i t y , and o v e r e x e r t i o n as causes f o r t h e i r Mis. s u b j e c t who had these  However, not every  f a c t o r s i d e n t i f i e d them and other  f a c t o r s such as d i a b e t e s , high blood pressure,  risk  lack of  e x e r c i s e , and being overweight were never mentioned by the s u b j e c t s f o r whom these were major r i s k supports  previous  factors.  This  finding  r e s e a r c h done on the p a t i e n t ' s p e r s p e c t i v e  as t o the causes of MI. Rudy (1980) found i n her study of p a t i e n t s ' and spouses' causal explanations  of a MI t h a t t e n s i o n was the most  cause given by both p a t i e n t s and spouses.  frequent  She f u r t h e r s t a t e s  t h a t " i n g e n e r a l , p a t i e n t s with an i d e n t i f i a b l e medical  risk  f a c t o r and t h e i r spouses d i d not name t h a t r i s k f a c t o r as an e x p l a n a t i o n of t h e i r heart a t t a c k a t e i t h e r the acute or convalescent Fielding  phase of t h e i r  illness"  (p.355).  (1987) and Murray (1989) a l s o examined the  p a t i e n t s ' b e l i e f s regarding psychosocial  the causes of MI and found  that  f a c t o r s such as overwork, s t r e s s , and worry were  most o f t e n c i t e d by p a t i e n t s .  Although smoking was a l s o  found  to be the most c i t e d p h y s i c a l cause, the percentage of smokers recognizing  i t as a f a c t o r v a r i e d between the two s t u d i e s .  It  should be noted t h a t both smokers In t h i s study had acknowledged t h e i r smoking as a f a c t o r . The emphasis placed and by h e a l t h  by p a t i e n t s  professionals  on p s y c h o s o c i a l  on the more standard r i s k f a c t o r s  concerned both F i e l d i n g (1987) and Murray believed  that what p a t i e n t s  would i n f l u e n c e therefore  causes  perceived  (1989).  They  as causes of t h e i r MI  the l i f e s t y l e adjustments made by p a t i e n t s ,  possibly leading  to poor compliance  f o l l o w i n g a MI.  Although t h i s study d i d not address adjustments and compliance s p e c i f i c a l l y the adjustments made by the p a r t i c i p a n t s f o l l o w i n g t h e i r Mis were noted t o r e f l e c t somewhat the p a r t i c i p a n t s b e l i e f s as t o the cause or causes of t h e i r MI.  Thus, smokers q u i t smoking, and people who viewed  d i e t as a f a c t o r made d i e t changes.  Also,  the s u b j e c t  who  f e l t her Ml was caused by pushing h e r s e l f too hard had made decisions  to decrease her Involvement  in certain a c t i v i t i e s .  More than one s u b j e c t  had r e l a t e d s t r e s s as a cause of t h e i r  MI but these s u b j e c t s  were unsure of how they would change  that  i n their l i f e s t y l e s .  Since the s u b j e c t s  who had d i a b e t e s  and h y p e r t e n s i o n d i d not r e l a t e them as r i s k f a c t o r s I t was  96  not s u r p r i s i n g t h a t keeping these i l l n e s s e s mentioned  i n c o n t r o l was  as being important f o l l o w i n g t h e i r  I t appears  that the adjustments  not  Mis.  made, or not made, by  p a r t i c i p a n t s i n t h i s study were i n f a c t i n f l u e n c e d by the p a r t i c i p a n t s ' p e r c e p t i o n s , whether a c c u r a t e or not, as to the cause of t h e i r Mis.  As w e l l , s u b j e c t s were unsure as t o  they c o u l d manage some f a c t o r s such as s t r e s s .  how  T h i s lends  support t o Murray's (1989) c o n t e n t i o n "that account needs t o be taken of the p a t i e n t s ' b e l i e f s  i n t h i s area so that  c o r r e c t i o n of misconceptions can form a p a r t of the process of individually-planned r e h a b i l i t a t i o n " The  (p.691).  Impact of the Ml on the p a r t i c i p a n t s i n t h i s  study  v a r i e d , with two s u b j e c t s viewing i t as an lmptetus f o r 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 ,  one b e l i e v i n g  i t was  not there was  not much he c o u l d do about  another.  something  The most s i g n i f i c a n t  p h y s i c a l nature.  i t one way  Impact appeared  i f he d i d or  to be one of a  A l l s u b j e c t s r e p o r t e d f a t i g u e and a decrease  i n t h e i r p h y s i c a l stamina. other s t u d i e s  he would get over and  and  (Dunn, 1985;  W i l l i a m s o n , & F o s t e r , 1978;  F a t i q u e post-MI has been noted i n H i l g e n b e r g , & Crowley,  1987;  Wishnie, Hackett, & Cassem,  Mayou, 1971).  For the s u b j e c t s i n t h i s study f a t i q u e continued throughout the r e c o v e r y p e r i o d with most s u b j e c t s r e p o r t i n g t h a t they were not back t o normal a c t i v i t i e s by the time of t h e i r i n t e r v i e w a t l e a s t s i x weeks a f t e r d i s c h a r g e from  second  hospital.  The  initial  complaints and  two  s u b j e c t s , who  were followed longer, s t i l l  of being t i r e d and not f e e l i n g "back to normal" 14  16 weeks post d i s c h a r g e .  One  s u b j e c t r e l a t e d t h a t the  days she f e l t blue were the days she had The  had  l e s s energy.  o l d e r three s u b j e c t s a l s o r e p o r t e d a slow r e t u r n to  s o c i a l and  recreational a c t i v i t i e s .  T h i s f i n d i n g was  to t h a t of Hilgenberg and Crowley (1987) who  found  similar  one  third  of the 25 post-MI p a t i e n t s they interviewed r e p o r t e d going to fewer s o c i a l  gatherings.  