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Perceptions of learning needs for patients with heart valve replacements four to ten weeks after hospital… Lespérance, Andrew Michael 1995

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P E R C E P T I O N S OF L E A R N I N G N E E D S F O R P A T I E N T S W I T H H E A R T V A L V E R E P L A C E M E N T S F O U R TO T E N W E E K S A F T E R H O S P I T A L D I S C H A R G E B y ANDREW M I C H A E L L E S P E R A N C E B . S . N . , L a u r e n t i a n U n i v e r s i t y , 1 9 9 0 A T H E S I S . S U B M I T T E D I N P A R T I A L F U L F I L M E N T OF T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R OF S C I E N C E I N N U R S I N G i n T H E F A C U L T Y O F G R A D U A T E S T U D I E S T h e S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d U n i v e r s i t y o f B r i t i s h C o l u m b i a O c t o b e r 1 9 9 5 © A n d r e w M i c h a e l L e s p e r a n c e In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. 6 Department of The University of British Columbia Vancouver, Canada Date DE-6 (2/88) A b s t r a c t T h i s s t u d y w a s u n d e r t a k e n b e c a u s e a r e v i e w o f t h e l i t e r a t u r e r e v e a l e d t h a t t h e r e h a d b e e n l i m i t e d r e s e a r c h p e r t a i n i n g t o t h e l e a r n i n g n e e d s o f p a t i e n t s w i t h h e a r t v a l v e r e p l a c e m e n t s . T h e f o c u s o f t h e s t u d y w a s t o d e t e r m i n e w h a t t h i s p a t i e n t p o p u l a t i o n p e r c e i v e d t h e i r l e a r n i n g n e e d s t o b e d u r i n g t h e e a r l y w e e k s a f t e r h o s p i t a l d i s c h a r g e , w h e n t h e y o c c u r r e d , a n d h o w t h e y s h o u l d b e a d d r e s s e d . E t h i c a l a p p r o v a l f o r t h e s t u d y w a s o b t a i n e d f r o m b o t h t h e V a n c o u v e r H o s p i t a l a n d T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a e t h i c s a p p r o v a l c o m m i t t e e s . A d e s c r i p t i v e m e t h o d o l o g y w a s u s e d . H e n d e r s o n ' s p h i l o s o p h y o f n u r s i n g w a s u s e d t o a s s i s t i n d e v i s i n g p r o m p t s f o r t h e s e m i - s t r u c t u r e d i n t e r v i e w p r o c e s s . E i g h t e e n p a t i e n t s w e r e r e c r u i t e d f r o m a l o c a l t e a c h i n g h o s p i t a l a n d i n t e r v i e w e d i n t h e i r h o m e s f o u r t o t e n w e e k s a f t e r h o s p i t a l d i s c h a r g e . T h e i n t e r v i e w s w e r e t a p e d a n d t r a n s c r i b e d . M a n i f e s t a n d l a t e n t c o n t e n t a n a l y s i s w e r e u s e d t o a n a l y z e t h e d a t a . T h e r e s u l t s r e v e a l e d m a n y o f t h e t r a d i t i o n a l c a r d i a c l e a r n i n g n e e d s a p p l i e d t o t h i s p a t i e n t p o p u l a t i o n i n c l u d i n g s u c h t h i n g s a s t h e n e e d f o r e d u c a t i o n r e l a t e d t o f a t i g u e , m o b i l i t y , e m o t i o n s , a c t i v i t i e s o f d a i l y l i v i n g , s u p p o r t a n d m e d i c a t i o n , e x e r c i s e s a n d t h e r e s u m p t i o n o f s e x u a l a c t i v i t y . H o w e v e r , w i t h i n t h e s e g e n e r a l c a t e g o r i e s , s p e c i f i c e d u c a t i o n r e q u i r e m e n t s r e l a t e d t o t h e v a l v e r e p l a c e m e n t p o p u l a t i o n w e r e I l l n o t e d . I n f o r m a t i o n a n d e d u c a t i o n w a s r e q u i r e d f o r s u c h i s s u e s a s t h e v a l v e ' s l i f e e x p e c t a n c y , t h e p o t e n t i a l f o r v a l v e f a i l u r e , t h e a n t i c o a g u l a n t r e g i m e n , a n d n u t r i t i o n a l r e q u i r e m e n t s . P a r t i c i p a n t s a l s o e x p r e s s e d v a l v e r e l a t e d f e a r s , a n d r e q u i r e d t i m e t o a d j u s t t o t h e s e . T h e n e e d f o r s o c i a l , s u p p o r t w a s e x p r e s s e d b y a l l p a r t i c i p a n t s . I t w a s d e t e r m i n e d t h a t s i n g l e p e o p l e a n d w o m e n r e s u m e d v a r i o u s a c t i v i t i e s e a r l i e r i n r e c o v e r y t h a n m a r r i e d a n d m a l e p a r t i c i p a n t s . P a r t i c i p a n t s p r e f e r r e d h a v i n g t h e i r p h y s i c i a n s e d u c a t e t h e m o n a o n e t o o n e b a s i s a b o u t t h e r e c o v e r y p r o c e s s , a n d b e l i e v e d p o s t - o p e r a t i v e e d u c a t i o n w a s b e s t p r o v i d e d i n h o s p i t a l w e l l b e f o r e d i s c h a r g e . C o n c l u s i o n s a r e d r a w n a n d t h e i m p l i c a t i o n s t h e r e s u l t s h a v e f o r n u r s i n g e d u c a t i o n , p r a c t i c e , r e s e a r c h a n d o t h e r h e a l t h c a r e p r o f e s s i o n a l s a r e d i s c u s s e d . T A B L E O F C O N T E N T S i v P a g e A b s t r a c t . . . . i i T A B L E O F C O N T E N T S . i v T a b l e s v i i A c k n o w l e d g e m e n t s . . . . . . . . . . . . . v i i i C H A P T E R O N E 1 I n t r o d u c t i o n 1 B a c k g r o u n d . . . . . . . . . . 2 P r o b l e m S t a t e m e n t ' H P u r p o s e o f t h e S t u d y 12 R e s e a r c h Q u e s t i o n . 13 T h e o r e t i c a l F r a m e w o r k . . . . . . . 13 D e f i n i t i o n o f T e r m s . . . . . . . . 15 ' A s s u m p t i o n s 17 L i m i t a t i o n s 17 Suxt imary . 18 C H A P T E R TWO 20 R e v i e w o f t h e L i t e r a t u r e 20 C a r d i a c R e h a b i l i t a t i o n 20 P h y s i c a l a n d F u n c t i o n a l O u t c o m e s 22 F u n c t i o n a l a n d P s y c h o l o g i c a l O u t c o m e s . . . . . . 24 P s y c h o s o c i a l F u n c t i o n i n g 27 R e t u r n t o W o r k 29 P s y c h o l o g i c a l A d j u s t m e n t t o H e a r t . S u r g e r y 31 P s y c h o s i s a n d S l e e p D e p r i v a t i o n . . . . . . . . 32 A n x i e t y a n d D e p r e s s i o n 33 P a t i e n t E d u c a t i o n 37 P a t i e n t C o m p l i a n c e . 39 E v a l u a t i o n o f P a t i e n t E d u c a t i o n . 4 1 H e a r t V a l v e R e c i p i e n t s a n d E d u c a t i o n . . . . . 43 P a t i e n t s ' P e r c e p t i o n s o f E d u c a t i o n a l P r o g r a m s . . 45 P a t i e n t s ' P e r c e p t i o n s o f L e a r n i n g N e e d s . . . . . . 4 8 C a r d i a c P a t i e n t s ' P e r c e p t i o n s o f L e a r n i n g N e e d s . 50 P a t i e n t s ' a n d N u r s e s ' B e l i e f s a n d L e a r n i n g n e e d s 52 T e l e p h o n e F o l l o w U p a n d L e a r n i n g N e e d s 54 S u m m a r y . . 56 C H A P T E R T H R E E . . . 59 > M e t h o d o l o g y . 59 R e s e a r c h D e s i g n . 59 T h e S a m p l e > 59 P a r t i c i p a n t S e l e c t i o n 60 Participant Recruitment . . . 61 Human Rights and Ethical Considerations . . . . . . 62 Data Collection and Analysis '. 63 Learning Needs Interview Guide 63 Data Analysis 65 Validity and Reliability . . . . . 66 Summary 67 CHAPTER FOUR . . . . . . . . 68 Findings. . . 68 Section One: Participant Characteristic 68 Section Two: The Pre-Operative Process 70 The Stories . •• . 70 Choices: Surgery and Valves . . . . . . . . . . 72 Discussion 76 Emotions . . . 77 Discussion 80 Section Three: Postoperative Experiences . . . . . 81 Discharge Process . . . . 81 Discussion . . . . . . . . . 81 Fatigue and Weakness 82 Discussion 84 Mobility 86 Discussion 89 Resumption of Activities . 90 Discussion . . . . . . . . . . . 92 Resumption of Sexual Activity 93 Discussion 95 Pain and Medications . 96 Discussion 101 Valve Clicking . . . . 103 Discussion . . . . . . . . . . . 104 The Incision . 104 Discussion . . . . . . . . . . . 108 Nutrition 108 Discussion I l l Post-Operative Complications . . . I l l Return to Work . . . 112 Discussion . . . . . . . . . . 114 Emotions . 115 Discussion . 119 Support . 122 Discussion 127 Section Summary . . . . . . . . . . . . . . . . . . 128 Section Four: Addressing Learning Needs' . . . . . . 129 Post-Operative Education 129 Educational Materials 130 Discussion . . . . 133 Encountering Learning Needs 134 Discussion . . . 135 v i Education: Transferring Knowledge . . . 137 Discussion . . . . 140 Henderson's Framework . 141 Surrimary 143 CHAPTER FIVE - . . . . . . . . . . . . 145 Conclusions . . . . . . . . . . . . . 145 Implications 147 Implications for Nursing Education . . . . . . . 147 Implications for Practice 148 Implications for Further Research 152 Implications for Health Care Professionals . . . 154 Summary . . . . ; 155 References 156 Appendix A Information Letter to Participants . . . 165 B Consent Form for the Research . . . . . 169 C Learning Needs Interview Guide 172 D Information Letter to the Surgeons . . . . 177 E Intermediary Information Sheet 180 F Demographics Tables 182 T a b l e s T a b l e I : A g e R a n g e s . . . T a b l e I I : S u r g i c a l R e p l a c e m e n t T a b l e I I I : E d u c a t i o n . . . V l l l A C K N O W L E D G E M E N T S T h i s r e s e a r c h w o u l d n o t h a v e b e e n r e a l i z e d i f i t w a s n ' t f o r t h e w i l l i n g n e s s o f t h e e i g h t e e n p a r t i c i p a n t s t o s h a r e t h e i r p e r s o n a l s t o r i e s , h a p p i n e s s a n d t r a g e d i e s . I t h a n k t h e m " w i t h a l l m y h e a r t " . T h e r e a r e s e v e r a l p e o p l e w h o m r e q u i r e s p e c i a l m e n t i o n . I b e g i n b y t h a n k i n g L u c y , m y l o v i n g p a r t n e r , f o r h e r p a t i e n c e a n d e n d l e s s m o r a l s u p p o r t . I a l s o t h a n k t h o s e p e o p l e w i t h i n U B C w h o c h e e r e d me u p , b r o u g h t i n c h o c o l a t e t r e a t s , h e l p e d w i t h e -m a i l i n g a n d p r i n t i n g o f t h e m a n y d r a f t s , t o o k me t o l u n c h i n t h e ' 5 6 c a d d y ' , e t c . T h e s e w e r e t r u l y e x p e r i e n c e s I w i l l a l w a y s r e m e m b e r M y c o m m i t t e e c o n s i s t i n g o f C a r o l J i l l i n g s , J a n e t G o r m i c k a n d C o n n i e C a n a m a l s o r e q u i r e a s p e c i a l t h a n k y o u . F i n a l l y , I w o u l d l i k e t o t h a n k my f a m i l y , E d g a r a n d C e c i l e , G e r r y , V a l a n d A n t h o n y , C o n n i e a n d G r a h a m , C a r m e n , A n d r e , T i m m y . a n d K e v i n . f o r t h e i r c o n t i n u e d u n c o n d i t i o n a l l o v e a n d s u p p o r t t h r o u g h o u t t h i s a n d my o t h e r i n c r e d i b l y s t u p i d a d v e n t u r e s . CHAPTER ONE Introduction Diseases of the cardiovascular system remain the p r i n c i p a l cause of premature morbidity, death and hospital days u t i l i z a t i o n i n Canada (Dubois, Cassidy, & Wilson, 1994; O'Connor, 1987). In 1987, diseases of the cardiovascular system accounted for approximately 25 percent of a l l long term d i s a b i l i t y pensions paid by the Canada Pension Plan (O'Connor, 1987). Cardiac disorders can lead to chronic i l l n e s s , d i s a b i l i t y and unemployment, a l l of which contribute to a less than productive l i f e s t y l e (King, 1994). Deterioration i n the functioning of one or more of the heart's valves i s an example of a gradual chronic cardiac i l l n e s s (Finkelmeier, Hartz, Fisher, & Michaelis, 1989). Progressive valve f a i l u r e exacerbates cardiac symptoms, bringing with i t the need for aggressive medical management and eventually surgery (King, 1994). When surgery i s indicated, the patient requires information pertaining to the process of cardiac r e h a b i l i t a t i o n . This i s t y p i c a l l y accomplished through the process of patient education designed to a s s i s t the individual i n developing the requisite knowledge, attitudes and behaviours required to manage recovery at home, thus assuring continuity i n patient care (Boyd, 1987). Consequently patient education i s an essential component of the r e h a b i l i t a t i o n process (Canadian Council of Cardiovascular Nurses (CCCN), 1993; Lindsay, Jenrich, & Biemolt, 1991). Limited research exists pertaining to patients with heart valve replacements and their' self-perceived learning needs during recovery (Hagenhoff, Feutz, Conn, Sagehorn, & Moranville-Hunziker, 1994). Determining these learning needs and including them i n hospital discharge planning and r e h a b i l i t a t i o n programs w i l l a s s i s t i n meeting this patient population's needs once home, thus allowing the patient to regain an optimal level of functioning during r e h a b i l i t a t i o n (Boogaard, 1984; CCCN, 1993; G i l l i s s , 1984; J i l l i n g s , 1988; MacKenzie, 1993; Wingate, 1991). Background During the l a s t three decades, advances i n the diagnosis and treatment of heart defects have made a larger percentage of d e f i c i t s operable (Lumpp, 1968; Wingate, 1991). From A p r i l of 1991 to March of 1992, 5719 valve replacement surgeries were performed i n Canada ( S t a t i s t i c s Canada, 1992). Of these, 841 cases were completed i n B r i t i s h Columbia, with approximately the same number of male and female patients undergoing surgery ( S t a t i s t i c s Canada, 1992). Rankin (1990) noted that h i s t o r i c a l l y a greater percentage of valve disorders have occurred i n women, due to their increased incidence of rheumatic heart disease. The f i r s t heart valve prosthesis was developed more than t h i r t y years ago (Nolan, 1992). Over the past three decades, more than s i x t y valve replacement devices have been conceived and rejected, but each has contributed to the current understanding of heart valve disease and performance (Nolan, 1992) Heart valve diseases can be either congenital or acquired (King, 1994; Schakenback, 1987). Acquired diseases are s i g n i f i c a n t l y more common i n those over the age of 30 and resul t predominantly from rheumatic heart disease, infections and c a l c i f i c a t i o n (King, 1994; Rosen, Klein, Rosen, Laczkovics, Rokitansky, & Beck, 1992; Utz & Grass, 1987; Schakenback, 1987; Wingate, 1987). Valve disorders are i r r e v e r s i b l e and. progressive i n nature.with the ao r t i c and mi t r a l valves predominantly affected (King, 1994; Lumpp, 1968). Acquired valvular diseases include stenosis and regurgitation (King, 1994; Schakenback, 1987). Schakenback (1987) described valvular stenosis as a gradual narrowing of the blood flow pathway by the valve and i t s surrounding structures. Eventually, greater pressure i s required to open the valve and allow for normal blood flow, increasing the work of the surrounding heart muscle. Regurgitation or i n s u f f i c i e n c y occurs when there i s a poorly functioning or leaky valve. The blood flow through the valve becomes b i - d i r e c t i o n a l , again increasing the work of the heart. Stenosis and regurgitation can occur i n i s o l a t i o n or i n combination with one or multiple valves. Regardless, the result i s a gradual decrease i n cardiac function, an increased workload on either the right or l e f t v e n t r i c l e of the heart and complications such as pulmonary oedema, syncope and angina (King, 1994; Lumpp, 1968). Manifestations of progressive chronic i l l n e s s include pedal oedema, shortness of breath, decreased a c t i v i t y tolerance, malaise, fatigue, fever and chest pain (King, 1994; Utz & Grass, 1987). ~ Those individuals affected are compelled to make si g n i f i c a n t changes i n their patterns of d a i l y l i v i n g (Utz & Grass, 1987) . Such changes include working less (or not at a l l ) , l i m i t i n g physical a c t i v i t i e s (eg. moving to one flo o r of a house i n order to avoid s t a i r s ) , i n s t i t u t i n g a medication regimen, l i m i t i n g s o c i a l interactions, and dietary changes. Consequently, the replacement of a diseased valve with a new mechanical, mosaic or porcine prosthesis has offered the hope of longevity and improved quality of l i f e to those who undergo surgery (King, 1994; Lumpp, 1968). Due to the chronic nature of valve disease, surgery-followed by seven to ten days i n hospital i s not i n i t s e l f , a cure for the patient (Costelld, 1992; Wingate, 1991). . Consequently, much patient anxiety regarding recovery during the ensuing days and weeks i s common (Wingate, 1987)'. Once discharged home, the patient i s without the support and guidance of nurses, physicians, physiotherapists and other health care professionals, thereby p o t e n t i a l l y producing greater anxiety ( G i l l i s s , 1984). The uninformed patient may experience d i f f i c u l t y i n exerting control over needed l i f e s t y l e changes such as anticoagulation therapy and exercise (Wingate, 1987). Patient anxiety and the necessary l i f e s t y l e changes combined with the patient's s i g n i f i c a n t physical deconditioning due to the valve disease process, make patient education and. cardiac r e h a b i l i t a t i o n imperative (Costello, 1992; Marshall, 1985; Wingate, 1987). A variety of pre-discharge and post-hospital patient education and r e h a b i l i t a t i o n programs have been developed by-health care professionals to address heart valve patients' learning needs i n the recovery period. Typically, information related to diet, medication, a c t i v i t y and related r e s t r i c t i o n s , rest, resumption of sexual a c t i v i t y , smoking, i n c i s i o n care, pain management, psychosocial issues (mood swings, anxiety and depression) and post-operative complications i s provided by the nurse p r i o r to hospital discharge (Beckie, 1989; Bubela, Galloway, McCay, McKibbon, Nagle, Pringle, Ross, & Shamian, 1990; H i l l , 1989; Karlik & Yarcheski, 1987; Marshall, Penckofer, & Llewellyn, 1986; Sealzi, Burke, & Greenland, 1980) . As demonstrated, post-operative teaching has been designed to cover a wide variety of material. However, obstacles to patient learning i n hospitals exist. Bubela et a l . (1990) noted that with the current trend towards early hospital discharge the patient may not have the "physiological s t a b i l i t y or cognitive energy to learn" (p.21; Wingate, 1991) the required material. In addition to not being ready to learn, patients may not know what they need to learn, being unaware of the d i f f i c u l t i e s that w i l l arise once home (Bubela et a l . 