A n x i e t y and d e p r e s s i o n have been r e p o r t e d i n the l i t e r a t u r e as outcomes f o l l o w i n g MI 1987;  Nagle, & Gangola, 1971;  1978;  Wishnie,  Hackett,  (Hilgenberg, & Crowley,  Mayou, W i l l i a m s o n , & F o s t e r ,  & Cassem, 1971)  Two  subjects in t h i s  study r e p o r t e d f e e l i n g down or blue post-MI and same two These two  s u b j e c t s who  expressed  i t was  f e a r s of having another  MI.  s u b j e c t s a l s o viewed the MI as a c a t a l y s t f o r change  i n t h e i r l i v e s , thus the MI appeared to have impacted more than  the  i t had  on the others i n t h i s study.  viewing the MI as not s e r i o u s and of "what w i l l be, w i l l be" may  on them  For the o t h e r s ,  having a p e r s o n a l  philosophy  have helped them  p s y c h o l o g i c a l l y i n t h e i r r e c o v e r y post-MI. I t i s e v i d e n t t h a t the occurrence  of a MI d i d not hold  the same meaning for a l l of the s u b j e c t s i n t h i s study. attempt by each s u b j e c t to r a t i o n a l i z e why and  to focus o n l y on c e r t a i n r i s k  The  they had had a MI  f a c t o r s r e f l e c t s an  effort  98  by the s u b j e c t s t o understand what had occurred their perspective.  T h e i r understanding  MI and the s e r i o u s n e s s  to them from  of the causes of t h e i r  of i t a l s o appears to have i n f l u e n c e d  t h e i r adjustments and outcomes post-MI.  Learning  Needs  In t h i s study a l e a r n i n g need was d e f i n e d as a concern i d e n t i f i e d and expressed required  information  f o l l o w i n g a MI.  by the p a t i e n t , f o r which the p a t i e n t  i n order t o manage on a day-to-day b a s i s  The s u b j e c t s found i t d i f f i c u l t  a r t i c u l a t e l e a r n i n g needs or areas where they i n f o r m a t i o n but the researcher  of concern.  t r a d i t i o n a l t o p i c s f o r c a r d i a c p a t i e n t education  as anatomy and p h y s i o l o g y of the h e a r t , r i s k coronary  lacked  through the a n a l y s i s of the  i n t e r v i e w s was able t o I d e n t i f y areas The  to d i r e c t l y  factors for  a r t e r y d i s e a s e , s i g n s and symptoms of heart  cardiac diet  such  i n s t r u c t i o n , and use of medications  attack,  were not the  type of areas acknowledged by the p a r t i c i p a n t s as causing them concern.  I t can e i t h e r be assumed from t h i s t h a t the  i n f o r m a t i o n r e c e i v e d by the s u b j e c t s was p e r c e i v e d to be adequate i n these areas  or t h a t these  t o p i c s were not  p e r c e i v e d by the s u b j e c t s as a p r i o r i t y i n the recovery at home. all  period  The f a c t t h a t most of the s u b j e c t s were not aware of  their risk  f a c t o r s may lend credence t o the idea the  s u b j e c t s d i d not p e r c e i v e c e r t a i n t o p i c s as p r i o r i t i e s .  However, t h i s find  i s not t o say t h a t the p a r t i c i p a n t s d i d not  i n f o r m a t i o n on such t o p i c s as d i e t , and medications,  b e n e f i c i a l , o n l y t h a t they expressed knew In these a r e a s . evaluate  In what  they  The purpose of t h i s study was not t o  the s u b j e c t s ' l e v e l of knowledge i n these  t h e r e f o r e i t i s impossible required.  satisfaction  areas,  t o s t a t e i f more i n f o r m a t i o n was  The f a c t t h a t the s u b j e c t s put p e r s o n a l  limitations  on such t h i n g s as t h e i r d i e t adjustments suggests t h a t the s u b j e c t s were only w i l l i n g , r e g a r d l e s s of the i n f o r m a t i o n g i v e n , t o make c e r t a i n changes i n t h e i r l i f e s t y l e s . area of e x e r c i s e , personal  In the  l i m i t a t i o n s were a l s o noted as one  s u b j e c t r e l a t e d she was walking  but wanted t o do i t a t her own  pace and t h a t she was not w i l l i n g to s t a r t something she d i d not  f e e l she c o u l d  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 to be the o n l y t r a d i t i o n a l area of c a r d i a c p a t i e n t i n which the s u b j e c t s i n t h i s study  education  lacked Information.  was very Important f o r the s u b j e c t s to know when they resume d r i v i n g , working, t r a v e l i n g , and e x e r c i s i n g . general guidelines for a c t i v i t i e s  appeared  It  could The  l a i d out i n the Ml book were  viewed as h e l p f u l but most s u b j e c t s v a r i f i e d with  their  i n d i v i d u a l 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 f o r them and when they c o u l d resume c e r t a i n a c t i v i t i e s . Some p a t i e n t s r e p o r t e d they had r e c e i v e d I n s t r u c t i o n s from t h e i r c a r d i o l o g i s t s r e g a r d i n g a c t i v i t i e s before  l e a v i n g the  100  hospital, their  yet once home they o f t e n wanted to v a r i f y again with  cardiologist  before t r y i n g  some a c t i v i t i e s .  T h i s focus on the need f o r more i n f o r m a t i o n on a c t i v i t y restrictions  and  limitations  i n the r e c o v e r y stage a t home was  a l s o i d e n t i f i e d by Moynihan ( 1 9 8 4 )  i n her study of the  e d u c a t i o n a l needs of post-MI p a t i e n t s .  According to Moynihan  Phase I I I of recovery, which begins a t d i s c h a r g e and ends when the p a t i e n t r e t u r n s t o p r e v i o u s p r o d u c t i v e l i f e s t y l e , was  the  time when p a t i e n t s i d e n t i f i e d t h e i r e d u c a t i o n a l 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  t h a t " p a t i e n t s expressed a need to have I n s t r u c t i o n s on which would f a c i l i t a t e (p.445).  The  their  resumption  of a normal  f a c t t h a t s u b j e c t s i n t h i s study  discouraged because they were s t i l l  lifestyle"  appeared  experiencing fatique  had not resumed f u l l y t h e i r normal a c t i v i t i e s shows t h a t s u b j e c t s were a l s o concerned  with resuming  In c o n j u n c t i o n with resuming  a normal  their  prognoses  and these  lifestyle.  a normal l i f e s t y l e  s u b j e c t s i n t h i s study were a l s o q u i t e concerned out the s p e c i f i c s about  items  the  with  finding  the damage caused by t h e i r Mis, what  would be, g i v e n the amount of damage, and what  treatments would be o f f e r e d .  I t appeared  t h a t they were  still  s e a r c h i n g f o r what the occurrence of a MI would u l t i m a t e l y mean to t h e i r  f u t u r e s and what type of r e s t r i c t i o n s  they could  expect, thereby p l a c i n g the emphasis on the r e a l i t y of the  situation.  Focusing  to know Information and  on the r e a l i t y of an  wanting  t h a t would h e l p to plan f o r both immediate  long-range problems an  Identified  i l l n e s s and  i l l n e s s would Impose was  also  by Dodge (1969) i n her study of l e a r n i n g needs as  the p a t i e n t ' s main c o g n i t i v e need.  In the present  s u b j e c t s appeared s a t i s f i e d with the r e c e i v e d f o r the  study  i n f o r m a t i o n they  the  had  immediate recovery p e r i o d but once home they  were concerned with long-range p l a n s . G e n e r a l l y , the s u b j e c t s i n t h i s study appeared s a t i s f i e d with the  i n f o r m a t i o n given i n the t r a d i t i o n a l areas  education.  The  concerns i d e n t i f i e d  d e s i r e to know more about t h e i r  focus on the  individual  subjects  situations  r e g a r d i n g a c t i v i t y r e s t r i c t i o n s , damage done by MI, and  treatments.  prognosis  I t appeared t h a t the s u b j e c t s were concerned  about the r e a l i t y of the s i t u a t i o n t h e i r MI  of c a r d i a c  i n p e r s p e c t i v e by planning  and  were t r y i n g  f o r the  to put  long-term.  Meeting Learning Needs The study was  p a t i e n t education  r e c e i v e d by the s u b j e c t s i n t h i s  not c o n s i s t e n t , as d e s c r i b e d p r e v i o u s l y .  However,  other than the t i m i n g of the one-on-one i n s t r u c t i o n  received  by one had  s u b j e c t , the s u b j e c t s appeared s a t i s f i e d with what they  r e c e i v e d from h e a l t h p r o f e s s i o n a l s .  to the researcher education  t h a t o n l y two  from nurses.  I t was  I t was  disconcerting  s u b j e c t s r e c e i v e d any  patient  encouraging however, t h a t  the  102 two s u b j e c t s who had r e c e i v e d t h i s  i n s t r u c t i o n found i t  beneficial. 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 s u b j e c t s i n t h i s study as the p r i n c i p a l sources of information.  The s u b j e c t s o f t e n asked questions  c a r d i o l o g i s t s while questions visits had  of t h e i r  i n h o s p i t a l and a l l had prepared  l i s t s of  t o take with them when they went f o r t h e i r  later  i n t h e i r recovery.  follow-up  Four of the f i v e s u b j e c t s had  c o n t a c t with t h e i r f a m i l y p h y s i c i a n s d u r i n g t h i s time as  well. P a t i e n t s ' preference  f o r t e a c h i n g , r e g a r d i n g the  s p e c i f i c s of t h e i r own heart c o n d i t i o n , t o come from p h y s i c i a n s was a l s o noted by T i l l e y , Gregor, and Thiessen (1987). education  In t h e i r study of the nurse's r o l e these  incongruencies  researchers  in patient  found not only were there  between nurses and p a t i e n t s i n who p a t i e n t s  viewed as the p r e f e r r e d teacher, but when p a t i e n t s t e a c h i n g should  felt  be done, and what t e a c h i n g the p a t i e n t s  d e s i r e d from nurses.  They concluded  t h a t nurses must stop  making assumptions about p a t i e n t s ' d e s i r e s r e g a r d i n g p a t i e n t education  and t h a t nurses need t o v a l i d a t e p a t i e n t s '  preferences  i n : "(a) the e d u c a t i o n a l approaches with which  p a t i e n t s f e e l most comfortable strategies), type  (e.g. group or i n d i v i d u a l  (b) the t i m i n g of p a t i e n t t e a c h i n g , and (c) the  of i n f o r m a t i o n p a t i e n t s can accommodate d u r i n g  various  103 stages of t h e i r The  i l l n e s s and  recovery"  (pp. 299-300).  f i n d i n g s from the present study support the need f o r  p a t i e n t s ' p r e f e r e n c e s to be v a l i d a t e d .  Of the f i v e s u b j e c t s  i n t h i s study, three p r e f e r r e d reading and two  p r e f e r r e d one-  on-one I n s t r u c t i o n as methods of o b t a i n i n g Information. w e l l , only one s u b j e c t expressed  As  Interest in participating  In  a group education program with the other s u b j e c t s r e l a t i n g t h a t groups were not t h e i r s t y l e .  Only three s u b j e c t s  commented on the t i m i n g of education r e c e i v e d , and p r e v i o u s l y d e s c r i b e d they were not  as  i n agreement as to when  t e a c h i n g should take p l a c e , which i n d i c a t e s t i m i n g of e d u c a t i o n was  a personal preference.  As p r e v i o u s l y d i s c u s s e d ,  the type of i n f o r m a t i o n p a t i e n t s wanted i n the r e c o v e r y p e r i o d at home d i f f e r e d  from the t r a d i t i o n a l t o p i c s of c a r d i a c  p a t i e n t education suggesting t h a t p a t i e n t s needs v a r y at d i f f e r e n t stages of t h e i r  illness.  