1990) . Thus, the education and information provided must be concise and relevant ( J i l l i n g s , 1988). This author has observed that patient education programs have been structured around the learning needs common to patients who have had either coronary artery bypass graft surgery (CABG) or a myocardial i n f a r c t (MI), and not around those of patients with heart valve diseases. C l i n i c a l observations made by this author and others have revealed that post-operative and post-hospital learning needs for patients with heart valve diseases d i f f e r from those of CABG and other cardiac patients (King, 1994; Wingate, 1991). This i s due, i n part, to the chronic nature of cardiac i l l n e s s (eg. the physically deconditioned heart valve patient). It also stems from the nature of the valves themselves because the various prostheses employed continue to have limitations. For example, mechanical valves are po t e n t i a l l y thrombogenic, therefore once discharged from hospital recipients must be instructed to undergo d a i l y prothrombin time evaluation during the f i r s t few weeks afte r h o s p i t a l i z a t i o n and monthly for l i f e thereafter (Costello, 1992; F i t z p a t r i c k & McCone, 1991; Harnmermeister, Sethi, Henderson, Oprian, Kim, & Rahimtoola, 1993). This patient population requires instruction regarding the side effects and risks associated with the use of anticoagulants (Fitzpatrick & McCone, 1991). They require teaching and support i n order to adapt to the constant c l i c k i n g of the new valve, recognize the increased s u s c e p t i b i l i t y to endocarditis and ensure prophylactic a n t i b i o t i c therapy p r i o r to having dental work (Finkelmeier et a l . 1989; F i t z p a t r i c k & McCone, 1991; Shaffer, Schulkers, & Wexler, 1991). Those with b i o l o g i c a l valves also have special learning needs due to this, valve's ten year average l i f e span (Nolan, 1992). The recipients must adjust to having a foreign substance i n their bodies which may break or f a i l , p o t e n t i a l l y r e s u l t i n g i n the need for emergency care or further surgical interventions (Finkelmeier et a l . 1989; Shaffer, et a l . 1991; Utz & Grass, 1987; Wingate, 1987). Women of c h i l d bearing age also require special consideration with regards to the type of valve implanted and anticoagulation, because th e i r choice w i l l greatly affect their c h i l d bearing potential (Rosen, Klein, Rosen, Laczkovics, Rokitansky, & Beck, 1992) . Jenkins, Stanton, Savageau, Ockene, Denlinger, and Klein (1983) have established that patients who have CABG and valve surgery experience a variety of learning needs during the f i r s t eight weeks at home. Tack & G i l l i s s (1990), and Wiggins (1989) supported this, stating that the c r u c i a l time for nursing intervention related to patient education and support was during the immediate post-hospitalization period. As well, Grady, Buckley, Cisar, Fink & Ryan (1988) concluded that learning needs change over time during recovery. In order to ensure that heart valve patients learning needs were explored as f u l l y as possible, this study examined learning needs up to the f i r s t ten weeks after hospital discharge. Patients were home a minimum of four weeks p r i o r to the interview, thereby ensuring they have had time to determine or encounter any potential learning needs. Patient education has been established as an essential component of the cardiac r e h a b i l i t a t i o n process (Canadian Council of Cardiovascular Nurses, 1993; Beckie, 1989; Tack & i G i l l i s s , 1990). However, the professionals' perceptions of learning needs, and not those of the patient have often been used as the basis for developing patient education programs (Hart & Frantz, 1977; King, 1994). Disparity remains amongst health professionals and i n the l i t e r a t u r e regarding what information i s needed and deemed most helpful i n a s s i s t i n g the patient to understand the cardiac i l l n e s s , and develop the requisite knowledge base required for recovery ( J i l l i n g s , 1988; Moynihan, 1984; Stanton, Jenkins, Savageau, Harken, & Aucoin, 1984). As J i l l i n g s (1988) noted, i t i s a mistake to "assume that what professionals know about pathophysiology and disease i s what c l i e n t s need to know" (p.210). Nurses are i n constant interaction with patients, observing, caring.for and counselling them (Henderson, 1964). Consequently, patient education has come to be considered a nursing r e s p o n s i b i l i t y (Bubela et a l . 1990; Comoss, Burke, & Swails, 1979; Duryee, 1992; Finkelmeier et a l . 1989; Marshall, 1985). Henderson (1991) stated that e f f e c t i v e nursing involves a constant assessment and vali d a t i o n of the professional's interpretation of patient needs with the patient. Yet when interviewed after hospital discharge, cardiac patients have often stated that they have had l i t t l e or no discharge information provided. (Cooke & Alley, 1992; Raleigh & Odtohan, 1987). There are a number of possible reasons why patient . education has been less than optimal. / The perceived deficiency may h i s t o r i c a l l y stem from a lack of nursing preparation at an academic l e v e l , a lack of time, or the nurses' perception that patient education was not a p r i o r i t y . Additionally, i t may arise.from the lack of knowledge regarding what to teach the patient (Baker, 1989) . Regardless of the reason, patient education must be geared toward what the patient "must know" and perceives as important to know for discharge and re h a b i l i t a t i o n . Nurses need to think beyond the hospital setting to what patients w i l l need, i n order to e f f e c t i v e l y recover once home (Cooke & Alley, 1992). Ultimately, i t must 10 be remembered that even i f patient teaching i s undertaken, i t does not mean that learning has taken place. While the l i t e r a t u r e i s replete with research pertinent to the learning needs of patients who have had Mis and CABGs, no research was found that dealt exclusively with heart valve replacement patients', self-perceived learning needs i n the early weeks af t e r discharge. Furthermore a review of the l i t e r a t u r e revealed that many studies using CABG patients contained forced response questionnaires designed by the researchers (Grady, Buckley, Cisar, Fink, & Ryan, 1988; Stanton, Jenkins, Savageau, Harken, & Aucoin, 1984). Thus respondents may have been unable to indicate what they perceived to be their true learning needs. Instead, they would have t a i l o r e d their responses to f i t the pre-defined questions established by the researcher. Despite decades of nursing and medical research aimed at identifying patients' needs, research pertaining to the learning needs of patients with heart valve disease i s lacking (Hagenhoff et a l . 1994; Moser, Dracup, & Marsden, 1993). To e f f e c t i v e l y recover.from surgery and achieve a state of optimal health, patients with heart valve replacements must have their learning needs c l e a r l y i d e n t i f i e d . This i s the f i r s t step leading to a comprehensive patient education and r e h a b i l i t a t i o n program, which w i l l translate into improved patient care (Moser et a l . 1993). A study of this patient population's learning 11 needs four to ten weeks after hospital discharge was required to f u l l y i d e n t i f y what patients perceived as important to know for early recovery and the fulfilment of independence once home. Problem Statement In order to establish a comprehensive patient education program as part of the r e h a b i l i t a t i o n "process, nurses must incorporate what patients perceive as important to know for the post-hospital experience. Therefore the problem under study was the lack of knowledge and perceived learning needs related to patients with heart valve replacements following hospital discharge. Increased patient acuity, h o s p i t a l i z a t i o n , diagnostic studies, valve surgery and early hospital discharge are dramatic events which occur i n as l i t t l e as seven to ten days (Wingate, 1991). Patient education i s currently being provided during a time when the patient i s feeling anxious and does not have'/the. physical or cognitive a b i l i t y to learn (Bubela et a l . 1990). These events, coupled with the patient's "lack of strength, w i l l or knowledge" (Henderson, 1991, p.21) required to accomplish the various a c t i v i t i e s of d a i l y l i v i n g create multiple learning needs for the patient once discharged from hospital. . ,, Considerable research has been undertaken to explore the learning needs and r e h a b i l i t a t i o n of CABG patients (Sczekalla-. Meyer, & Latz, 1979; Stanton et a l , 1984). Common findings from th i s research have been incorporated into patient education programs for patients with heart valve replacements pr i o r to hospital discharge (Jenkins et a l . 1983; Sczekalla-Meyer & Latz, 1979). However patients with heart valve replacements have learning needs which are unique and d i f f e r from those of patients with coronary artery disease (CAD) and to date these have not been c l e a r l y defined using empirical research (King, 1994; Wingate, 1991). Since patients with heart valve replacements experience many learning needs i n the early weeks after surgery, study participants were interviewed between four and ten weeks after hospital discharge. Purpose of the Study The purpose of this study was to determine the learning needs of patients with heart valve replacements. S p e c i f i c a l l y i t sought to: (1) Determine what patients with heart valve replacements perceived their learning needs to be between four and ten weeks after hospital discharge; (2) Determine when the i d e n t i f i e d learning need(s) arose; (3) Determine i f patients with heart valve replacements believed further post-operative or post-hospital patient education was required; 13 (4) Determine when patients with heart valve replacements, believed this education would have been most help f u l . Research Question The s p e c i f i c question used to guide the study was: What learning needs do patients with heart valve replacements id e n t i f y as having occurred during the f i r s t four to ten weeks following hospital discharge? Theoretical Framework' V i r g i n i a Henderson's (1961) philosophy of nursing was used as a conceptual guide for the patient interviews i n t h i s study. This philosophy i s rooted i n Henderson's concept of man's fundamental human needs. She stated that a l l people have similar needs which are expressed and s a t i s f i e d i n varying ways and degrees of intensity, depending on the individual culture and style of l i v i n g (Henderson, 1961). Furthermore, individual needs, and the motivation to meet those needs may be stronger i n certain individuals than others (1961, p.6). Henderson has catalogued fourteen fundamental needs, including: 1. Breathe normally; 2. Eat and drink adequately; 3. Eliminate body wastes; 4. Move and maintain desirable postures; 5. Sleep and rest; 6. Select suitable clothes-dress and undress; 7. Maintain body temperature within normal range by adjusting clothing and modifying the environment; 8. Keep the body clean and well groomed and protect the integument; 9. Avoid dangers i n the environment and avoid injuring others; 10. Coiranunicate with others i n expressing emotions, needs, fears, or opinions; 11. Worship according to one's f a i t h ; 12. Work i n such a way that there i s a sense of accomplishment; 13. Play or participate i n various forms of recreation; 14. Learn, discover, or s a t i s f y the c u r i o s i t y that leads to normal development and health and use the available health f a c i l i t i e s . (Henderson, 1991, p.22). Henderson believed that when people have the "necessary strength, w i l l or knowledge" (1991, p.21), they independently undertake those a c t i v i t i e s which contribute to meeting their various needs, thus attaining the goal of independence. However, i f individuals, through a lack of strength, w i l l or knowledge, are unable to meet their needs independently, the nurse serves as a f a c i l i t a t o r , by becoming "the patient's prime helper..."(p.24), as s i s t i n g i n the recovery toward independence. ' -Henderson believes the nurse's unique function i s that of: "assisting the individual, sick or well, i n the performance of those a c t i v i t i e s contributing to health or -its recovery (or to peaceful death) that he would perform unaided i f he had the necessary strength, w i l l or knowledge. And to do this i n such a way as to help him gain independence as rapidly as possible" (Henderson, 1991, p.21). Henderson's framework, which was i n part conceptualized 15 from a r e h a b i l i t a t i o n perspective, relates well to patients with heart valve replacements because of i t s emphasis on the patient achieving independence i n part through patient education. For both patients and their families, the cardiac surgical event and recovery from i t are s t r e s s f u l times which may create a lack of strength, w i l l or knowledge required to meet individual needs (Henderson, 1991). During recovery from cardiac surgery, the nurse i s able to a s s i s t the patient and family by providing patient education concerning recovery and re h a b i l i t a t i o n (Henderson, 1991). This f a c i l i t a t i v e process assists patients i n meeting th e i r s p e c i f i c learning needs, thus maintaining or eventually re-establishing patient independence (Henderson, 1991). Henderson's fourteen needs were used as prompts when conducting the participant interviews. It was recognized from the outset that not a l l of the needs would be applicable to every person interviewed, however a l l 14 needs were included i n the interview guide. This ensured that the participant's needs were thoroughly.assessed. Henderson's philosophy was also useful when discussing the results of the study i n r e l a t i o n to recovering from heart valve replacement surgery, regaining of patient independence,, and timing of the provision of information. Def i n i t i o n of Terms 16 Perceived Learning Need: A perceived learning need i s a s e l f i d e n t i f i e d gap i n knowledge or behaviour, or that which the patient i d e n t i f i e s as requisite knowledge or behaviour i n order to advance toward and achieve the goal of self-care and independence (Henderson, 1991). Pat i e n t s with Heart Valve Disease / Replacement: A person who has undergone open heart surgery for an aortic, mitral, t r i c u s p i d and/or pulmonic heart valve replacement and has subsequently received nursing care. This person must be discharged to a home environment within 20 days of admission to the cardiac surgery unit. Patient education: Patient education " i s a process of deliberate, planned teaching that imparts information, encourages learner p a r t i c i p a t i o n and stimulates the c l i e n t ' s decision-making a b i l i t i e s " ( J i l l i n g s , 1988, p.189). Through the process of knowledge acquisition and behavioural changes, patient education assists the patient during the r e h a b i l i t a t i v e process toward the goal of self-care and independence (Henderson, 1991). R e h a b i l i t a t i o n : " [ R e h a b i l i t a t i o n is] the sum of a c t i v i t i e s required to ensure cardiac patients the best possible physical, mental and s o c i a l conditions so that they may by their own 17 e f f o r t s regain as normal as possible a place i n the community and lead an active, productive l i f e " (World,Health Organization, 1964, p.3). Assumptions For the purposes of this study, the following assumptions were made: (1) Patients with heart valve replacements, having had open heart surgery, would best speak of t h e i r own learning needs; (2) Patients with heart valve replacements would encounter various learning needs once discharged from hospital; (3) A l l patients with heart valve replacements would participate i n the previously