The degree to which the p a t i e n t s In t h i s participated  study  i n s e l f education f o l l o w i n g t h e i r MI v a r i e d .  There appeared to be a c o r r e l a t i o n between l e a r n i n g s t y l e s , impact  of Ml and m o t i v a t i o n f o r s e l f l e a r n i n g , with the  s u b j e c t s who most, and who roles  had  f e l t the MI had  impacted  on t h e i r  lives  two the  p r e f e r r e d r e a d i n g , t a k i n g on the most a c t i v e  in s e l f education.  These two  s u b j e c t s used a v a r i e t y of  sources to o b t a i n f u r t h e r 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 p a t i e n t s r e q u i r e d  104 further  i n f o r m a t i o n appeared to be a p e r s o n a l preference  with  the s u b j e c t most a c t i v e i n s e l f education d e s c r i b i n g h e r s e l f as a person who 'craves'  information.  Both s u b j e c t s who r e p o r t e d  inadequate reading  ability  p r e f e r r e d the one-on-one method of I n s t r u c t i o n and n e i t h e r a c t i v e l y sought any f u r t h e r i n f o r m a t i o n except f o r q u e s t i o n i n g their physicians.  T h i s would suggest t h a t nurses need t o  assess p a t i e n t s ' p r e f e r e n c e s  i n i n s t r u c t i o n a l methods t o  ensure t h a t p a t i e n t s r e c e i v e i n f o r m a t i o n  In a way t h a t i s  e a s i l y comprehended by them. Although not a l l s u b j e c t s p r e f e r r e d r e a d i n g , a l l f i v e s u b j e c t s r e p o r t e d reading the MI book r e c e i v e d i n h o s p i t a l and four continued  to use i t as a r e f e r e n c e a t home.  encouraging f o r p a t i e n t educators developing  T h i s Is  who spend time and e f f o r t i n  these w r i t t e n t e a c h i n g a i d s .  However, i t must be  s t r e s s e d t h a t the presence of these a i d s does not r e l i e v e the nurse of her r e s p o n s i b i l i t y i n making sure p a t i e n t s are equiped with the i n f o r m a t i o n they need f o r t h e i r r e c o v e r y a t home.  As d i s c u s s e d p r e v i o u s l y , p a t i e n t s may have needs f o r  more s p e c i f i c  information regarding t h e i r  needs cannot be d e a l t with The  i n a general  i l l n e s s and these  i n f o r m a t i o n book.  s u b j e c t s i n t h i s study used t h e i r  physicians,  s p e c i f i c a l l y t h e i r c a r d i o l o g i s t s , and the Ml book r e c e i v e d In h o s p i t a l as t h e i r p r i n c i p a l sources  of i n f o r m a t i o n .  degree to which s u b j e c t s p a r t i c i p a t e d i n s e l f  The  education  v a r i e d , as d i d the amount of i n f o r m a t i o n d e s i r e d by each participant. obtaining  The s u b j e c t s who  p r e f e r r e d r e a d i n g as a means of  i n f o r m a t i o n took on a more a c t i v e r o l e  in their  own  education.  R e l a t i o n of F i n d i n g s to Conceptual Framework Anderson's (1985) a d a p t a t i o n of Kleinman's h e a l t h care system framework was investigated  used to c o n c e p t u a l i z e the problem being  i n t h i s study.  According to Anderson  " i n t e r a c t i o n s between the nurse and c l i e n t are t r a n s a c t i o n s between e x p l a n a t o r y models which d i f f e r e x p e c t a t i o n s and g o a l s " (p.238).  In c o g n i t i v e content,  E x p l a n a t o r y models " c o n t a i n  e x p l a n a t i o n s of any or a l l of the f i v e  issues: etiology;  onset  of symptoms; pathophysiology; course of s i c k n e s s ( s e v e r i t y type of s i c k r o l e ) ; and treatment"  (Kleinman,  1978,  Using the r e s e a r c h method of phenomenology i t was b e t t e r uunderstandlng  The  f i n d i n g s from t h i s study have shown t h a t p a t i e n t s  treatment Regardless  f o r t h e i r MI  i l l n e s s and  from the p e r s p e c t i v e of t h e i r  the  world.  of the i n f o r m a t i o n the p a t i e n t s had on standard  f a c t o r s they analyzed t h e i r s i t u a t i o n s  comparing themselves their  hoped t h a t a  obtained.  p e r c e i v e the e t i o l o g y , the course of t h e i r  risk  pp.87-88).  of the p a t i e n t ' s e x p l a n a t o r y model of  the MI experience would be  to others and  and  Individually  identifying factors in  l i f e s t y l e s which they b e l i e v e d c o n t r i b u t e d to t h e i r  by  106 having a HI.  Some adjustments  were made a c c o r d i n g to these  b e l i e f s , with the s u b j e c t s a p p l y i n g p e r s o n a l l i m i t a t i o n s these adjustments.  on  The p a t i e n t s d e s i r e to know the amount of  damage caused by t h e i r MI, t h e i r p r o g n o s i s , and f u t u r e treatments demonstrate i l l n e s s would e f f e c t the s u b j e c t s appeared  that they were concerned  their  with how t h i s  l i v e s i n the f u t u r e .  to be a r e t u r n to normal  The g o a l of activities.  Summary of F i n d i n g s The  initial  r e a c t i o n t o the Ml event, f o r these s u b j e c t s ,  was that of s u r p r i s e and d i s b e l i e f . rationalize because  The s u b j e c t s attempted t o  t h e i r Ml and expressed f e e l i n g s  they c o n s i d e r e d the e f f e c t s  of i n j u s t i c e  of t h e i r  risk  factors to  be minor when compared t o other people they knew. s u b j e c t s analyzed t h e i r  risk  f a c t o r s from t h e i r  The  own  p e r s p e c t i v e s o f t e n f o c u s i n g on one or two f a c t o r s 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  s e r i o u s n e s s and causes of the MI appear both t h e i r  outcomes and adjustments  r e g a r d i n g the  t o have i n f l u e n c e d  f o l l o w i n g t h e i r MI.  