established, routine post-operative educational instruction provided by the teaching hospital; (4) A l l participants would respond to the questions i n an honest manner. Limitations Constraints or limitations placed on the study included: (1) Participants for the study were from one l o c a l teaching hospital; ' 1 8 (2) P a r t i c i p a t i o n w a s l i m i t e d t o t h o s e w h o w e r e a b l e t o s p e a k t h e E n g l i s h l a n g u a g e ; c o n s e q u e n t l y t h e l e a r n i n g n e e d s o f t h o s e w h o s p o k e o t h e r l a n g u a g e s w e r e n o t p r o p e r l y r e p r e s e n t e d ; " (3) T h e n u m b e r o f p a r t i c i p a n t s w a s l i m i t e d , a n d t h e s a m p l e w a s o n e o f c o n v e n i e n c e , w h i c h d e c r e a s e d t h e g e n e r a l i z a b i l i t y o f t h i s s t u d y . S u m m a r y C h a p t e r o n e h a s i n t r o d u c e d t h e p r o b l e m , p u r p o s e a n d f r a m e w o r k f o r t h i s s t u d y . P a t i e n t s w i t h h e a r t v a l v e r e p l a c e m e n t s e n c o u n t e r l e a r n i n g n e e d s w h i c h d i f f e r f r o m o t h e r c a r d i a c p a t i e n t g r o u p s . H o w e v e r , h e a l t h p r o f e s s i o n a l s h a v e y e t t o e m p i r i c a l l y i n q u i r e a s t o t h e p a t i e n t ' s p e r c e p t i o n s o f t h e d i f f e r i n g l e a r n i n g n e e d s e n c o u n t e r e d b y p a t i e n t s w i t h c h r o n i c v a l v u l a r i l l n e s s e s . T h i s h a s l e d t o t h e u n t i m e l y d e l i v e r y o f i n f o r m a t i o n a n d e d u c a t i o n t h a t i s n o t n e c e s s a r i l y r e l e v a n t . I n t u r n , p a t i e n t k n o w l e d g e a c q u i s i t i o n , b e h a v i o u r , a n d t h e a t t i t u d e s w h i c h g u i d e t h e i r d a i l y l i v e s a r e a f f e c t e d . B e c a u s e t h e n u r s e i s p r e s e n t l y t h e p r i m a r y b e d s i d e p a t i e n t e d u c a t o r , f u r t h e r i n g t h e e x p l o r a t i o n o f t h e p a t i e n t ' s p e r s p e c t i v e s r e g a r d i n g t h e i r l e a r n i n g n e e d s s e r v e s t o i m p r o v e t h e p a t i e n t e d u c a t i o n p r o v i d e d . T h e ' r e m a i n d e r o f t h i s t h e s i s i s o r g a n i z e d i n t o f o u r c h a p t e r s . I n c h a p t e r t w o , t h e r e l e v a n t m e d i c a l a n d n u r s i n g l i t e r a t u r e h a v e b e e n r e v i e w e d , a n d t h e p a t i e n t ' s l e a r n i n g n e e d s a n d e d u c a t i o n a r e d i s c u s s e d . C h a p t e r t h r e e p r e s e n t s a d e s c r i p t i o n o f t h e s t u d y ' s m e t h o d o l o g y . T h e r e s u l t s o f t h e . s t u d y a r e p r e s e n t e d a n d d i s c u s s e d i n c h a p t e r f o u r . C h a p t e r f i v e p r o p o s e s c o n c l u s i o n s t o b e d r a w n f r o m t h e d a t a , a n d r e v i e w s t h e i m p l i c a t i o n s f o r o t h e r h e a l t h c a r e p r o f e s s i o n a l s , ' a s w e l l a s n u r s i n g p r a c t i c e , e d u c a t i o n , r e s e a r c h . CHAPTER TWO 20 Review of the Literature This chapter examines the current state of the research l i t e r a t u r e as i t pertains to the learning needs of patients undergoing heart valve replacements. This process assisted i n placing the study i n the context of work done by others.. The review also provided a foundation to support the need for the research undertaken. There were no studies i d e n t i f i e d which dealt exclusively with the learning needs of patients with heart valve replacements during the f i r s t four to ten weeks after hospital discharge. However there are several bodies of nursing and medical l i t e r a t u r e related to the r e h a b i l i t a t i o n and education of patients with other cardiac diseases, and these have been explored. The l i t e r a t u r e review has been organized into f i v e sections including: 1. Cardiac r e h a b i l i t a t i o n ; 2. Psychological adjustment to heart surgery; 3. Patient education 4. Evaluation of patient education 5. Patients' perceptions of their learning needs. Cardiac Rehabilitation Today's health care system i s oriented toward treatment of acute i l l n e s s e s (Thome & Robinson, 1988) . Unfortunately there 21 are no cures for chronic heart valve conditions. Consequently, chronically i l l patients seeking medical attention require ongoing "care" for their i l l n e s s (Thome & Robinson, 1988) . Rehabilitation programs for heart valve replacement patients constitute part of this care. Post cardiac event individuals are often ambivalent when encouraged to engage i n some form of r e h a b i l i t a t i o n . This i s due to their prolonged i l l n e s s , continued fatigue, a c t i v i t y intolerance, anxiety and fear (Utz & Grass, 1987). In a review of the l i t e r a t u r e , Certo (1985) concluded that the 1960s were witness to the formalization of cardiac r e h a b i l i t a t i o n programs for MI patients. This was undertaken i n an e f f o r t to modify the lack of enthusiasm and anxiety encountered toward r e h a b i l i t a t i o n . Programs were developed based on progressive physical a c t i v i t y , a c t i v i t i e s of d a i l y l i v i n g and to some, extent patient education (Certo, 1985). The challenge for health care professions then and now has been to devise strategies e f f e c t i v e i n f a c i l i t a t i n g patient recovery, while simultaneously encouraging patient p a r t i c i p a t i o n and control i n the process ( J i l l i n g s , 1988> p. 211). Today's goals of cardiac r e h a b i l i t a t i o n are broad, incorporating much more than simple progressive a c t i v i t y . They include the following: "(1) prevention of further impairment; (2) monitoring existing a b i l i t y ; and (3) restoring as much function as possible" (Diehl, 1989,- p. 258). 22 To this end, much of the current nursing and medical research l i t e r a t u r e on r e h a b i l i t a t i o n pertains to the b e n e f i c i a l functional, physical, psychological and psychosocial facets of r e h a b i l i t a t i o n for patients who have experienced Mi's and CABG's (Allen, Becker, & Swank, 1990; Dion, Grevenow, Pollock, Squires, Foster, Johnson, & Schmidt, 1982; Fletcher, Lloyd, & Fletcher, 1988; Holmback, Sawe, & Fagher, 1994; Roviaro, Holmes, & Holmstein, 1984; Wenger, 1986). Physical and Functional Outcomes As a part of the r e h a b i l i t a t i o n process, exercises aimed at improving the individual's physical and functional outcomes are often taught p r i o r to hospital discharge (Allen, 1990). Dion, Grevenow, Pollock, Squires, Foster, Johnson, & Schmidt (1982) completed a prospective study pertaining to the medical problems and physiological responses encountered during early, low l e v e l exercise after cardiac surgery. They followed 521 patients with CABG and combination CABG with valve(s) replacements through surgery. An exercise program was i n s t i t u t e d on the f i r s t post-operative day with stable patients. Sixty one percent of these patients ambulated for ten or more minutes. The study demonstrated that early a c t i v i t y was safe, because there were no increased risks of sudden cardiac death or serious complications with early, low-l e v e l exercise. This study i s one i n a series which has successfully documented the need for early instruction and patient education pertaining to early a c t i v i t y i n cardiac r e h a b i l i t a t i o n . Roviaro, Holmes, & Holmstein (1984) examined the influence of a cardiac r e h a b i l i t a t i o n program on the functional status of 48 male MI and CABG patients after hospital discharge. The treatment group (n=28) was assigned to a three month exercise-based cardiac, r e h a b i l i t a t i o n program. The control group (n=20) was assigned the routine treatment and did not undergo a routine r e h a b i l i t a t i o n class. The treatment group experienced lower resting heart rates (p= 0.006), lower d i a s t o l i c pressure, increased physical a b i l i t y as evidenced by increased treadmill time (p= 0.06), and lower exercise heart rates (p= 0.059). Furthermore, patients i n the treatment condition rated their physical exercise as more frequent (p= 0.001), of longer duration (p= 0.001) and more demanding (p= 0.001). Allen, Becker, & Swank (1990), surveyed 125 male CABG surgical patients to determine what factors were related to functional status during the f i r s t s i x months,of recovery. Like the Roviaro study, All e n et a l , (1990) found that patient functional status improved s i g n i f i c a n t l y from one month before to six months afte r surgery (p= 0.0001). However six months after recovery, 45% of participants s t i l l reported d i f f i c u l t y with or no p a r t i c i p a t i o n i n moderately vigorous a c t i v i t y (such as l i f t i n g 10 lbs or more). Additionally, 45% reported doing 24 less or reported no changes i n a c t i v i t y levels. Interestingly, a multiple regression analysis revealed that the best predictor t of post-operative functional status was one's s e l f - e f f i c a c y i n performing a c t i v i t i e s of d a i l y l i v i n g . Measured p r i o r to hospital discharge, s e l f - e f f i c a c y explained 20% of variance i n patient behaviours. . , • Hertanu, Davis, Focseneanu, & Lahman (1986), Marshall (1985), and Wenger (1986) support the need for early a c t i v i t y i n patients who have had CABG's and Mi's. Wenger (1986) p o s i t i v e l y correlated increased a c t i v i t y to a reduction of pulmonary atelectasis, thromboembolic complications and a reduction i n anxiety and depression. Notably, Wenger (1986) concluded that patients with impaired l e f t ventricular function, congestive heart f a i l u r e and valve replacements who receive comprehensive pre and post-operative education pertaining to a c t i v i t y resumption, could safely participate i n low l e v e l exercise programs planned for recovery. The actual measures for functional outcomes varied between studies making comparisons d i f f i c u l t . Nonetheless, the research data suggests that patient s e l f - e f f i c a c y assessments provide insight to the patient's functional status, and that patient education directed toward early a c t i v i t y resumption w i l l a s s i s t i n improving overall functional status. Functional and Psychological Outcomes 25 Several attempts have been made to compare patients' functional and psychological status, because i t has been hypothesized that one's functional status i s related to psychological well being. For example, Holmback, Sawe & Fagher (1994) examined the long term effects of exercise i n r e l a t i o n to psychological adjustment after an MI on 69 patients. Patients were randomized to control (n=35) and experimental (n=34) groups. Both groups were given a supervised exercise program designed by a physiotherapist. The program began eight weeks post-MI, and was i n s t i t u t e d twice a week for 45 minutes with i n t e r v a l t raining including b i c y c l i n g , c a l l i s t h e n i c s , jogging and relaxation. Those i n the experimental group were encouraged to continue the training program aft e r the 12 week session while the control group was not s p e c i f i c a l l y instructed to do so. A s e l f report questionnaire was provided to both groups i n order to evaluate the relationship between perceived physical performance and psychological well-being. The v a l i d i t y , r e l i a b i l i t y and o r i g i n of the two tools were not reported i n the study. Despite c h a r a c t e r i s t i c s i m i l a r i t i e s i n both groups, the 6 month and one year follow-up results showed no positive correlations between functional status and any of the variables for measurement of psychological well being for either the experimental or control groups. This i s despite data regarding compliance to the exercise regimen being similar for both groups. The experimental group's fitness l e v e l was o n l y e i g h t p e r c e n t b e t t e r , t h a n t h a t o f t h e c o n t r o l g r o u p ( n o t s t a t i s t i c a l l y s i g n i f i c a n t , p = . 1 0 ) . T h e e x p e r i m e n t a l g r o u p ( t h o s e e n c o u r a g e d t o e x e r c i s e ) a c t u a l l y r e p o r t e d p o o r e r p s y c h o l o g i c a l r e c o v e r y t h a n t h e c o n t r o l g r o u p . T h e l o n g t e r m p s y c h o l o g i c a l b e n e f i t s o f a n e x e r c i s e p r o g r a m w e r e n o t s e e n . T h e s t u d y p u r p o r t s t o h a v i n g r e c r u i t e d g e n e r a l l y h e a l t h i e r i n d i v i d u a l s w h i c h m a y p a r t i a l l y a c c o u n t f o r t h i s r e s u l t . T h o s e w h o w e r e p h y s i c a l l y h e a l t h i e r p r i o r t o a n M I w o u l d n o t h a v e n e c e s s a r i l y s h o w n t h e p h y s i c a l i m p r o v e m e n t s m e a s u r e d f o r w i t h o n l y m o d e r a t e e x e r c i s e t w i c e w e e k l y . A d d i t i o n a l l y a l a r g e r s a m p l e m a y h a v e a s s i s t e d i n d e t e c t i n g t h e d e s i r e d e f f e c t s . J e n k i n s , S t a n t o n , S a v a g e a u , O c k e n e , D e n l i n g e r & K l e i n ( 1 9 8 3 ) i n t e r v i e w e d 89 p a t i e n t s w i t h v a l v e a n d b y p a s s - v a l v e , c o m b i n a t i o n s b e f o r e s u r g e r y a n d a g a i n s i x m o n t h s l a t e r . T h e i r s t u d y , l i k e t h e o t h e r s , d i d n o t f i n d a n y c o r r e l a t i o n b e t w e e n i n c r e a s e d f u n c t i o n a l c a p a c i t y a n d m e a s u r e s o f p s y c h o l o g i c a l s t a t e i n c l u d i n g w e l l - b e i n g , s e l f - e s t e e m a n d h o p e . T h e J e n k i n s s t u d y d i d n o t p r o v i d e i n f o r m a t i o n a s t o w h a t f o r m s o f i n t e r v e n t i o n o r r e h a b i l i t a t i o n w e r e p r o v i d e d t o t h e v a r i o u s g r o u p s ; a s s u c h i t i s d i f f i c u l t t o c r i t i q u e t h e i n t e r v e n t i o n s a n d r e s u l t s . B e n g t s s o n ( 1 9 8 3 ) , R o v i a r o e t a l . ( 1 9 8 4 ) , a n d S t e r n & C l e a r y ( 1 9 8 2 ) r e p o r t e d s i m i l a r c o n c l u s i o n s , w h e n t h e i r s t u d i e s f a i l e d t o e m p i r i c a l l y v a l i d a t e t h e b e n e f i t s o f l o n g t e r m s u p e r v i s e d e x e r c i s e o n v a r i o u s p s y c h o l o g i c a l v a r i a b l e s . A f t e r an extensive l i t e r a t u r e review and meta-analysis of works done, Greenland (1988) also concurred. He stated that as of 1988, despite the various measures used, there had not been any studies conclusively supporting a positive correlation between functional improvements resulting from r e h a b i l i t a t i v e exercise programs and improvements i n psychological status. Although not s t a t i s t i c a l l y s i g n i f i c a n t , the Roviaro et a l . (1984) study found that the treatment group rated t h e i r present health as better and had an o v e r a l l better body and s e l f -concept (p= 0.18). This r e s u l t lends credence to the A l l e n et a l . (1990) study which, as previously mentioned, established s e l f - e f f i c a c y and not psychological well being as a predictor of functional status. Holmback et a l . (1994) most succinctly concluded that physical conditioning i s not "an i s o l a t e d determinant of adaptation i n cardiac disease" (p. 554) and that "sociopsychological issues and counselling" (p. 554) were essential components of the t o t a l cardiac r e h a b i l i t a t i o n program. Psychosocial Functioning Zyzanski, Stanton, Jenkins, & Klein (1981) examined psychosocial outcomes after heart surgery. Nine hundred and forty nine CABG and valve patients from the Mended Hearts Association responded to a questionnaire on'average 3.5 years . after t h e i r surgery. A strong positive relationship was 28 established between post-operative physical status and perceived psychosocial functioning. The researchers found that post-operative heart related complications and hospitalizations decreased psychosocial functioning. They further concluded that patients with valve and bypass replacements experienced similar post-operative s o c i a l adjustments. Several studies conducted since 1981 have supported the relationship between physical status and psychosocial functioning. The Jenkins et a l . (1983) study.reported that only 15% of patients had fewer s o c i a l role functions such as house cleaning after their surgery and that t h e i r participants (n=89) overall functional status had improved. The treatment group i n the Roviaro et a l . (1984) study displayed similar results, reporting the house and yard work undertaken to be more physically demanding (p= 0.035), and an increase i n sexual a c t i v i t y . Several years later, the A l l e n et a l . (1990) study found similar results, with patients reporting a s i g n i f i c a n t increase i n s o c i a l and leisure a c t i v i t y s i x months (p= 0.0001) post surgery. Despite the positive correlations, i t i s d i f f i c u l t to know what s p e c i f i c components of the various treatment packages were responsible for the psychosocial effects observed. For example, while Jenkins et a l . (1983) and Roviaro et a l . (1984) included measures of marital relations i n th e i r psychosocial assessments, others did not. Additionally, the two studies measured marital relations using d i f f e r e n t scales. Nonetheless, i t i s reasonable to conclude that one's psychosocial status w i l l be somewhat dependent on physical and functional status. For, i f serious chronic i l l n e s s persisted despite surgical intervention, i t would make one's psychosocial " a c t i v i t i e s " more d i f f i c u l t to undertake. Return to Work ^ One of the main objectives of r e h a b i l i t a t i o n programs has been to increase the rate of return to work among a l l types of patients who have experienced heart surgery. Cronin (1990) stated that patients who perceived themselves as " i l l or damaged" (p.17) post-operatively were less l i k e l y to return to work or engage i n s o c i a l a c t i v i t y , despite an improved post-operative functional status. Alle n (1990) concluded from a l i t e r a t u r e review that pre-operative work status may be a major predictor of post-operative, employment. A period of invalidism greater than s i x months resulted i n a 50 percent chance of permanent i n a c t i v i t y a f t e r surgery. Age, sex, education and income.all affected return to work status. Clancy, Wey and Guinn (1984) also studied influences on return to work after CABG. A s i g n i f i c a n t relationship was found between the patient's perceptions of th e i r a b i l i t y to return to work and the actual return to work (p= 0.004). A 3 0 f u r t h e r s i g n i f i c a n t r e l a t i o n s h i p w a s f o u n d b e t w e e n t h e i n d i v i d u a l ' s p e r c e p t i o n o f a b i l i t y l e v e l a n d r e t u r n t o w o r k (p= 0 . 