Thus,  the impact of the MI v a r i e d from having minimal e f f e c t t o being an Impetus f o r change. feelings  A decrease  of l i m i t a t i o n appeared  i n stamina  t o be the most  with  significant  p h y s i c a l outcome noted by these s u b j e c t s . The t r a d i t i o n a l t o p i c s of c a r d i a c p a t i e n t e d u c a t i o n were not i d e n t i f i e d as c a u s i n g concern f o r these s u b j e c t s .  The  107 l e a r n i n g needs of these s u b j e c t s d u r i n g the p e r i o d of r e c o v e r y a t home r e l a t e d t o knowing more about t h e i r own i n d i v i d u a l s i t u a t i o n r e g a r d i n g such t h i n g s as a c t i v i t y damage done by the MI focus  f o r these  f  and t h e i r prognosis  restrictions, and treatment.  p a t i e n t s appeared t o be o b t a i n i n g  The  information  t h a t would enable them t o p l a n f o r the long-term. The  c a r d i a c p a t i e n t education  r e c e i v e d by these  from h e a l t h p r o f e s s i o n a l s was not c o n s i s t e n t .  subjects  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 i n f o r m a t i o n and those who had r e c e i v e d i n f o r m a t i o n nurses,  and d i e t i c i a n s considered  from  i t b e n e f i c i a l as w e l l .  MI book, The heart t a l k s e r i e s heart a t t a c k  r  The  was p e r c e i v e d by  the s u b j e c t s as being h e l p f u l and was o f t e n used as a r e f e r e n c e by the s u b j e c t s a t home. The  degree t o which the s u b j e c t s p a r t i c i p a t e d i n s e l f  education  v a r i e d with the s u b j e c t s who p r e f e r r e d r e a d i n g , as a  method of o b t a i n i n g Information, i n t h e i r own e d u c a t i o n .  t a k i n g the most a c t i v e r o l e  The amount of i n f o r m a t i o n sought  appeared to be i n f l u e n c e d by the s u b j e c t s p e r s o n a l d e s i r e f o r Information  and the impact the MI had had on the s u b j e c t .  Conclusions The  s u b j e c t s d e s i r e t o r a t i o n a l i z e t h e i r MI by comparing  themselves t o others may have r e s u l t e d i n these minimizing  subjects  the magnitude of t h e i r own r i s k f a c t o r s .  Risk  f a c t o r s that appeared obvious t o t h i s h e a l t h p r o f e s s i o n a l were overlooked by these s u b j e c t s , such as d i a b e t e s , and  being  overweight.  T h i s supports the s u p p o s i t i o n  subjects' b e l i e f s regarding  However, there appeared to be  a w i l l i n g n e s s on the p a r t of the s u b j e c t s i n areas they viewed as important.  t o make adjustments  Thus, i t should  s t r e s s e d t h a t an assessment of the p a t i e n t ' s risk  that  the causes of t h e i r MI may d i f f e r  from that of the p r o f e s s i o n a l .  regarding  hypertension,  be  perceptions  f a c t o r s and causes of MI Is d e s i r e d  In order to  promote and encourage r i s k f a c t o r m o d i f i c a t i o n on an individual The  basis.  information  r e c e i v e d by the s u b j e c t s  on the  t r a d i t i o n a l t o p i c s of c a r d i a c p a t i e n t education beneficial.  However, the d e s i r e of the s u b j e c t s  were viewed as t o know more  of the s p e c i f i c s about t h 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 t h e i r prognosis and treatment the s u b j e c t s ' situation. order  focus  on the r e a l i t y of t h e i r own  Thus, general  information  t o make long-term plans  information  reflect  individual  may be h e l p f u l but i n  p a t i e n t s r e q u i r e t h a t the  r e c e i v e d be organized  according  to their  i n d i v i d u a l needs. The  information  needs of these s u b j e c t s v a r i e d , as d i d  t h e i r d e s i r e and m o t i v a t i o n preferences education,  to o b t a i n  Information.  Personal  f o r the method of i n s t r u c t i o n , t i m i n g of and type and amount of i n f o r m a t i o n  r e c e i v e d were  109  expressed  by these s u b j e c t s .  The type  of i n f o r m a t i o n  requested  i n the recovery p e r i o d a t home r e f l e c t e d the  s u b j e c t s ' d e s i r e to understand the long-term e f f e c t s of t h e i r MI.  Therefore,  general  i n f o r m a t i o n r e g a r d i n g MI and i t s  treatment can be viewed as h e l p f u l t o p a t i e n t s but they require s p e c i f i c  still  i n f o r m a t i o n about t h e i r own MI.  Although the MI book was viewed as b e n e f i c i a l i t contained  only general  i n f o r m a t i o n , thus the d e s i r e f o r  i n f o r m a t i o n s p e c i f i c to themselves may have been the Impetus for  these  resources.  s u b j e c t s t o use t h e i r p h y s i c i a n s as p r i n c i p a l The s u b j e c t s appeared unclear as t o the r o l e of  nurses i n the education  process, with only one of the three  s u b j e c t s not r e c e i v i n g i n s t r u c t i o n from nurses even commenting on i t s absence.  In the next s e c t i o n the i m p l i c a t i o n s these  f i n d i n g s have f o r n u r s i n g p r a c t i c e , e d u c a t i o n , will  and r e s e a r c h  be presented.  implications for Nursing Practice Nurses i n the p r a c t i c e s e t t i n g must be cognizant  of the  f a c t t h a t the p a t i e n t ' s p e r s p e c t i v e of the MI experience differ  from t h a t of the h e a l t h p r o f e s s s l o n a l .  