0 1 ) , p e r c e p t i o n o f p h y s i c a l a b i l i t y a n d r e t u r n t o w o r k (p= 0 . 0 0 2 ) , p e r c e p t i o n o f c u r r e n t h e a l t h s t a t u s a s i m p r o v e d a n d r e t u r n t o w o r k (p= 0 . 0 0 8 ) . C o n s e q u e n t l y , p a t i e n t p e r c e p t i o n s a r e s i g n i f i c a n t i n d i c a t o r s o f r e t u r n t o w o r k a f t e r C A B G s u r g e r y . R e s e a r c h e r s h a v e s o u g h t t o m e a s u r e a n i n c r e a s e i n w o r k r e l a t e d a c t i v i t i e s , b u t t h i s i s p e r h a p s a n i n a p p r o p r i a t e m e a s u r e m e n t a n d p e r h a p s e v e n a v a l u e j u d g m e n t . F o r s o m e a r e t u r n t o w o r k i s n o t a p p r o p r i a t e o r d e s i r e d . F o r e x a m p l e , s o m e p e o p l e m a y c h o o s e t o w o r k l e s s a f t e r s u r g e r y , t h u s d e l i b e r a t e l y r e d u c i n g w o r k r e l a t e d s t r e s s . T h e r e f o r e a n a b s o l u t e i n c r e a s e i n t h e n u m b e r o f p e r s o n s r e t u r n i n g t o w o r k o r t h e n u m b e r o f h o u r s w o r k e d , w i t h o u t a n a s s e s s m e n t o f t h e i n d i v i d u a l ' s r e a s o n s f o r c h o o s i n g t o r e t u r n o r n o t r e t u r n t o • w o r k , i s m o s t p r o b a b l y a p o o r a s s e s s m e n t o f t h e s i t u a t i o n . O n e a l s o n e e d s t o e x a m i n e h o w l o n g t h e I n d i v i d u a l w a s o f f w o r k b e f o r e t h e s u r g e r y . I n s u m m a r y , t h e s t u d i e s p r e v i o u s l y n o t e d s e r v e t o d e m o n s t r a t e t h e r e l a t i o n s h i p s b e t w e e n f u n c t i o n a l s t a t u s a n d p s y c h o l o g i c a l a n d p s y c h o s o c i a l o u t c o m e s . I t i s e v i d e n t t h a t e x e r c i s e t r a i n i n g a l o n e d o e s n o t r e t u r n t h e i n d i v i d u a l t o a f u l l y f u n c t i o n a l s t a t e . P a t i e n t p e r c e p t i o n s a n d s e l f - e f f i c a c y a r e i m p o r t a n t v a r i a b l e s i n i m p r o v i n g s o c i a l a n d f u n c t i o n a l 31 a b i l i t y and returning to work. Therefore discovering and c l a r i f y i n g patient perceptions i s a requisite f i r s t step i n the re h a b i l i t a t i v e process i f patients are to return to a l e v e l of optimal functioning. Psychological Adjustment to Heart Surgery Despite the lack of a proven relationship to functional outcomes, the psychological element of cardiac surgery plays a meaningful role i n the patient r e h a b i l i t a t i o n process. Over a period of several months, most cardiac patients recover from their surgery and re-engage i n many of th e i r previous a c t i v i t i e s (Cronin, 1990). However many patients experience d i f f i c u l t i e s i n adjusting to the surgical intervention and subsequent r e h a b i l i t a t i o n . Meyer, Blacher & Brown (1961) were among the f i r s t to attempt to document patient psychological responses to mitral . valve surgery. During 1957 and 1958, they observed 29 patients who had cardiac surgery and concluded that the individual "healthy or diseased, i s highly susceptible to emotional influence" (p. 214). They concluded that certain patients experienced a "catastrophic reaction" (p. 197) to the procedure, i n which patients are frozen, immobilized and apathetic. The case study descriptions provided insight to the many emotional changes which patients experience after open heart surgery. Intriguingly, the study concluded that i n "some instances, the bad heart i s regarded as a consequence of bad 32 deeds or bad thoughts..."(p. 215) . , Responses to surgery vary within individuals and their families, with most finding the experience disorganizing and st r e s s f u l (Rankin & G i l l i s s , 1987). Wilson-Barnett & Carrigy (1978) noted that as many as 50% of patients with CAD become invalids because of psychological and not physiological problems. Psychosis and Sleep Deprivation Cronin (1990) stated that patients who displayed emotional i n s t a b i l i t y at the beginning of their i l l n e s s were more l i k e l y to experience complications l a t e r i n the i r i l l n e s s trajectory. Emotional d i f f i c u l t i e s are occasionally encountered i n the early post-operative hours with individuals who experience sleep deprivation and psychosis. Adverse psychological adjustment to cardiac surgery has been accorded many names, including post-cardiotomy delirium (Blachly & Starr, 1964). During this time, the post-operative patient experiences a cluster of common signs and symptoms including agitation, paranoia, and occasionally violence (Mirka & Rukholm, 1993). Kloosterman (1991) noted that the incidence of reported delirium varied between 24% to 72% depending on the li t e r a t u r e reviewed. The delirium cleared by about six weeks according to Jenkins et a l . (1983) who found that during s i x week follow up v i s i t s , patients demonstrated improved l o g i c a l memory. 33 Mirka and Rukholm (1993) c i t e d h i s t o r i c a l research which suggests deep sleep deprivation due to the noise of an intensive care unit, i s a potential cause of post-operative psychosis. Other potential factors include anaesthetic agents, cardiopulmonary bypass and the general stress of surgery. Documentation of this issue from the early 1950's onward has resulted i n a greater understanding of the patient's adverse psychological adaptation to heart surgery. More importantly however, pre-operative teaching pertaining to the potential for such a reaction i n patient education programs would help patients and families understand that mild post-operative disorientation i s a potential but not unforeseen part of recovery from heart surgery.. Anxiety and Depression In addition to post-operative psychosis, recent research has highlighted patient anxiety and depression as two of the most common psychological responses experienced by patients after surgery (Cronin, 1990; Jenkins et a l . 1983;-MacKenzie, 1993; Raleigh & Odtohan, 1987). Alle n (1990) stated that some patients tend to be f e a r f u l and anxious about th e i r physical state and recovery. This anxiety interferes with t h e i r a b i l i t y to learn and ultimately recover (MacKenzie, 1993). A l l e n (1990) concluded that although not often noted i n hospital, many patients become fe a r f u l , anxious, withdrawn and depressed. Raleigh & Odtohan (1987) administered a State T r a i t 34 Anxiety Inventory (STAI) questionnaire to 18 patients. Using an experimental group (n=9) a patient education program was implemented and evaluated p r i o r to and after the intervention. When surveyed before discharge the experimental group displayed decreased anxiety levels, while the anxiety of the control group increased. When tested after discharge the anxiety of both groups decreased. However the experimental group displayed a greater reduction i n anxiety, and an increase i n learning. Jenkins et a l . (1983) also found decreased post-operative anxiety as measured by the STAI scale (p=.0001) and an overall decrease i n depression and improved mood state as measured by the McNair P r o f i l e of Mood States (POMS) (p=.01). Forty percent of patients i n this study reported a quicker than anticipated psychological recovery. Although not s t a t i s t i c a l l y s i g n i f i c a n t , Roviaro et a l . (1984) found similar results. Consequently, despite the small sample size, Raleigh & Odtohan's results were supported, suggesting that patients who participate i n patient education and r e h a b i l i t a t i o n programs benefited from the formalized patient education as evidenced by their decreased anxiety levels. Rankin (1990) conducted a prospective longitudinal study to evaluate the differences i n psychological recovery of male and female patients after CABG and valve procedures. She interviewed 93 male and 24 female patients pre-operatively and 35 at one and three months after hospital discharge v i a telephone. The POMS was used to measure mood disturbances and depression. Measures of v a l i d i t y and r e l i a b i l i t y were not provided for these tools. While a l l patients showed fewer mood disturbances over time (p=0.0001), female patients reported s i g n i f i c a n t l y fewer mood disturbances over time than men on the POMS. Over time, women scored higher i n measures of family s a t i s f a c t i o n , while men displayed greater amounts of anger. Despite the use of convenience sampling, Rankin had disproportionate group sizes with only 24 women and 93 men. The results of this study were supported by MacKenzie (1993) who reported on the emotional responses of women with ischaemic heart disease four to six weeks afte r hospital discharge. Her l i t e r a t u r e review suggested that women t y p i c a l l y experience greater emotional distress, anxiety and depression than.men after hospital discharge. This was thought to be linked to women's gender role orientation i n which perceived role r e s p o n s i b i l i t y negatively influenced the re h a b i l i t a t i o n process (Boogaard, 1984; MacKenzie, 1993). Contrary to this, and i n support of the,Rankin (1990) study, MacKenzie's results demonstrated that of the 19 women studied ( a l l Mi's), high incidences of anxiety or depression were not found. However, the women did report feelings of loss of control and poor aff e c t for four to s i x weeks afte r hospital discharge. In an e a r l i e r study, Zyzanski et a l . (1981) 36 concluded that changes i n anxiety levels, depression and general emotional status were s i g n i f i c a n t l y related to the person's sex and type of surgery. For example female multiple bypass patients reported feeling emotionally worse than male bypass patients i n the weeks after surgery. The Zyzanski study was retrospective i n nature, questioning participants on average 3.5 years after hospital discharge. Conversely, MacKenzie used a prospective design, but had a small sample size (n=19), therefore one has to question the g e n e r a l i z a b i l i t y of the results. Because of the methodological questions which arise from both of these studies, more research i s required i n this area. From the aforementioned, one can conclude that information suggesting that the occurrence of post-operative psychosis i s common, would be useful for patients and their family. Research evidence further suggests that educational sessions are successful i n reducing patient anxiety after surgery. It would appear that men experience greater anger, and take longer to adjust to heart surgery than women. However more research i s required to validate t h i s . Further exploration and discovery of what the heart valve patient's perceptions and learning needs are regarding emotional responses and recovery from heart surgery w i l l a s s i s t i n the r e h a b i l i t a t i v e process. It may also a s s i s t the patient to develop the desired behaviours needed to avoid or work through anxiety or 37 depression. This i s supported by J i l l i n g s (1977) who noted that since "pre-operative teaching has been demonstrated to reduce the incidence of post-operative complications, perhaps post-operative teaching strategies (focused on the needs perceived by the patient) would a l l e v i a t e adverse emotional outcomes" (p.64). Patient Education Varvaro (1965) noted that patients have a d e f i n i t e need for "planned, systematic teaching" (p. 115). H i s t o r i c a l evidence for this i s gleaned from Henderson's (1964) statement in which she declared that the " i n s t i t u t i o n a l regimen nevertheless often f a i l e d to change the factors i n the patients way of l i v i n g that had hospitalized him i n the f i r s t place" (p. 64; 1991, p.14). Diehl (1989) suggested that a r e h a b i l i t a t i o n program which incorporated a strong educational component, developed around the r e h a b i l i t a t i o n expectations of the patient and family would a s s i s t the patient to achieve the goals of recovery. As part of the r e h a b i l i t a t i o n process, an educational program should help the patient acquire new information, develop new s k i l l s , achieve competence i n the application of s k i l l s , and assume behaviours that prevent further d i s a b i l i t y , ultimately f a c i l i t a t i n g a return to personal independence (Certo, 1985; Diehl, 1989; J i l l i n g s , 1988; Raleigh & Odtohan, 1987; Wenger, 1986) . While the educational process needs to transfer information, convey knowledge and change behaviours, i t should most importantly result i n a change i n patient attitude ( J i l l i n g s , 1988). The process of patient education can be considered from both an ideological and p r a c t i c a l perspective (Leino K i l p i , l i r e , Suominen, Vuorenhimo, & Valimaki 1993). An ideological perspective stresses the importance of knowledge and information with regards to "patient autonomy, dignity and s e l f respect" (Leino K i l p i et a l . 1993). It i s argued that pure education must e n t a i l a process of emancipation which i s that of "li b e r a t i n g people to make their own decisions on their own terms" (Fahrenfort, 1987, p.- 30). This occurs through the real discussion and exchange of information between two individuals. The p r a c t i c a l , p a t e r n a l i s t i c perspective i s the one more often seen when nurses provide patient care. The inherent assumption i s that patients who have an understanding of their condition w i l l work towards pre-planned and a r t i c u l a t e d nursing or medical objectives and demonstrate compliance with their treatment regimen (Leino K i l p i et a l . 1993). Currently the various theories regarding patient education are structured around the idea of changing patient behaviour (Webber, 1990). Webber (1990) noted that correcting patient knowledge d e f i c i t s i s not s u f f i c i e n t enough to educate the patient since personal, s o c i a l and environmental factors can and do affect patient behaviour. Whether considering an ideological or p r a c t i c a l 39 perspective, the education provided should serve to empower individuals toward self-care and independence, ensuring that they have the requisite s k i l l s and attitudes to prevent complications during t h e i r recovery process. Patient Compliance Patient education and i t s relationship, to compliance has received much attention i n recent years (Holm, Fink, Christman, & Reitz, 1985). However, the issue of compliance remains problematic from both an ideological and p r a c t i c a l perspective because i t i s based on the assumption that "Dr. knows best" and on the assumed adherence to pre-defined obj ectives. When examining the l i t e r a t u r e related to compliance, i t became evident that the physician "prescribed" or directed the patient or the overall r e h a b i l i t a t i o n program, the patient was t o l d what to do and when. This i s done with the expectation that compliance w i l l be the end result (Fahrenfort, 1987; Fleming, 1992). A general assumption underlying compliance i s that greater knowledge w i l l lead to increased adherence to recommendations (Luker & Caress, 1989). Conversely, the concept of informed consent dictates the patient's right to choose. Therefore the physician or nurse cannot "prescribe" or , force a patient to choose any a c t i v i t y or action. Because patients are free to accept or reject medical advice, measuring patient compliance seems, an unproductive exercise (Lipetz, Bussigel, Bannerman, & Risley, 1990). However, there i s research evidence suggesting a generally positive correlation between patient education and compliance (Fahrenfort, 1987; Holm et a l . 1985; Linde & Janz, 1979; Marshall, Penckofer, & Llewellyn, 1986). The l i t e r a t u r e reviewed suggested that while patient knowledge i s an important factor i n compliance, there are other determinants to be considered (Linde & Janz, 1979; Raleigh & Odtohan, 1987). Clients must know and understand the regimen, agree with, i t , and choose to adhere (Miller, Johnson, Garrett, Wickoff, & McMahon, 1982). Consequently, one's intention to adhere seems most relevant to the concept of compliance. Compliance has h i s t o r i c a l l y been used as an outcome measure when considering the effectiveness of patient education. This author contends that assessing patients' perceptions of their learning needs would improve patient education programs and as s i s t i n creating more r e a l i s t i c , mutually acceptable patient goals. This i n turn would give r i s e to new outcome measurements pertaining to the effectiveness of patient education and r e h a b i l i t a t i o n . Consequently, i t i s possible that an assessment of patient learning needs w i l l a s s i s t i n changing the reference points or outcome measures used when evaluating education and i t s relationship to "compliance". Evaluation of Patient. Education For nurses, doctors and other health professionals to spend time educating patients, they must believe that, i t i s ef f e c t i v e i n imparting knowledge and that i t can lead to an improved understanding of the patients' situation., (Lipetz et a l . 1990). Consequently, i t i s important to evaluate patient education. Patient feedback i s an important source of information for this evaluation (Waitkoff & Imburgia, 1990). Evaluation data can a s s i s t health care providers to determine what constitutes relevant materials for patient education programs. In 1977, Hart & Frantz surveyed 512 hospitals to describe the common characteristics of post-operative patient education programs for open heart surgery patients i n the United States. Of the 358 hospitals which were ac t i v e l y performing heart surgery, 66% had programs designed to a s s i s t patients with their various post-operative and discharge learning needs. Scalz i , Burke, and Greenland (1980) used a quasi-experimental time series design to evaluate the impact of an in-patient educational program on patients who had Mi's and their families. The study revealed that the retention of information provided during the hospital stay was limited. However, continued instruction during the post-discharge phase improved patient's knowledge r e l a t i n g to medications, sexual, and physical a c t i v i t y , weight reduction and treatment of chest 42 pain. Steele and Ruzicki (1987) also evaluated the effectiveness of patient education during hospitalization. Using a controlled experimental design, CABG patients were tested using a knowledge acquisition survey. Unlike Scalzi et a l . (1980), Steele and Ruzicki found that CABG patients who participated i n the education programs demonstrated a s i g n i f i c a n t increase i n knowledge acquisition. This result was further supported six weeks after discharge when patients reported that they were able to follow their r e h a b i l i t a t i o n program. Steele & Ruzicki concluded that those preparing pre-discharge education programs should concentrate their e f f o r t s on the "immediate needs" (p.310) of heart patients. Like Scalzi et a l . (1980), Steele and Ruzicki' believe that patient education focused toward long-term behavioural changes i s of limited effectiveness i n hospital. The results i n the two cognitively based studies are co n f l i c t i n g . S c a l z i et a l . (1980) were unable to demonstrate an increase i n knowledge after instruction however Steele and Ruzicki (1987) did. Scalzi's study used a small sample size (n=13 i n the control group and n=19 i n the experimental group), whereas the Steele study had 38 participants i n each of the pre and post-test groups. As well, several of Scalzi's tools for data c o l l e c t i o n (knowledge, compliance and denial) had not been previously validated p r i o r to their use. Conversely, Steele 43 and Ruzicki used previously validated tools. The Steele study i s supported by Raleigh and Odtohan (1987) who concluded that a structured teaching program was more effe c t i v e i n conferring knowledge about heart disease and r e h a b i l i t a t i o n . They concluded that post-cardiac event patient education p o s i t i v e l y influenced the r e h a b i l i t a t i o n process through knowledge retention. They further surmised that a lack of patient knowledge can lead to cardiac invalidism. The . assertion of increased patient knowledge after instruction i s a d d i t i o n a l l y supported by.Mills, Barnes, Rodell, and Terry (1985), and Roviaro et a l . (1984) who reported an increase i n patient knowledge d i r e c t l y attributable to their patient education program. Heart Valve Recipients and Education F i t z p a t r i c k and McCone (1991) retrospectively audited 190 patients who had had valve surgery and were placed on an anticoagulation regimen. Patients were interviewed by telephone and asked about the occurrence of s i g n i f i c a n t medical problems since their surgery. . The l e v e l of patient knowledge pertaining to anticoagulation therapy was evaluated, although no description of the tool u t i l i z e d was provided. Twenty-five percent of the patient group were not aware of the need for a n t i b i o t i c prophylaxis during dental procedures. Nine cases of i n f e c t i v e endocarditis were found, res u l t i n g i n three deaths a n d s i x v a l v e r e - o p e r a t i o n s . T h i r t e e n m a j o r b l e e d i n g e p i s o d e s r e q u i r i n g h o s p i t a l i z a t i o n a n d t r a n s f u s i o n w e r e f o u n d , a l o n g w i t h 1 8 t h r o m b o e m b o l i c e v e n t s . T h e i n v e s t i g a t o r s s i m u l t a n e o u s l y s u r v e y e d 2 3 2 l o c a l p h y s i c i a n s b y m a i l w i t h a r e s p o n s e r a t e o f 6 5 % , t o e s t a b l i s h w h a t t h e y p e r c e i v e d a s a d e q u a t e i n t e r n a t i o n a l n o r m a l i z e d r a t i o s ( I N R ) . T h e m a j o r i t y o f p a t i e n t s (74%) d i d n o t k n o w t h e i r l a t e s t p r o t h r o m b i n r a t i o s o r I N R ' s , b u t g r e a t e r t h a n 50% o f p h y s i c i a n s f e l t p a t i e n t s c o u l d m a n a g e t h e i r a n t i c o a g u l a t i o n r e g i m e n w i t h o u t m e d i c a l a s s i s t a n c e ! O v e r a l l h o w e v e r , 95% o f p a t i e n t s w e r e p l e a s e d w i t h t h e d i s c h a r g e e d u c a t i o n p r o v i d e d . A f u r t h e r d i s c r e p a n c y w a s n o t e d a m o n g s t t h e p h y s i c i a n s w h o r e p o r t e d a c c e p t a b l e i n t e r n a t i o n a l n o r m a l i z e d r a t i o s ( I N R ) o f l e s s t h a n o n e t o g r e a t e r t h a n f o u r . T h i s s t u d y r e v e a l e d d i s c r e p a n c i e s w i t h i n t h e p r o f e s s i o n a s - t o w h a t i s a c c e p t a b l e a n t i c o a g u l a t i o n t r e a t m e n t . C o n f u s i o n o n t h e e d u c a t o r s p a r t u n d o u b t e d l y l e a d s t o p o o r e d u c a t i o n a n d u n d e r s t a n d i n g f o r p a t i e n t s . T h e l a r g e n u m b e r o f a d v e r s e e v e n t s d e m o n s t r a t e t h a t p a t i e n t e d u c a t i o n a n d u n d e r s t a n d i n g p e r t a i n i n g t o e f f e c t i v e a n t i c o a g u l a t i o n m a n a g e m e n t h a s b e e n p o o r l y u n d e r t a k e n . T h e s t u d y r e i n f o r c e s t h e n e e d t o i m p r o v e p a t i e n t e d u c a t i o n p r a c t i c e s c o n c e r n i n g a n t i c o a g u l a t i o n r e g i m e n s , a s w e l l a s t h e n e e d t o i m p r o v e p a t i e n t a w a r e n e s s o f t h e p o t e n t i a l c o m p l i c a t i o n s a s s o c i a t e d w i t h t a k i n g t h e a n t i c o a g u l a n t s . F i n k e l m e i e r , H a r t z , F i s h e r & M i c h a e l i s ( 1 9 8 9 ) i n a f o l l o w 45 up of 509 valve patients also demonstrated a disturbing incidence of endocarditis (12%) and thromboembolic event (3%). Like F i t z p a t r i c k and McCone (1991) they were concerned with the increased incidence of possibly preventable post-hospital complications. Finkelmeier et a l . (1989) c a l l e d for an emphasis on patient education by the nurse and improved follow up by the health care team after hospital discharge. Patients' Perceptions of Educational Programs A knowledge of the patient's perceptions of educational programs w i l l a s s i s t i n improving of the education program i t s e l f . When possible, improved programs should have increased emphasis on patient i d e n t i f i e d issues, and r e l y less on the researchers' assumptions of the heart patients' learning needs. Stanton, Jenkins, Savageau, Harken & Aucoin (1984) conducted a longitudinal survey of the patient's perception of the adequacy of patient education after cardiac surgery. The study had 249 patients involved, (43 with valve implants). Data for this study were collected pre-operatively and at six month intervals for two years after hospital discharge. Data were collected using a standardized interview and a s e l f -administered multiple choice questionnaire designed by the authors. .. These researchers noted that the patients reported having - inadequate preparation with regards to changes i n how others treat them (43.3%), emotional reactions (32.3%), 46 possible symptoms (24.2%), sexual a c t i v i t y (23.9%), and return to work (20.5%). The patients agreed that these issues had been addressed i n their educational sessions but f e l t inadequately prepared to deal with them. The authors concluded that this discrepancy suggested in-hospital patient education programs could not provide a complete solution to the r e h a b i l i t a t i o n process. Instead, patients required post-hospital follow up, reinforcement and encouragement. Interestingly, results of the study showed no s i g n i f i c a n t correlation between patients 1 perceptions of adequacy of preparation and the subsequent fears and worries encountered at home. Fears, and worries included such issues as job loss, heart valve l i f e , noisy valve sounds, overexertion, repeat . surgery, others reactions and tr a v e l . Stanton et a l . (1984) added that these fears were generally r e a l i s t i c (eg. repeat surgery) and not exaggerated. Consequently, even those patients who f e l t well prepared for discharge experienced a small number of fears and adjustments during recovery. Whether patients perceived that the education received helped or hindered i n the management of these fears was not reported. Grady, Buckley, Cisar, Fink & Ryan (1988) completed a study on patients' perceptions of the importance and adequacy of preparation concerning pre-operative and post-operative information. One hundred bypass patients were recruited for the study and given a pre-discharge questionnaire designed by 47 t h e r e s e a r c h e r s . F i f t y f o u r p e o p l e c o m p l e t e d t h e p o s t -d i s c h a r g e q u e s t i o n n a i r e . T h e p a t i e n t s w e r e s e e n b e f o r e s u r g e r y a n d 1 - 4 w e e k s a f t e r h o s p i t a l d i s c h a r g e . T h e q u e s t i o n n a i r e c o m p l e t e d u s e d c l o s e d e n d e d q u e s t i o n s a n d a L i k e r t t y p e s c a l e . P a t i e n t s r e p o r t e d h i g h p r e - o p e r a t i v e p r e p a r e d n e s s a n d h i g h l e v e l s o f i m p o r t a n c e t o k n o w i n g a b o u t t h e t y p e o f s u r g e r y , i n t e n s i v e c a r e e n v i r o n m e n t a n d d e e p b r e a t h i n g a n d c o u g h i n g e x e r c i s e s . H o w e v e r , l i k e t h e S t a n t o n s t u d y , t h e y r e p o r t e d b e i n g u n p r e p a r e d f o r t h e e m o t i o n a l c h a n g e s e n c o u n t e r e d . F o r d i s c h a r g e , p a t i e n t s r a n k e d e x e r c i s i n g a t h o m e a s t h e o n l y i t e m h i g h f o r b o t h l e v e l s o f i m p o r t a n c e a n d p r e p a r e d n e s s . L i k e t h e S t a n t o n s t u d y , p a t i e n t s r a n k e d m e d i c a t i o n s i d e e f f e c t s , q u e s t i o n s r e g a r d i n g m e d i c a t i o n s a n d d i e t p l a n n i n g a s h i g h l y i m p o r t a n t b u t l o w i n t e r m s o f p e r c e i v e d p r e p a r e d n e s s . I n t e r e s t i n g l y p a t i e n t s f e l t w e l l p r e p a r e d f o r t h e l i m i t a t i o n s i n l i f t i n g , d r i v i n g , r e s t i n g a n d f o r m a l e x e r c i s e p r o g r a m s , b u t t h e s e w e r e o f l o w i m p o r t a n c e t o t h e m . T h e r e s u l t s g e n e r a l l y c o n c l u d e d t h a t h i g h s c h o o l a n d c o l l e g e g r a d u a t e s r a n k e d t h e i m p o r t a n c e a n d a d e q u a c y o f i n f o r m a t i o n h i g h e r t h a n d i d g r a d e s c h o o l p a t i e n t s . Y o u n g e r p a t i e n t s p e r c e i v e d t h e m s e l v e s a s l e s s p r e p a r e d f o r r e h a b i l i t a t i o n , b u t a l s o f e l t l e s s o f a n e e d t o b e p r e p a r e d . F r o m t h e a b o v e , o n e c a n n o t e t h a t e v e n w h e n p a t i e n t s d o r e c e i v e d i s c h a r g e e d u c a t i o n , i t i s n o t n e c e s s a r i l y r e l a t e d t o w h a t t h e y p e r c e i v e a s r e l e v a n t i n f o r m a t i o n f o r t h e i r r e c o v e r y . A d d i t i o n a l l y , w h a t e d u c a t o r s p e r c e i v e a s i m p o r t a n t t o t e a c h w a s n o t n e c e s s a r i l y w h a t t h e p a r t i c i p a n t s r a n k e d a s i m p o r t a n t t o l e a r n . P a t i e n t e d u c a t i o n m u s t b e a n i n t e g r a l c o m p o n e n t o f t h e r e h a b i l i t a t i o n p r o c e s s . H o w e v e r i t m u s t b e d e e m e d r e l e v a n t i n o r d e r t o a s s i s t w i t h a r a p i d , h o l i s t i c p a t i e n t r e c o v e r y . • P a t i e n t s ' P e r c e p t i o n s o f L e a r n i n g N e e d s C l a n c y e t a l . ( 1 9 8 4 ) s t a t e d t h a t i f " t h e p a t i e n t s p e r c e i v e t h a t t h e i r c o n d i t i o n h a s n o t i m p r o v e d , t h e s u r g e r y c a n n o t b e c a l l e d s u c c e s s f u l " ( p . 3 7 1 ) . P a t i e n t p e r c e p t i o n s a r e a n i m p o r t a n t v a r i a b l e o v e r w h i c h p a t i e n t s h a v e f u l l a u t o n o m y ( C l a n c y e t a l . 1 9 8 4 ) . P e r c e p t i o n s c a n b e m e a s u r e d a t d i f f e r i n g i n t e r v a l s a l o n g a c o n t i n u u m s u c h a s b e f o r e a n d a f t e r s u r g e r y , a n d a s s u c h c a n p r o v i d e a w e a l t h o f d a t a p e r t a i n i n g t o r e h a b i l i t a t i o n . A p a u c i t y o f l i t e r a t u r e e x i s t s p e r t a i n i n g t o t h e p e r c e i v e d l e a r n i n g n e e d s o f c a r d i a c v a l v e r e p l a c e m e n t p a t i e n t s a f t e r h o s p i t a l d i s c h a r g e . C o n s e q u e n t l y , r e s e a r c h s t u d i e s e x a m i n i n g p a t i e n t s ' p e r c e p t i o n s o f p o s t - o p e r a t i v e t e a c h i n g w e r e r e v i e w e d a l o n g w i t h s t u d i e s w h i c h i n c l u d e d v a l v e p a t i e n t s a s a s u b - s e t o f a l a r g e r g r o u p . I n a l a n d m a r k r e s e a r c h s t u d y , D o d g e ( 1 9 6 9 ) e x a m i n e d t h e g e n e r a l m e d i c a l a n d s u r g i c a l p a t i e n t s ' p e r c e p t i o n s o f t h e i r c o g n i t i v e n e e d s a n d t h e r e l a t i o n s h i p o f v a r i o u s b a c k g r o u n d f a c t o r s t o t h e s e p e r c e p t i o n s . D o d g e u s e d o p e n - e n d e d q u e s t i o n s , 49 during a series of verbally administered interviews. She concluded that patients were p a r t i c u l a r l y concerned with receiving the kinds of information which allowed them to "plan r e a l i s t i c a l l y for their immediate and long-range l i v e s " (p.509). Patients did not concern themselves with things they were unable to understand. Dodge hypothesised that the degree of understanding desired by patients may be d i r e c t l y related to their l e v e l of education. The results have had some impact on the development of ensuing patient education programs. Sullivan (1993) supported Dodge's claim during her assessment of the learning needs of pregnant women. Sullivan concluded that the pregnant women's learning needs and the information presented i n the instructor planned pre-natal classes were disparate. For example, pregnant women did not see the value of "nutrition i n the f i r s t trimester" counselling during t h i r d trimester pre-natal classes. Sullivan c a l l e d for a paradigm s h i f t i n pre-natal education, from that of teacher controlled to a learner controlled.system. I f the information were accessible at a time convenient for pregnant woman (via computer, for example) when she i s motivated to learn, i t would have greater effectiveness, and i t would adhere to the pr i n c i p l e o f adult learning. Sullivan's (1993) proposed paradigm s h i f t may have relevance and a p p l i c a b i l i t y i n the cardiac r e h a b i l i t a t i o n domain. Patients with cardiac diseases may not be able to a r t i c u l a t e w h a t t h e y n e e d t o l e a r n i n h o s p i t a l d u e i n p a r t t o t h e i r n a r r o w f o c u s o f w h a t t h e i r l e a r n i n g n e e d s m i g h t b e . H o w e v e r g r e a t e r e m p h a s i s o n p r o v i d i n g a s s i s t a n c e a f t e r h o s p i t a l d i s c h a r g e i s s u p p o r t e d b y a n u m b e r o f a u t h o r s ( B e c k i e , 1 9 8 9 ; M c K n i g h t N i c k l i n , 1 9 8 6 ; S t a n t o n e t a l . 