assume t h a t what i s obvious to them, i n regards m o d i f i c a t i o n and l i f e s t y l e  may  Nurses cannot to risk factor  adjustments post-MI, w i l l be  obvious to the p a t i e n t . In order t o d e l i v e r p a t i e n t education  t h a t w i l l be more  110 b e n e f i c i a l to the p a t i e n t nurses must complete i n d i v i d u a l assessments which i d e n t i f y the p a t i e n t s : (1) b e l i e f s risk  regarding  f a c t o r s and causes of MI; (2) d e s i r e f o r i n f o r m a t i o n ;  preference  (3)  f o r method of i n s t r u c t i o n ; and, ( 4 ) preference f o r  t i m i n g of e d u c a t i o n .  T h i s type of assessment w i l l help  nurses  i n c l a r i f y i n g misconceptions t h a t might i n f l u e n c e adjustments made by p a t i e n t s and t o i d e n t i f y the method and t i m i n g of i n s t r u c t i o n d e s i r e d by p a t i e n t s . The  f a c t that only two of the f i v e s u b j e c t s  in this  study  r e c e i v e d p a t i e n t education  from nurses d u r i n g  the h o s p i t a l  s t a y leads one to q u e s t i o n  the p r i o r i t y given  to p a t i e n t  education  i n the p r a c t i c e s e t t i n g .  As w e l l , the f i n d i n g s In  t h i s study demonstrate that p a t i e n t s do have i n f o r m a t i o n f o l l o w i n g t h e i r Mis but t h a t they are unclear of nurses i n f u l f i l l i n g  these needs.  needs  as t o the r o l e  Thus, nurses must be  more a c t i v e i n d e l i n e a t i n g t h e i r r o l e i n p a t i e n t education and actually functioning  i n that  role.  Implications for Nursing Education The  promotion of the nurse as a p a t i e n t educator begins  with each nurse's e d u c a t i o n a l  development.  Students must be  prepared to take on the r o l e of p a t i e n t educator and to be s u p p l i e d with the t o o l s necessary t o teach t h e i r It  i s hoped that the p r i o r i t y given  throughout the students e d u c a t i o n a l  to p a t i e n t  patients. education  experience w i l l be  Ill transferred  to the  practice setting.  Nurse educators must a l s o prepare t h e i r students to consider  that the  experience may  patient's  differ  perspective  patient's  small  and  I l l n e s s experience by  including  to  the  sample s i z e i n t h i s study l i m i t s the amount of be taken from the  f i n d i n g s suggest t h a t  MI  w i l l prompt the student  f o r Nursing Research  d i r e c t i o n t h a t can  to b e t t e r  professional.  perspective.  Implications The  Illness  from t h a t of the h e a l t h  An awareness of these d i f f e r e n c e s more f u l l y analyze the  of an  However, the  f u r t h e r study i n t h i s area i s  understand the  required  i l l n e s s experience of p a t i e n t s  t h e i r e d u c a t i o n needs.  t h i s study using  findings.  post-  T h e r e f o r e , a r e p l i c a t i o n of  a l a r g e r sample i s recommended.  During the a n a l y s i s of the data other areas of concern were r a i s e d that experience.  i n v i t e f u r t h e r research  These areas i n c l u d e :  patients' health  b e l i e f s on  the m a i n t a i n i n g of p a t i e n t s '  (1) the  of the p a t i e n t ' s Influence  of  l i f e s t y l e adjustments post-MI; l i f e s t y l e adjustments over  long-term; (3) the d i f f e r e n c e s  i n p e r c e p t i o n s of  experience i n r e l a t i o n to p a t i e n t s ' gender; (4) differences  MI  the  the the  i n p e r c e p t i o n s of the experience i n r e l a t i o n to  p a t i e n t s ' age;  and,  (5) the  influence  p a t i e n t s ' p a r t i c i p a t i o n i n t h e i r own  of l e a r n i n g s t y l e s patient education.  on As  (2)  112 w e l l , the f i n d i n g s In t h i s study support research  i n t o the nurse's r o l e  the need f o r more  In p a t i e n t education  from both  the p e r s p e c t i v e of the nurse and the p a t i e n t .  summary In t h i s chapter  the f i n d i n g s of t h i s study were d i s c u s s e d  i n r e l a t i o n t o the purpose of the study,  the conceptual  framework, and the a v a i l a b l e l i t e r a t u r e .  The f i n d i n g s were  summarized and the c o n c l u s i o n s presented. i m p l i c a t i o n s of these education,  L a s t l y , the  f i n d i n g s f o r nursing p r a c t i c e ,  and r e s e a r c h were  presented.  In c o n c l u s i o n , the f i n d i n g s of t h i s study suggest t h a t h e a l t h p r o f e s s i o n a l s and p a t i e n t s do view the MI from d i f f e r e n t understanding world  perspectives.  occurrence  The emphasis of the p a t i e n t s on  the MI experience  i s reflected  from the r e a l i t y of t h e i r  i n t h e i r attempts t o r a t i o n a l i z e the  of the MI and t h e i r d e s i r e s t o know more about  t h e i r own MI, p r o g n o s i s , p a t i e n t education  and treatment.  In order to plan  t h a t w i l l a s s i s t post-MI p a t i e n t s i n t h e i r  r e c o v e r y h e a l t h p r o f e s s i o n a l s must assess individually  for their:  method of i n s t r u c t i o n ;  patients  (1) b e l i e f s r e g a r d i n g r i s k f a c t o r s and  causes of MI; (2) d e s i r e f o r i n f o r m a t i o n ;  education.  experience  and, ( 4 ) preference  (3) preference f o r f o r t i m i n g of  113 References Anderson, J . M. (1985). The s o c i o c u l t u r a l context of h e a l t h 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 h e a l t h n u r s i n g i n Canada (pp. 233-245). Toronto: Gage E d u c a t i o n . Boogaard, M. A. K. (1984). R e h a b i l i t a t i o n of the female p a t i e n t a f t e r myocardial I n f a r c t i o n . Nursing C l i n i c s of North America, 19(3), 433-439. Burgess, A. W., & Hartman, c. R. (1986). P a t i e n t s ' p e r c e p t i o n s of the c a r d i a c c r i s i s . 