1 9 8 4 ) . C a r d i a c P a t i e n t s ' P e r c e p t i o n s o f L e a r n i n g N e e d s A l e a r n i n g n e e d s a s s e s s m e n t f o r c a r d i a c p a t i e n t s w a s c o n d u c t e d b y S c z e k a l l a - M e y e r a n d L a t z ( 1 9 7 9 ) . T h e y i n t e r v i e w e d 5 0 o p e n h e a r t s u r g e r y p a t i e n t s b e t w e e n o n e a n d n i n e m o n t h s a f t e r s u r g e r y t o e s t a b l i s h w h a t t h e y p e r c e i v e d t h e i r l e a r n i n g n e e d s t o b e o n c e d i s c h a r g e d f r o m h o s p i t a l . ( I n f o r m a t i o n w a s n o t p r o v i d e d a s t o t h e t y p e o f s u r g e r y t h e p a t i e n t s h a d ) . T h e s t u d y u s e d a c o m b i n a t i o n o f o p e n a n d c l o s e d - e n d e d q u e s t i o n s t o e l i c i t t h e r e q u i r e d i n f o r m a t i o n . T h e r e s u l t s r e v e a l e d e i g h t m a j o r c a t e g o r i e s o f c o n c e r n a s s t a t e d b y p a t i e n t s . T h e c a t e g o r i e s i n c l u d e d h e a r t f u n c t i o n , d r u g s t o t a k e , d r u g s n o t t o t a k e , s u r g i c a l p r o c e d u r e , d i e t , c a r e o f t h e i n c i s i o n , a c t i v i t y , a n d c o m p l i c a t i o n s . T h e i n v e s t i g a t o r s a s k e d p a t i e n t s w h o t h e t e a c h e r s w e r e ( t h e m a j o r i t y r e s p o n s e w a s n u r s e s ) , h o w h e l p f u l t h e y p e r c e i v e d t h e t e a c h i n g t o b e ( o v e r a l l , n o t v e r y h e l p f u l ) , a n d i f t h e y h a d a n y o t h e r c o n c e r n s a b o u t t h e r e c o v e r y p e r i o d . T h i s l a s t q u e s t i o n b r o u g h t a b o u t a n o u t p o u r i n g o f p a t i e n t c o n c e r n s a r o u n d p a i n , r e s u m p t i o n o f a c t i v i t y , m e d i c a t i o n a n d w a r f a r i n t h e r a p y , d i e t a n d p o t e n t i a l c o m p l i c a t i o n s . T h e s e d a t a 51 strongly suggested that patient teaching was inadequate. Based on the information received, Sczekalla-Meyer and Latz i n i t i a t e d changes to t h e i r patient education program. Moynihan (1984) conducted a study which asked 17 patients who had experienced an MI to complete a questionnaire designed to e l i c i t information pertinent to their post-discharge educational needs. At the time, there were no formal patient education classes i n the community where the research was undertaken. Moynihan's results were similar to Sczekella-Meyer and Latz, reporting that 65% of patients stated they were not counselled regarding emotional responses encountered and 47% were not counselled regarding sexual a c t i v i t y . Most others (88%) reported adequate counselling on diet, medications, necessary follow up, a c t i v i t y limitations and the need for hobbies. The respondents did state that t h e i r educational instruction was sporadic i n nature. The patients i d e n t i f i e d that i t would be helpful to have continued reinforcement of the information throughout the r e h a b i l i t a t i o n process. Newton & K i l l i e n (1988) undertook a longitudinal survey i n order to examine the timing and content of knowledge requirements of patients and t h e i r spouses a f t e r CABG surgery.. . Patients.were seen i n person and also interviewed over the phone at one, six, 12 and 24 weeks after hospital discharge. The most common learning needs expressed i n this group included information about complications, signs and symptoms of 52 complications, the need for learning CPR, stress management, and medications. Interestingly, at the one week interview, patients' spouses expressed the greater concern and need for additional information i n the majority of the 12 learning areas l i s t e d by the researchers. It i s evident that general cardiac patients have learning needs which remain unmet at the time of hospital discharge. Additionally, i t wouid appear that the cardiac patient's family also requires information pertaining to the individual's recovery. This might be due to. patient education and counselling being undertaken when the patient's spouse i s not present. It may also derive from the d i s p a r i t y i n b e l i e f s between what patients and hospital s t a f f f e e l the patient needs to know. Patients' and Nurses' Beliefs and Learning Needs A study by Gerard and Peterson (1984) compared patients' and nurses' perceptions regarding the importance of s p e c i f i c learning needs r e l a t i v e to the cardiac i l l n e s s . Thirty one patients and 36 nurses completed the survey. The patients i d e n t i f i e d r i s k factors as the most important learning category, whereas nurses believed medications to be most important. There was agreement on two p r i o r i t y topics: '"what to do for chest pain" and "signs and symptoms of angina" (Gerard & Peterson, 1984). 53 Karlick and Yarcheski (1987) completed a p a r t i a l r e p l i c a t i o n of Gerard and Peterson's study. Thirty people who . had a myocardial i n f a r c t were recruited along with 30 nurses. The sample population were given two forced response questionnaires asking them to rate the importance of various information (eg. information around diet, a c t i v i t y , anatomy and physiology). Like Gerard and Peterson's study, nurses and patients both ranked learning about r i s k factors and the i r modification as most important. However many other areas varied i n importance to either the nurse or patient. Again, nurses ranked information about medications as very important, while patients did not. An interesting finding i n the study was that patients expressed greater preference for physicians than nurses to give them the cardiac information. These results highlight the d i f f e r i n g perspectives regarding what information should be contained i n a post-operative educational program. This then lends credence to the idea that,educational programs are not necessarily designed according to what patients f e e l they must know. The studies previously noted asked questions of patients based on predetermined categories of information. Because participants were able to l i s t a number of issues relevant to them that did not f i t within these categories, i t i s obvious that further assessment of their needs i s warranted. The incongruence between nursing assessed learning needs and 54 patient i d e n t i f i e d learning needs serves'only to slow the educational process and make programs in e f f e c t i v e (Waitkoff & Imburgia, 1990). Ultimately the patient i s negatively affected. Because of the aforementioned, i t was important to use a study design which allowed participants learning needs to emerge from them, and not i n response to predetermined categories of information. Telephone Follow Up and Learning Needs Several d i f f e r e n t studies have used a telephone c a l l i n g system to follow up patient concerns after their hospital discharge. McKnight-Nicklin (198.6) used a telephone c a l l back system whereby patients who had been discharged from hospital after either a myocardial i n f a r c t i o n or unspecified cardiac surgery could c a l l the hospital and address their questions to the nurse coordinator. Over a four and a half month period, 217 c a l l s were received from 2 07 patients with f i v e to ten c a l l s received on average per day. Forty percent of the c a l l s were received i n the f i r s t week and 70 percent within the f i r s t month. The greatest number of concerns and questions centred around the cardiopulmonary system (23%), medications (14%), gastrointestinal disorders (9.4%). The results indicated that patients continued to have multiple learning needs during the early convalescent period at home and that they were w i l l i n g to use an alternative source to obtain the requisite knowledge for 55 recovery. Beckie (1989) investigated the impact of a supportive-educative telephone program for CABG patients on their levels of knowledge and anxiety. Seventy-four patients were enrolled i n the study conducted during the f i r s t s i x weeks afte r the patient was discharged from hospital. Beckie concluded that higher levels of patient knowledge surrounding coronary artery disease, diet, s e l f care, medications and physical a c t i v i t y were reported i n patients who participated i n the telephone counselling sessions. She also reported s i g n i f i c a n t l y lower anxiety i n this same group of patients. Beckie concluded that attempting to provide patients with " a l l they need to know" i n the short period of time between surgery and discharge i s a f u t i l e exercise. She further stated that while teaching i s necessary i n the hospital setting, i t should be focused more on the immediacy of the moment (what the patient feels i s needed to be known today) and further teaching should be undertaken when the patient has been discharged from hospital. These conclusions are similar to those by Sc a l z i et a l . (1980), and Steele and Ruzicki (1987). Tack and G i l l i s s (1990) arranged a similar system whereby they telephoned patients at home, at one, two, three, four, six, and eight weeks after discharge. The purpose of their study was to intervene i f necessary i n order to f a c i l i t a t e early recovery at home. Seventy-five patient and care-giver • 56 pairs were contacted (of which 29 patients had valve surgery). The teaching most required during the f i r s t four weeks included management of symptoms, coping with recovery, pain, sleep disturbances, fatigue, n u t r i t i o n a l problems and orthostatic hypotension. After four and eight weeks, patients continued to complain of i n e f f e c t i v e coping, pain and a c t i v i t y intolerance. The content areas encountered which required further elaboration were similar to the other studies reviewed. A conclusion can be drawn that follow up phone c a l l s after hospital discharge are an ef f e c t i v e way of repeating instructions, increasing knowledge and a s s i s t i n g with retention of information (Waitkoff & Imburgia, 1990). This i s a positive f i r s t step i n promoting behavioural and a t t i t u d i n a l changes. Summary Rankin (1990) stated that recovery from CABG and valve surgeries are similar. Both groups of patients are anxious, t i r e d and require time to recover. However, the issues and learning needs i n r e h a b i l i t a t i o n vary, for once a cardiac valve prosthesis i s inserted into the myocardium, the potential for valve related morbidity i s present for l i f e (Finkelmeier et a l . 1989) . It i s evident from the review of the l i t e r a t u r e that much progress surrounding patient education has been made, but that more work i s needed. As heart surgery has evolved, so too have t h e n e e d s o f i t s r e c i p i e n t s . P a t i e n t s u n d e r g o i n g h e a r t s u r g e r y -e n c o u n t e r a v a r i e t y o f e m o t i o n a l r e s p o n s e s f r o m d e l i r i u m , t o d e p r e s s i o n , a s w e l l a s a m u l t i t u d e o f l e a r n i n g n e e d s a n d l i f e s t y l e a d j u s t m e n t s . D e v e l o p i n g e f f e c t i v e p a t i e n t e d u c a t i o n a l p r o g r a m s w i l l s e r v e t o a s s i s t t h e p a t i e n t i n t h e r e h a b i l i t a t i v e p r o c e s s . U n f o r t u n a t e l y , t h e p r i n c i p l e s o f a d u l t l e a r n i n g h a v e n o t a l w a y s b e e n a p p l i e d t o p a t i e n t e d u c a t i o n p r o g r a m s d e v e l o p e d t o d a t e a n d d i s c r e p a n c i e s r e m a i n b e t w e e n w h a t n u r s e s a n d p a t i e n t s f e e l i s i m p o r t a n t t o a d d r e s s i n t h e s e p r o g r a m s . A s s i s t a n c e i n a d d r e s s i n g s o m e o f t h e s e d e f i c i t s m a y b e a c h i e v e d v i a t e l e p h o n e f o l l o w u p , b u t t h e r e a r e t o d a t e f e w s u c h s y s t e m s i n N o r t h A m e r i c a . A c o n c l u s i o n t h a t c a n b e r e a c h e d i s t h a t i n - p a t i e n t e d u c a t i o n i s e f f e c t i v e i n p r o m o t i n g t h e g o a l s o f s h o r t t e r m r e c o v e r y , b u t m a y h a v e l i m i t e d e f f e c t s w h e n u s e d t o r e a c h l o n g - t e r m g o a l s r e q u i r i n g a t t i t u d i n a l a n d b e h a v i o u r a l c h a n g e s ( W a i t k o f f & I m b u r g i a , 1 9 9 0 ) . T h e r e s e a r c h r e v i e w e d h a s s h o w n t h a t p a t i e n t s g e n e r a l l y b e l i e v e d t h e i r p o s t - o p e r a t i v e e d u c a t i o n w a s l a c k i n g i n c e r t a i n a r e a s . I t w a s h o p e d t h a t a s t u d y d e s i g n e d t o a l l o w t h e i n d i v i d u a l p a t i e n t ' s p e r s p e c t i v e a n d i d e a s t o e m e r g e , w o u l d a s s i s t i n i m p r o v i n g p o s t - o p e r a t i v e e d u c a t i o n . U l t i m a t e l y , t h i s s t u d y w i l l a d d t o t h e g r o w i n g b o d y o f k n o w l e d g e a r o u n d c h r o n i c c a r d i a c c o n d i t i o n s b y i d e n t i f y i n g t h e s e l e a r n i n g n e e d s . H e n d e r s o n s t a t e d t h a t f o r p a t i e n t s t o w o r k t o w a r d a n d a c h i e v e i n d e p e n d e n c e , t h e y m u s t f i r s t p o s s e s s t h e n e c e s s a r y s t r e n g t h , w i l l a n d knowledge ( H e n d e r s o n , 1 9 9 1 ) . 59 CHAPTER THREE Methodology This section describes the choice of design, processes of sample selection, data c o l l e c t i o n and analysis, and procedures for the protection of human rights for this study. Research Design A qualitative, descriptive research methodology was used for t his study (LoBiondo-Wood & Haber, 1990). A review of the l i t e r a t u r e did not reveal any s i g n i f i c a n t research pertaining to this subject area. Consequently i t was necessary to choose a method which allowed f u l l exploration of a subject about which l i t t l e was known and a descriptive method i s appropriate and e f f e c t i v e when attempting to describe the unknown (Wilson, 1989). S p e c i f i c a l l y , this design allowed the participants to describe their post-operative learning needs between four and ten weeks after hospital discharge, when they arose, and how they f e l t these needs could best be addressed. Semi-structured interviews were conducted and the data collected were analyzed using latent and manifest content analysis (Field & Morse, 1985). The Sample A convenience sample of 18 participants were recruited for t h e s t u d y . O t h e r t y p e s o f s a m p l i n g , s u c h a s a p r o b a b i l i t y s a m p l i n g w e r e n o t p r a c t i c a l d u e t o t h e l i m i t e d n u m b e r o f v a l v e r e p l a c e m e n t s u r g e r i e s d o n e p e r m o n t h a t t h e l o c a l t e a c h i n g h o s p i t a l , c o u p l e d w i t h t h e l a r g e c a t c h m e n t a r e a f r o m w h i c h t h e p a r t i c i p a n t s w e r e d r a w n . P a r t i c i p a n t S e l e c t i o n P a t i e n t s f u l f i l l i n g t h e f o l l o w i n g s e l e c t i o n c r i t e r i a w e r e d e e m e d e l i g i b l e f o r p a r t i c i p a t i o n i n t h e s t u d y : (1 ) P a r t i c i p a n t s w e r e 2 5 y e a r s a n d o l d e r ; ( 2 ) P a r t i c i p a n t s w e r e a b l e t o c o m m u n i c a t e i n t h e E n g l i s h l a n g u a g e ; (3 ) P a r t i c i p a n t s w e r e a b l e t o p r o v i d e i n f o r m e d c o n s e n t f o r p a r t i c i p a t i o n i n t h e s t u d y ; (4 ) P a r t i c i p a n t s w e r e u n d e r g o i n g t h e i r f i r s t h e a r t v a l v e r e p l a c e m e n t s u r g e r y ; ( 5 ) S u r g e r y h a d t o c o n s i s t o f a r e p l a c e m e n t o f e i t h e r a m i t r a l , t r i c u s p i d , p u l m o n a r y o r a o r t i c v a l v e , o r a c o m b i n a t i o n o f t h e s e ; (6 ) P a r t i c i p a n t s w e r e r e s i d e n t s o f t h e V a n c o u v e r , B r i t i s h C o l u m b i a a r e a a n d h a d b e e n t r e a t e d a t t h e l o c a l t e a c h i n g h o s p i t a l ; ( 7 ) P a r t i c i p a n t s w e r e f o u r t o t e n w e e k s p o s t -h o s p i t a l i z a t i o n a t t h e t i m e o f t h e I n t e r v i e w . 61 P a r t i c i p a n t R e c r u i t m e n t T h e s a m p l e p o p u l a t i o n w e r e r e c r u i t e d f r o m o n e l o c a l t e a c h i n g ' h o s p i t a l . O n e t h o u s a n d a n d f o r t y p a t i e n t s h a d h e a r t s u r g e r y o f a l l t y p e s a t t h i s h o s p i t a l i n 1 9 9 4 . A n i n f o r m a t i o n l e t t e r o u t l i n i n g t h e p u r p o s e s o f t h e s t u d y w a s p r o v i d e d t o t h e h o s p i t a l ' s s e v e n h e a r t s u r g e o n s ( s e e A p p e n d i x D ) . A l l t h e s u r g e o n s g a v e t h e i r c o n s e n t t o t h e i r p a t i e n t s b e i n g a p p r o a c h e d f o r s t u d y p a r t i c i p a t i o n . P a t i e n t s w e r e r e c r u i t e d f r o m t h e w a r d b e f o r e d i s c h a r g e , o r a t t h e i r s u r g e o n ' s o f f i c e a t t h e t i m e o f t h e i r s i x w e e k f o l l o w u p v i s i t . P o t e n t i a l p a r t i c i p a n t s w e r e a p p r o a c h e d b y a n i n t e r m e d i a r y , e i t h e r t h e p h y s i c i a n ' s o f f i c e a s s i s t a n t w h e n s u b j e c t r e c r u i t m e n t o c c u r r e d i n t h e s u r g e o n ' s o f f i c e , o r t h e a s s i s t a n t h e a d n u r s e o n t h e c a r d i a c . s u r g e r y r e c o v e r y w a r d w i t h i n t h e h o s p i t a l . I n t e r m e d i a r i e s w e r e p r o v i d e d w i t h a r e d f o l d e r c o n t a i n i n g a n e x p l a n a t i o n o f t h e s t u d y , i n c l u s i o n c r i t e r i a , a n d a s t a t e m e n t t o r e a d t o p o t e n t i a l p a r t i c i p a n t s ( s e e A p p e n d i x E ) . A d d i t i o n a l l y , a h a n d o u t i n c l u d i n g a d e s c r i p t i o n o f t h e s t u d y , i t s p u r p o s e s , t h e c o m m i t m e n t o f t h e p a r t i c i p a n t a n d h o w t h e s t u d y w a s t o b e c a r r i e d o u t , w a s i n c l u d e d t o p r o v i d e t o p a r t i c i p a n t s w h e n a p p r o a c h e d ( s e e A p p e n d i x A ) . A l l k n o w n p e r s o n s f i t t i n g t h e c r i t e r i a f o r t h e s t u d y w e r e a p p r o a c h e d u n t i l t h e a p p r o p r i a t e n u m b e r o f p a r t i c i p a n t s ( 1 8 ) w a s o b t a i n e d . T w o p o t e n t i a l c a n d i d a t e s r e f u s e d t o p a r t i c i p a t e 62 i n the study for unknown reasons. A t h i r d was asked but developed complications requiring re-hospitalization which excluded him from the study. When patients chose to participate, they recorded their names and phone numbers on a sheet of paper attached to the l e t t e r of information. This was remitted to the intermediary (Appendix A) and forwarded to the researcher, who contacted the potential participant by telephone to set up an appointment for an interview and to obtain written consent (Appendix B). Human Rights and Et h i c a l Considerations In order to protect human rights and privileges, the study complied with, and was approved by, the University of B r i t i s h Columbia Behavioural Sciences Screening Committee. Eth i c a l approval from the Research Committee of the Medical Advisory Committee at the teaching hospital used was also obtained. Participants were assured of c o n f i d e n t i a l i t y and informed of their right to refuse to participate without untoward effects. Those agreeing to participate were given a copy of the consent form. Because the interviews were audio taped, participants were informed that portions of the data were to be shared with the researcher's supervisors and that a l l tapes would then be erased. Participants were informed that they could have parts of the taped interview erased, or that the tape machine be 63 turned o f f at any point during the interview. Two requests were received for portions of the tape not to be used, and these requests were adhered to. When questions arose during the interview which were related to the individual's health care, the researcher informed the patient of the appropriate resources for follow up (eg. Heart and Lung Association for smoking cessation). - Data Collection and Analysis The participants were interviewed for approximately one hour. A Learning Needs Interview Guide (see Appendix C) was prepared by the researcher which assisted with the data c o l l e c t i o n during the semi-structured interviews. F i e l d notes were recorded after each interview. These consisted of observations made during the interview (eg. the state of cleanliness of the home). The potential for follow up interviews was discussed with each patient however a lack of c l a r i t y i n the discussion of a subject area was found i n only one interview, and this participant was contacted and the issue c l a r i f i e d . , Learning Needs Interview Guide -The interview guide was designed to provide some di r e c t i o n to the interviews. Henderson's (1991) fourteen needs were used as a guide when developing the question prompts. The questions 64 were designed to be f l e x i b l e , open-ended and non-threatening. F l e x i b i l i t y within the interview format "can bring out much useful material because i t allows the researcher to... e l i c i t the subjects' values, b e l i e f s and attitudes" (Brink and Wood, 1983, p.116). Semi-structured interviews were the preferred method of interviewing because the researcher was unable to anticipate a l l the possible responses to issues or questions (Morse, 1992). The interview guide also assisted i n ensuring that a l l participants were asked the same questions. It seemed that this interview method allowed study participants to talk f r e e l y about their post-operative learning needs. The interview guide was designed based on the assumption that the participants would have received the usual heart valve replacement discharge teaching offered by the st a f f of the hospital where the surgery was performed. Specific demographic information was asked of each participant at the end of the interview including: age, sex, type of valve implanted (porcine or mechanical), educational background, and the dates of surgery and discharge. Because pa r t i c i p a t i o n i n the study was limited, the demographic information obtained provided general information only and was not used for s t a t i s t i c a l analysis purposes. Age was noted because Grady et a l . (1988) have indicated that younger people perceive less of a need for post-operative education than older people. Consequently, i t was f e l t that i t would be interesting 65. to see weather this trend would be observed i n this study. Rankin (1990) and MacKenzie (1993) established that learning needs varied between men and women, so recording patient gender assisted i n identifying learning needs s p e c i f i c to men or women. There, was not a large enough sample for this to be s t a t i s t i c a l l y s i g n i f i c a n t . The type of valve was relevant because those with mechanical vaives experience d i f f e r e n t treatment regimens. Educational background was s i g n i f i c a n t because Dodge (1969) and Grady et a l . (1988) demonstrated a li n k between degree of understanding and level, of education. Hence th i s was also documented and considered during the analysis of the results. The date of the participant's surgery and discharge was required to ensure patient interviews were being conducted four to ten weeks after hospital discharge. At the conclusion of the study, the participants were offered the opportunity to provide any other information they believed would be b e n e f i c i a l . The participants were informed that a summary of the results could be obtained at the conclusion of the study. A l l 18 participants requested a copy of this summary. Data Analysis The interviews were audio-taped and transcribed. Patients' learning needs were related through the t e l l i n g of their whole experiences. Consequently, latent and manifest 66 content analysis was used when analyzing the data (Field & Morse, 1985). The various passages of the text were reviewed within the context of "the entire interview, i n order to ide n t i f y and code the major thrust or intent of the section and the s i g n i f i c a n t meanings within the passage" (Field & Morse, 1985, p.103). Several interviews were repeatedly re-read during the coding and analysis process to a s s i s t i n identifying the commonly emerging themes. The data from the interviews were also compared with one another by sorting into categories to i d e n t i f y commonly recurring themes and learning needs. Through the analysis of the underlying meanings and overall intent, a^IejLcrip^ion_o£^t^^ their learning needs emerged. V a l i d i t y and R e l i a b i l i t y The Learning Needs Interview Guide was reviewed by a cardiac C l i n i c a l Nurse Sp e c i a l i s t p r i o r to i t s use and several small wording changes were made. To further a s s i s t i n addressing content v a l i d i t y , a p i l o t study involving two patients was conducted. The c r i t e r i a and procedures for sample recruitment and data c o l l e c t i o n were used during the p i l o t study. Conducting the p i l o t study assisted i n increasing the c l a r i t y of the instrument designed, as i t demonstrated the guide's effectiveness i n e l i c i t i n g responses pertinent to the research questions. Date of hospital discharge was the only 67 addition made at this time. Intra-rater r e l i a b i l i t y i n the coding process was assured by having the researcher transcribe and code a l l the data (Downe-Wamboldt, 1992). The researcher also re-coded the f i r s t interview after having coded 10 other data sets to ensure the same themes emerged both times.. There were no major discrepancies noted i n the coding when the 2 transcripts were compared. Summary This study uses a descriptive methodology. An interview guide based on Henderson's needs was designed, refined and used during patient interviews. The study adhered to the regulations for protection of human rights and patient c o n f i d e n t i a l i t y of the University of B r i t i s h Columbia's Behavioural Sciences Screening Committee. The data from the interviews was coded and analyzed using latent, and manifest content analysis i n order to establish the common learning needs of heart valve replacement patients... C H A P T E R F O U R F i n d i n g s C h a p t e r f o u r p r e s e n t s t h e f i n d i n g s o f t h e s t u d y i n f o u r s e c t i o n s . I n S e c t i o n O n e : P a r t i c i p a n t c h a r a c t e r i s t i c s a r e i n i t i a l l y p r e s e n t e d . S e c t i o n T w o : T h e P r e - O p e r a t i v e P r o c e s s p r e s e n t s t h e p r e - o p e r a t i v e l e a r n i n g n e e d s e x p r e s s e d . S e c t i o n T h r e e : P o s t - O p e r a t i v e E x p e r i e n c e s o u t l i n e s t h e l e a r n i n g n e e d s e x p r e s s e d d u r i n g r e c o v e r y . S e c t i o n f o u r : A d d r e s s i n g L e a r n i n g N e e d s , p r e s e n t s t h e r e s u l t s p e r t a i n i n g t o w h e n t h e n e e d s a r o s e I t a l s o a d d r e s s e s " w h o " ( a c c o r d i n g t o t h e p a r t i c i p a n t s ) s h o u l d - u n d e r t a k e t h i s - - t a s k . , t w h e n t h e i n s t r u c t i o n s h o u l d t a k e p l a c e , a n d h o w i t s h o u l d b e u n d e r t a k e n . A t h o r o u g h d i s c u s s i o n o f t h e r e s u l t s i s p r e s e n t e d a f t e r e a c h t h e m e i n e a c h s e c t i o n . S e c t i o n O n e : P a r t i c i p a n t C h a r a c t e r i s t i c s A t o t a l o f 1 8 p a r t i c i p a n t s , ( n i n e m e n a n d n i n e w o m e n ) , w e r e r e c r u i t e d f o r t h e s t u d y . T h i s c o r r e l a t e d w i t h t h e p r e v i o u s l y n o t e d s t a t i s t i c s f r o m S t a t i s t i c s C a n a d a w h i c h r e v e a l e d t h a t a p p r o x i m a t e l y e q u a l n u m b e r s o f m e n a n d w o m e n u n d e r g o f i r s t t i m e v a l v e s u r g e r y e a c h y e a r i n B r i t i s h C o l u m b i a F i v e p a r t i c i p a n t s w e r e r e c r u i t e d f r o m t h e h o s p i t a l w a r d . T h e r e m a i n i n g 1 3 w e r e e n r o l l e d t h r o u g h t h e s u r g e o n s ' o f f i c e s . E i g h t m e n w e r e m a r r i e d a n d o n e h a d n e v e r m a r r i e d . F i v e w o m e n w e r e m a r r i e d , t h r e e w e r e w i d o w e d a n d o n e h a d n e v e r m a r r i e d . 69 Ethnic o r i g i n varied with participants being Chinese (3), B r i t i s h (2), Russian (1), I t a l i a n (1), Scottish (1), I r i s h (1), and Canadian (9). Male ages ranged from 29 to 79 years, while female ages ranged from 32 to 76 years. Thirty three percent of the sample, were between 66 and 75 years (see Table I, Appendix F). Ford's (1989) study reported that the largest percentage of her Canadian sample group (26.4% of valve patients) were also i n this age range. Education levels were r e l a t i v e l y homogeneous. A comparison of the male-female sample revealed that f i v e (two females and three males) had less than a grade eight education, six (three men and three women) had achieved grades nine through twelve, and seven (four women and three men) had college or university degrees. (Levels of education achieved are presented i n Table III, Appendix F). Occupational characteristics revealed that the majority (n=10) were r e t i r e d . This correlated with the majority age range of participants. Of the remaining eight, two men and two women were on sick leave from their place of employment, two men were attempting to begin new careers, one woman had been on long term sick benefits for more than f i v e years, and one woman was a home maker with a six month old c h i l d . The a o r t i c valve was the most commonly replaced valve (see Table two, Appendix F). Of the 18, f i v e had porcine prosthetic i m p l a n t s , 1 2 h a d m e c h a n i c a l v a l v e s a n d o n e h a d a n " e x p e r i m e n t a l " m o s a i c v a l v e . T h i r t e e n p a r t i c i p a n t s r e q u i r e d a n t i c o a g u l a n t s . P a r t i c i p a n t s s p e n t a n a v e r a g e o f 9 . 5 d a y s i n h o s p i t a l r e c o v e r i n g f r o m s u r g e r y ( n o t i n c l u s i v e o f t h e d a y o f s u r g e r y ) . M e n h a d a m e a n h o s p i t a l s t a y o f 8 . 2 d a y s , w h i l e w o m e n ' s p e n t a n a v e r a g e o f 1 0 . 7 d a y s i n h o s p i t a l . H o s p i t a l d a y u t i l i z a t i o n v a r i e d . f r o m s e v e n ( m o d e ) t o 1 9 d a y s . T h i s p r o v e d s i m i l a r ; t o . t h e r e c e n t p r o v i n c i a l a n d n a t i o n a l s t a t i s t i c s r e p o r t e d b y S t a t i s t i c s C a n a d a . -F o u r p e o p l e d i d n o t p a r t i c i p a t e i n p a r t s o f t h e r o u t i n e t e a c h i n g p r o g r a m s , i m p l e m e n t e d b y t h e h o s p i t a l . T w o c h o s e n o t t o s e e t h e p r e - o p e r a t i v e i n s t r u c t i o n a l v i d e o , f e a r i n g t h a t i t w o u l d h a v e , b e e n t o o g r a p h i c , b u t u n d e r w e n t t h e r o u t i n e t e s t s a n d i n t e r v i e w s o n a d m i s s i o n : Two p a r t i c i p a n t s d i d n o t s e e t h e . v i d e o e n t i t l e d " G o i n g Home a f t e r H e a r t S u r g e r y " . B o t h s t a t e d t h e y w o u l d h a v e l i k e d t o h a v e s e e n i t , , b u t i t w a s n o t o f f e r e d t o t h e m . T h e y d i d , h o w e v e r , p a r t i c i p a t e i n p h y s i o t h e r a p y a n d n u t r i t i o n c l a s s e s . I n t e r v i e w s w e r e c o n d u c t e d i n t h e p a r t i c i p a n t s h o m e s b e t w e e n 2 8 a n d 7 6 d a y s a f t e r h o s p i t a l d i s c h a r g e . ( T h e a v e r a g e w a s 5 4 d a y s ) . , T h e v i s i t s l a s t e d f r o m 5 0 m i n u t e s t o o n e h o u r a n d f i f t e e n m i n u t e s . . S e c t i o n T w o : T h e P r e - O p e r a t i v e P r o c e s s T h e S t o r i e s 71 T h e p a r t i c i p a n t s w e r e a n e a g e r g r o u p , w i t h s e v e n d i s c l o s i n g i n f o r m a t i o n p e r t a i n i n g t o t h e i r e x p e r i e n c e s p r i o r t o t h e r e s e a r c h e r i n t r o d u c i n g t h e s t u d y o r h a v i n g t h e t a p e m a c h i n e t u r n e d o n . D e s p i t e s p e c i f i c a l l y b e i n g a s k e d a b o u t l e a r n i n g n e e d s e n c o u n t e r e d a f t e r t h e s u r g i c a l e x p e r i e n c e , a l l p a r t i c i p a n t s d e s c r i b e d t h e i r " s t o r i e s " f r o m t h e o n s e t ( l o n g -t e r m i l l n e s s e s o r s u d d e n c r i s i s ) , t h r o u g h t h e p r o c e s s o f d i a g n o s i s , s u r g e r y , a s w e l l a s t h e i r p o s t - o p e r a t i v e e x p e r i e n c e s . j T h e s t o r y t e l l i n g p r o v e d s i g n i f i c a n t , b e c a u s e t h e s t o r i e s a n d h o w t h e y w e r e e x p r e s s e d p r o v i d e d i n s i g h t i n t o t h e p a r t i c i p a n t s e x p e r i