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Sex d i f f e r e n c e s In f a c t o r s a s s o c i a t e d with use of medical care and a l t e r n a t i v e i l l n e s s b e h a v i o r s . S o c i a l Science and Medicine. 12(3), 285-292. M i l l e r , B. F. & Keane, C. B. (1972). E n c y c l o p e d i a and d i c t i o n a r y of medicine and n u r s i n g . P h i l a d e l p h i a , PA: W.B.Saunders. M i l l e r , P., McMahon, M., G a r e t t , M. J . , & R i n g e l , K. (1989). A content a n a l y s i s of l i f e adjustments post I n f a r c t i o n . Western J o u r n a l of Nursing Research, 11(5), 559-567. M i l l s , G., Barnes, R., R o d e l l , D., & T e r r y , L. (1985). An e v a l u a t i o n of an I n p a t i e n t c a r d i a c p a t i e n t / f a m i l y education program. Heart and Lung, 14.(4), 400-406. M i n i s t e r of Supply and S e r v i c e s . (1987). Canada year book 1988. Ottawa: Author. Morse, J . M. (1986). Q u a n t i t a t i v e and q u a l i t a t i v e r e s e a r c h : Issues i n sampling. In P.L. Chlnn (Ed.), Nursing r e s e a r c h methodology Issues and implementation (pp.181-193). R o c k v i l l e , MD: Aspen. Moynihan, M. (1984). A s s e s s i n g the e d u c a t i o n a l needs of p o s t myocardial I n f a r c t i o n p a t i e n t s . Nursing C l i n i c s of North America. 19_(3), 441-447. Murray, P. J . (1989). R e h a b i l i t a t i o n Information and h e a l t h b e l i e f s i n the post-coronary p a t i e n t : Do we meet t h e i r i n f o r m a t i o n needs? J o u r n a l of Advanced Nursing, l i , 686-  693.  116 Nagle, R., Gangola, R., & Plcton-Robinson, I. (1971). F a c t o r s i n f l u e n c i n g r e t u r n t o work a f t e r 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). P o s t d i s c h a r g e concerns of c a r d i a c p a t i e n t s as presented v i a a telephone c a l l b a c k system. Heart and Lunq 15.(3), 268-272. r  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 p e r s p e c t i v e (pp. 69-84). Norwalk, CT: AppletonCentury-Crofts. Ott,  C. R., S i v a r a j a n , E. S., Newton, K. M., Almes, M. J . , Bruce, R. A., Bergner, M., & G i l s o n , B. S. (1983). A c o n t r o l l e d randomized study of e a r l y c a r d i a c r e h a b i l i t a t i o n : The s i c k n e s s 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). C a r d i a c r e h a b i l i t a t i o n : A p a t i e n t e d u c a t i o n program. Nursing Research, 21(3), 148-150. P f i s t e r e r , J . (1975). L e a r n i n g needs of the c a r d i a c p a t i e n t being d i s c h a r g e d from h o s p i t a l as seen by the p a t i e n t , h i s d o c t o r , and h i s nurse. Nursing Papers, 1 ( 2 ) , 29-31. Pozen, M. W., S t e c h m i l l e r , J . A., H a r r i s , W., Smith, S., F r i e d , D. D., & V o i g t , G. C. (1977). A nurse r e h a b l l l t a t o r * s impact on p a t i e n t s with myocardial i n f a r c t i o n . Medical Care, 15.(10), 830-837. R a l e i g h , E. H., & Odtohan, B. C. (1987). The e f f e c t of a c a r d i a c t e a c h i n g program on p a t i e n t r e h a b i l i t a t i o n . Heart and L u n g , 16.(3), 311-317. Rudy, E. B. (1980). P a t i e n t s ' and spouses' c a u s a l e x p l a n a t i o n s of a myocardial i n f a r c t i o n . Nursing Research, 22.(6), 352356. Runions, J . (1988). Research i n c a r d i a c 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). R o c k v i l l e , 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 p r e v e n t i o n f o r p a t i e n t s with acute myocardial i n f a r c t i o n as p a r t of a comprehensive community programme f o r c o n t r o l of c a r d i o v a s c u l a r d i s e a s e s (North K a r e l i a p r o j e c t ) . Scandinavian J o u r n a l of R e h a b i l i t a t i o n Medicine 12, 33-42.  117 Sandelowski, M. (1986). The problem of r i g o r i n q u a l i t a t i v e r e s e a r c h . Advances i n Nursing Science, 8_(3), 27-37. S c a l z i , C. C , Burke, L. E., & Greenland, S. (1980). E v a l u a t i o n of an i n p a t i e n t e d u c a t i o n a l program f o r coronary p a t i e n t s and f a m i l i e s . Heart and Luna, i ( 5 ) , 846-853. S i v a r a j a n , E. S., Newton, K. M., Almes, M. J . , Kempf, T. M., M a n s f i e l d , L. W., & Bruce, R. A. (1983). L i m i t e d e f f e c t s of o u t p a t i e n t t e a c h i n g and c o u n s e l i n g a f t e r myocardial i n f a r c t i o n : A c o n t r o l l e d study. Heart and Lung, 12.(1), 6573. Sorenson, G., P i r i e , P., Folsom, A., Luepker, R., & Jacobs, D. (1985). Sex d i f f e r e n c e s i n the r e l a t i o n s h i p between work and h e a l t h : the Minnesota heart survey. J o u r n a l of Health and S o c i a l Behavior, 2£_, 379-395. S t e e l e , J . M. & R u z i c k i , D. (1987). An e v a l u a t i o n of the e f f e c t i v e n e s s of c a r d i a c t e a c h i n g d u r i n g h o s p i t a l i z a t i o n . Heart and Lung, 16.(3), 306-311. S t e r n , M. J . , P a s c a l e , L., & Ackerman, A. (1977). L i f e adjustment postmyocardial i n f a r c t i o n . A r c h i v e s of I n t e r n a l Medicine, 137, 1680-1685. The heart t a l k s e r i e s h e a r t a t t a c k . (1988). Manitoba: Heart and Stroke Foundation of Manitoba. T i l l e y , J . D., Gregor, F. M., & T h i e s s e n , V. (1987). The nurse's r o l e i n p a t i e n t e d u c a t i o n : Incongruent p e r c e p t i o n s among nurses and p a t i e n t s . J o u r n a l of Advanced Nursing, 12., 291-301. Webster, K. K., & Christman, N. J . (1988). P e r c e i v e d u n c e r t a i n t y and coping post myocardial I n f a r c t i o n . Western J o u r n a l of Nursing Research, IpJ 4), 384-400. Wenger, N. K. (1979). R e h a b i l i t a t i o n of the p a t i e n t a f t e r 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: S t r a t t o n I n t e r c o n t i n e n t a l M e d i c a l Book. White, C. W., Lemon, D. K., & Albanese, M. A. (1980). E f f i c a c y of h e a l t h e d u c a t i o n e f f o r t s i n h o s p i t a l i z e d p a t i e n t s with s e r i o u s c a r d l v a s c u l a r I l l n e s s : Can t e a c h i n g succeed? P a t i e n t C o u n s e l l i n g and Health E d u c a t i o n , 1-3, 189-196.  118 Wishnie, H. A., Hackett, T. P., & Cassem, N. H. (1971). P s y c h o l o g i c a l hazards of convalescence f o l l o w i n g 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 i n t e r v e n t i o n f o r coronary a r t e r y d i s e a s e : C l i e n t s ' p e r c e p t i o n s and concerns. Unpublished master's t h e s i s , The U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C.  119  Appendix A P h y s i c i a n Information-Consent My name i s Dawna DeAdder.  Letter  I am a R e g i s t e r e d Nurse and a  student i n the Master  of Science i n Nursing Program a t the  U n i v e r s i t y of B r i t i s h  Columbia.  entitled  "The  I am conducting a study  I l l n e s s Experience of P a t i e n t s F o l l o w i n g a  Myocardial I n f a r c t i o n : I m p l i c a t i o n s f o r P a t i e n t E d u c a t i o n " . T h i s study w i l l examine what i t means t o p a t i e n t s to have had an MI and how The  having had an MI a f f e c t s t h e i r day-to-day  focus of t h i s study i s to examine how  lives.  these experiences  r e l a t e to what p a t i e n t s I d e n t i f y as t h e i r l e a r n i n g needs post MI and how  they meet these needs.  I would l i k e regarding t h e i r first,  of two  conducted  to Interview a sample of your p a t i e n t s  illness  experience f o l l o w i n g an MI.  Interviews, with each p a r t i c i p a n t w i l l  be  two t o four weeks f o l l o w i n g the p a r t i c i p a n t ' s  Second i n t e r v i e w s to v a l i d a t e and c l a r i f y data w i l l conducted  The  as data i s being a n a l y z e d .  The  be  Interviews w i l l  approximately one hour i n l e n g t h and w i l l be conducted p a r t i c i p a n t s ' homes. soon as  MI.  be  i n the  I would l i k e to commence i n t e r v i e w i n g as  possible.  To p a r t i c i p a t e  i n t h i s study an i n d i v i d u a l must be  between the ages of 30 and  65, able to speak and  English, experiencing his/her f i r s t c i t y of Vancouver.  MI, and  understand  l i v i n g w i t h i n the  E i g h t to ten p a r t i c i p a n t s are r e q u i r e d and  w i l l be obtained from the U n i v e r s i t y H o s p i t a l , UBC  Site.  The  121 Appendix B P a r t i c i p a n t Information-Consent My name Is Dawna DeAdder.  Letter  I am a R e g i s t e r e d Nurse and a  student i n the Master of Science i n Nursing Program a t the U n i v e r s i t y of B r i t i s h Columbia.  I am I n t e r e s t e d i n l e a r n i n g  about c a r d i a c p a t i e n t s ' i l l n e s s  experience f o l l o w i n g a heart  attack.  My study i s e n t i t l e d  "The I l l n e s s Experience of  P a t i e n t s F o l l o w i n g a Myocardial I n f a r c t i o n : I m p l i c a t i o n s f o r Patient  Education".  I am i n v i t i n g you t o p a r t i c i p a t e  in this  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 o c c a s i o n s .  If  you wish t o p a r t i c i p a t e you w i l l be interviewed i n your home i n 2 t o 4 weeks time. take approximately help c l a r i f y  I w i l l conduct  the i n t e r v i e w which w i l l  one hour and i t w i l l be tape r e c o r d e d .  To  i n f o r m a t i o n obtained d u r i n g the f i r s t i n t e r v i e w  i t w i l l be necessary t o i n t e r v i e w you again a t a l a t e r  time.  If a t any time you wish to stop the i n t e r v i e w , stop the r e c o r d i n g , or have p o r t i o n s of the tape erased you may. Although  your p a r t i c i p a t i o n  i n t h i s study may not b e n e f i t  you d i r e c t l y , the s h a r i n g of your experience w i l l help b e t t e r understand  the i l l n e s s  a heart a t t a c k which w i l l  nurses  experience of p a t i e n t s f o l l o w i n g  improve care f o r heart a t t a c k  p a t i e n t s i n the f u t u r e . Your p a r t i c i p a t i o n i n t h i s study i s s t r i c t l y v o l u n t a r y and  r e f u s a l t o p a r t i c i p a t e w i l l not a f f e c t your medical or  nursing care.  You may withdraw from the study a t any time.  Appendix C Demographic Data She (1) gender (2) age (3) e t h n i c o r i g i n (4) primary language (5) occupation (6) m a r i t a l s t a t u s (7) education (8) other  level  h e a l t h problems  Appendix D Interview T r i g g e r Questions (1) T e l l me about your f i r s t  few weeks a t home f o l l o w i n g your  heart a t t a c k . (2) How  has having had a heart a t t a c k a f f e c t e d your day-to-  day r o u t i n e ? (3)  What i n f o r m a t i o n d i d you r e c e i v e about your heart  attack?  and from whom? ( 4 ) Now  t h a t you are home, what Information do you f e e l i s  h e l p f u l or would be h e l p f u l  i n managing your heart  disease?  

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