e n c e s a n d t h e i r l e a r n i n g n e e d s . M o s t p a r t i c i p a n t s i n i t i a l l y v i s i t e d t h e i r f a m i l y p h y s i c i a n d u e t o i l l n e s s r e l a t e d p h y s i c a l l i m i t a t i o n s . T h e s e i n c l u d e d s h o r t n e s s o f b r e a t h , l a c k o f e n e r g y , d i f f i c u l t y w a l k i n g , d i z z i n e s s , a n d f l u i d r e t e n t i o n . T h r e e p a r t i c i p a n t s w e r e o r i g i n a l l y w r o n g l y d i a g n o s e d w i t h t h e f l u , p n e u m o n i a a n d a c o l d . T h o s e w h o u n d e r w e n t e m e r g e n c y s u r g e r y h a d p r e v i o u s l y s e e n t h e i r f a m i l y p h y s i c i a n s f o r c o l d s , s h o r t n e s s o f b r e a t h a n d g e n e r a l m a l a i s e . E i g h t p a r t i c i p a n t s d i s c u s s e d h a v i n g t h e p r e - o p e r a t i v e a n g i o g r a m a n d i t s e f f e c t s . T w o d e v e l o p e d c o m p l i c a t i o n s a s a r e s u l t o f t h e p r o c e d u r e . O n e p a r t i c i p a n t l o s t p a r t o f t h e v i s i o n i n h i s l e f t e y e , w h i l e t h e o t h e r d e v e l o p e d " p e r i p h e r a l n e r v e d a m a g e , r e s u l t i n g i n a m i l d l i m p a n d d i s e q u i l i b r i u m . B o t h s t a t e d t h e y w e r e n o t i n f o r m e d o f t h e s e p o t e n t i a l complications and expressed anger that this had occurred. The other 6 participants simply mentioned the angiogram as part of the diagnostic process and deemed i t "an interesting procedure". ' Choices: Surgery and Valves While recounting their stories, i t became evident that the participants perceived they had l i t t l e or no choice when making the decision to have the defective valve(s) s u r g i c a l l y replaced: My doctor had me go to the cardiologist and between them they decided that surgery was necessary. It was not a question of making a decision, they said i t just had to be. I wanted to decide whether or not I r e a l l y wanted to have this done. Then when I got short of breath and wound up i n intensive care, I more or less had no choice. I wasn't r e a l l y decided, but. Fifteen participants expressed similar concerns. Of these, the six participants who underwent emergency procedures (with l i t t l e or no p r i o r knowledge of their heart valve defect) were p a r t i c u l a r l y vocal about their perceived lack of choice pertaining to the surgical intervention: ... the surgeon said, I think we're going to do i t right now, i f you don't have any objections. I said "No, I guess not, I'm not doing anything this afternoon!" But I was r e a l l y quite unsure, I didn't know much of anything! Andrew, they indicated to me that i f I refused the surgery I wouldn't be here much longer... So the choice was already made. 73 T h e c h o i c e o f v a l v e i m p l a n t s w a s v e r b a l i z e d b y a l l . p a r t i c i p a n t s a s a n i m p o r t a n t t h o u g h s t r e s s f u l p a r t o f t h e p r o c e s s . F i f t e e n p a r t i c i p a n t s s t a t e d t h a t i t w a s d i f f i c u l t t o m a k e a d e c i s i o n p e r t a i n i n g t o t h e v a l v e t y p e . A g e w a s n o t a d e t e r m i n i n g f a c t o r . O n e 7 5 y e a r o l d m a n c o m m e n t e d : We t h o u g h t a b o u t i t a l o t a n d w e l l . . . t h e m o s a i c , u g h , m y w i f e , s h e f i g u r e s t h i s i s s o r t o f n e w a n d e x p e r i m e n t a l , a n d s i n c e t h e p o r c i n e a r e p r e t t y w e l l a c c e p t e d , w e t o o k t h a t o n e E l e v e n p a r t i c i p a n t s f e l t w e l l i n f o r m e d b y t h e i r s u r g e o n s a n d v a r i o u s p h y s i c i a n s a b o u t t h e t y p e s o f v a l v e s a n d t h e a d a p t a t i o n s r e q u i r e d f o r b o t h . T h e y s h o w e d me v i d e o s a n d t h e y s h o w e d me m e c h a n i c a l v a l y e s , t h e p i g v a l v e , t h e w h o l e w o r k s . I s e e n i t a l l m o n t h s p r i o r t o h a v i n g t h e s u r g e r y . I d e c i d e d I w o u l d r a t h e r h a v e t h e m e c h a n i c a l o n e . . . . a n d t h e r a m i f i c a t i o n s w e r e v e r y w e l l e x p l a i n e d . I f I h a d t h e p i g v a l v e I w a s g o i n g t o b e l o o k i n g f o r t r u f f l e s i n t h e f o r e s t ( l a u g h ) . I t w a s s t r o n g l y r e c o m m e n d e d t h a t I t a k e i t ( m e c h a n i c a l v a l v e ) b u t t h e d o w n s i d e i s t h a t I am s t u c k o n r a t p o i s o n f o r t h e r e s t o f my l i f e . T h e r e m a i n i n g s e v e n f e l t t h a t m o r e p r e - o p e r a t i v e e d u c a t i o n i n t h e f o r m o f s p e c i f i c w r i t t e n i n f o r m a t i o n w a s r e q u i r e d i n o r d e r t o h e l p w i t h t h e i r d e c i s i o n . I e x p e c t e d t o b e m o r e i n f o r m e d , a c t u a l l y . T h e r e w a s n o t a l o t o f e d u c a t i o n a h e a d o f t i m e . T h e y s h o u l d g i v e y o u m o r e i n f o r m a t i o n b e f o r e t h e s u r g e r y . Y o u ' r e w i t h y o u r d o c t o r . . . y o u ' r e s i t t i n g t h e r e a n d y o u r s t o m a c h i s g o i n g a n d y o u d o n ' t k n o w w h a t y o u ' r e d o i n g r e a l l y . Y o u k n o w y o u ' r e t h e r e , y o u k n o w y o u ' r e g o i n g t o g o f o r i t a n d e v e r y t h i n g l i k e t h a t , y o u ' r e q u i t e s e t , b u t y o u g e t o u t o f t h e r e a n d a l l o f a s u d d e n y o u t h i n k , n o w d i d h e t e l l me t h i s o r t h a t ? A p a m p h l e t o n t h i s v a l v e s t u f f 74 w o u l d b e g o o d . T h e i m p o r t a n c e a t t a c h e d t o t h e c h o i c e o f v a l v e w a s b e s t s e e n w i t h C , a 3 2 y e a r o l d w o m e n w h o w a s 2 8 w e e k s p r e g n a n t a t t h e t i m e o f h e r a c u t e v a l v e f a i l u r e . I n i t i a l l y , s h e w a n t e d t o h a v e a t l e a s t o n e m o r e c h i l d , t h e r e f o r e s h e p e r c e i v e d h e r c h o i c e o f v a l v e s a s b e i n g b o t h i m p o r t a n t , a n d d i f f i c u l t . P r i o r t o h e r c a e s a r e a n s e c t i o n , s h e w a s c o n s i d e r i n g a p o r c i n e v a l v e , w h i c h w o u l d h a v e a l l o w e d h e r t o a t t e m p t a r e p e a t p r e g n a n c y . H o w e v e r , a f t e r w h a t s h e d e s c r i b e d a s i n t e n s i v e p r e - o p e r a t i v e t e a c h i n g p e r t a i n i n g t o t h e v a r i o u s v a l v e s , a n d t h e s u c c e s s f u l b i r t h o f a p r e m a t u r e , b u t h e a l t h y b a b y g i r l , s h e o p t e d f o r s t e r i l i z a t i o n a n d r e p l a c e m e n t o f h e r d e f e c t i v e v a l v e w i t h a m e c h a n i c a l o n e . S h e d i d n o t w a n t t o r i s k h e r l i f e b y h a v i n g t o r e p e a t t h e s u r g e r y i n 1 0 t o 1 5 y e a r s . T h r e e i n d i v i d u a l s s t a t e d t h a t t h e y w e r e u n c e r t a i n a s t o w h a t t y p e o f v a l v e w a s i m p l a n t e d . W i t h o n e w o m a n , t h i s w a s d i s c o v e r e d d u r i n g t h e i n t e r v i e w w h e n t h e r e s e a r c h e r a s k e d i f s h e c o u l d h e a r t h e v a l v e c l i c k , a n d s h e w o n d e r e d w h y a n y o n e w o u l d a s k s u c h a s i l l y q u e s t i o n ! T h e s e c o n d p e r s o n v o l u n t e e r e d t h i s i n f o r m a t i o n , "I d i d n ' t e v e n k n o w u n t i l a f t e r w a r d s w h a t k i n d o f v a l v e I . h a d ! " D u r i n g a n o t h e r i n t e r v i e w , a p a r t i c i p a n t w a s a s k e d w h a t t y p e o f v a l v e h e w a s g i v e n a n d r e p l i e d " b e a t s m e " . I n t e r e s t i n g l y , a l l t h r e e w e r e e d u c a t e d w i t h a t l e a s t a h i g h s c h o o l d i p l o m a . T h e s e i n d i v i d u a l s h a d w a i t e d g r e a t e r t h a n t w o m o n t h s f o r t h e s u r g e r y . C o n s e q u e n t l y , i t w a s e v i d e n t t h a t e v e n w h e n t i m e p e r m i t t e d , n o t a l l p a r t i c i p a n t s w e r e w e l l i n f o r m e d . O b v i o u s l y , t h e s e t h r e e p a r t i c i p a n t s d i d n o t d i s c u s s t h e d i f f i c u l t i e s e n c o u n t e r e d w i t h v a l v e c h o i c e s . T h i s f u r t h e r s u p p o r t s - t h e p a r t i c i p a n t s c l a i m s t h a t t h e y d i d n o t a l w a y s h a v e a c h o i c e i n , a n d w e r e n o t a l w a y s i n f o r m e d a b o u t v a r i o u s a s p e c t s o f t h e p r o c e d u r e s . I t i s p o s s i b l e t h a t i n f o r m a t i o n w a s p r o v i d e d b u t n o t r e t a i n e d d u e t o t h e s t r e s s f u l n a t u r e o f c a r d i a c s u r g e r y . D e s p i t e s t a t e m e n t s i n d i c a t i n g t h e y f e l t w e l l p r e p a r e d f o r • t h e s u r g i c a l p r o c e d u r e , m a n y o f t h e p a r t i c i p a n t s a t t e m p t e d t o f i n d a d d i t i o n a l i n f o r m a t i o n r e l a t e d t o o p e n h e a r t s u r g e r y a n d t h e v a l v e s . F o r s o m e t h i s w a s n o t p o s s i b l e d u e t o t h e e m e r g e n c y n a t u r e o f t h e i r s u r g e r y . H o w e v e r , f o u r p a r t i c i p a n t s d i s c u s s e d t h e p r o c e d u r e p r e - o p e r a t i v e l y w i t h f r i e n d s , a c q u a i n t a n c e s , o r t h e i r p h a r m a c i s t s . N i n e p a r t i c i p a n t s u n d e r t o o k t h e i r o w n r e a d i n g o r r e s e a r c h . I h a v e t h i s a r t i c l e h e r e o n t h e m o s a i c s , f r o m t h e p a p e r . T h e y m a k e t h e m r i g h t i n B u r n a b y h e r e . T h e y h a v e a l i b r a r y i n r e c e p t i o n a t c h i l d r e n ' s h o s p i t a l a n d I ' d g o i n t h e r e a n d I ' d r e a d o n h e a r t c o n d i t i o n s a n d v a l v e r e p l a c e m e n t s a n d s t u f f l i k e t h a t . T h e s e i n d i v i d u a l s s e a r c h e d l i b r a r i e s ( m o s t f r e q u e n t l y ) , p h a r m a c i e s , h o m e m e d i c a l t e x t s a n d t h e P r i t c h e t t a n d H u l l s e r i e s o f c a r t o o n b o o k s o n G o i n g f o r H e a r t S u r g e r y . T w o i n d i v i d u a l s h a d d i f f i c u l t y f i n d i n g w r i t t e n i n f o r m a t i o n t h a t w a s e a s y t o r e a d , w i t h o n e e v e n s e a r c h i n g t h e m e d i c a l e q u i p m e n t r e n t a l s h o p s . B o t h c o m m e n t e d : 76 They should have pamphlets i n the s p e c i a l i s t s o f f i c e s . You go i n there and you see magazines, you don't see information regarding patient information. ... they are s p e c i a l i s t s i n hearts so they should have a l l sorts of heart information. Four participants asked their doctors many questions and persisted u n t i l they were s a t i s f i e d they had the answers and information they were seeking. This study did not seek to evaluate the perceived adequacy of pre-operative instruction and preparation, but seven participants openly stated that i t was inadequate. Discussion Stanton et a l . (1984), and Grady et a l . (1988) have previously documented patient surprise as i t pertains to being diagnosed with heart disease. The surprise experienced i n this study may have been an expression of denial or perceived lack of control and i n j u s t i c e at having to "choose" to undergo such an operation. Regardless, i t can be concluded that greater than one t h i r d of the participants were not adequately informed about the various.valves, the surgery and i t s complications at a l e v e l which they could e a s i l y understand, or which enabled them to "choose" to have the operation. In addition, i t i s clear that the s t r e s s f u l nature of the process caused poor information retention for some. Because of this, the issue of informed consent requires consideration. If written information were available i n a tangible form from a l l the surgeons' o f f i c e s , the participants may have perceived 77 t h e m s e l v e s t o b e b e t t e r i n f o r m e d , a n d m a y h a v e m a d e c h o i c e s w h i c h m o r e f u l l y r e f l e c t t h e i r o w n b e l i e f s a n d " u n i q u e " s i t u a t i o n s . E m o t i o n s A v a r i e t y o f e m o t i o n s w e r e e x p e r i e n c e d d u r i n g t h e p r e -o p e r a t i v e p r o c e s s . A l l t h e p a r t i c i p a n t s m a d e s t r o n g s t a t e m e n t s t o i n d i c a t e t h a t t h e i r i n d i v i d u a l p r o c e s s w a s u n i q u e a n d n o t g e n e r a l l y a p p l i c a b l e t o a l l . c a r d i a c p a t i e n t s . E v e r y b o d y y o u t a l k t o t h a t h a s h a d s u r g e r y , r e g a r d l e s s o f w h a t i t i s , . . . t h e y a r e e n t i r e l y d i f f e r e n t . I f i g u r e a n y t h i n g t h a t i s d o n e t o t h e b o d y , n o t w o p e o p l e a r e t h e s a m e . • I t h i n k t h i s i s a h i g h l y s e n s i t i v e a n d i n d i v i d u a l t o p i c a n d , u g h , y o u w i l l f i n d t h a t t h e r e s p o n s e s a r e v e r y i n d i v i d u a l i z e d . A n x i e t y a n d f e a r w e r e d e s c r i b e d b y 12 p a r t i c i p a n t s a s c o m m o n l y o c c u r r i n g p r e - o p e r a t i v e e m o t i o n s . T h e p a r t i c i p a n t s u s e d d e s c r i p t i o n s s u c h a s s c a r e d , w o r r i e d , s t u n n e d a n d s h o c k e d . S t a t e m e n t s s u c h a s "I w a s s c a r e d s t r a i g h t ! " o r "I h a d a f e a r u g h , m a y b e o f d e a t h I d u n n o , b u t i t w a s b i g t i m e ! " w e r e c o m m o n . O n e p e r s o n v o i c e d f e a r a n d c o n c e r n a b o u t t h e p o t e n t i a l o f h a v i n g a r e s i d e n t d o h i s s u r g e r y b e c a u s e a r e s i d e n t h a d i p e r f o r m e d h i s a n g i o g r a m , w h i c h r e s u l t e d i n p a r t i a l b l i n d n e s s . T h i r t e e n p a r t i c i p a n t s i d e n t i f i e d t h e p r e - o p e r a t i v e w a i t i n g t i m e a s s t r e s s f u l . E i g h t p a r t i c i p a n t s b e l i e v e d t h a t t h e i r c o n d i t i o n d e t e r i o r a t e d d u r i n g t h i s t i m e . T h i s f e e l i n g p r o m o t e d a s e n s e o f u r g e n c y w i t h i n , a n d a d d e d t o t h e i r p e r c e i v e d s t r e s s levels. One person commented "I was bumped three times... and I could f e e l myself getting - worse every day!" The participants waited up to three months for their surgery and were bumped as many as three times, but s t i l l commented that they were in hospital for surgery quicker than anticipated. I wasn't expecting that, because on the news there were delays because of the funding of the surgeries. And that they were only doing major surgeries to the people that had major problems f i r s t . So I wasn't expecting i t so soon. Two of the previous statements mention death. The fear of death was verbalized by six participants as being a genuine concern. One person even asked "Are you sure I am going to be able to be brought back to l i f e after?" Eight participants verbalized various forms of denial between the time of diagnosis and surgery. I f e l t that was wrong, me having any valve problems! I didn't f e e l anything. i guess I just didn't want to go through t h i s . I don't think i t r e a l l y c l i c k e d i n for me that i t was me. I think I went through the whole thing, ugh, on the outside looking i n . One man said that as his case was not considered urgent or l i f e threatening, he thought i t was not going to be much of a problem. 1 He l a t e r decided that this was a denial of the severity of the i l l n e s s . Shock was an additional emotion expressed, closely p a r a l l e l i n g denial. A l o t of things didn't register. I think I was i n more shock than anything else. But i t i s s t i l l a l i t t l e b i t of a j o l t to my system that I have a heart condition, and i t ' s not going to go away. 79 A n g e r w a s a l s o e v i d e n t p r e - o p e r a t i v e l y . A l t h o u g h n o t u n i v e r s a l , i t w a s p r o m i n e n t i n t h o s e w h o h a d b e e n m i s d i a g n o s e d a n d t h o s e w i t h r e s i d u a l e f f e c t s f r o m t h e a n g i o g r a m . F i v e p a r t i c i p a n t s , b o t h y o u n g a n d o l d , c o m m e n t e d o n t h e n e e d t o p r e p a r e t h e m s e l v e s a n d t h e i r f a m i l i e s f o r t h e s u r g i c a l p r o c e s s . P r e p a r a t i o n s i n c l u d e d p u r c h a s i n g a n a n s w e r i n g m a c h i n e t h e r e b y e n s u r i n g t h e o p p o r t u n i t y t o " g e t i n " f o r s u r g e r y , p a c k i n g o n e ' s t r a v e l b a g " j u s t i n c a s e " , p r e p a r i n g w i l l s , p a y i n g a l l b i l l s a n d s e t t l i n g d e b t s . A v a r i e t y o f e m o t i o n s w e r e d e s c r i b e d i n r e l a t i o n t o t h e h o s p i t a l a d m i s s i o n . T w o p a r t i c i p a n t s s t a t e d t h a t t h e y f e l t p a n i c k y o n c e i n h o s p i t a l , b e c a u s e t h i s m e a n t t h e y w e r e g o i n g t h r o u g h w i t h t h e s u r g e r y . T h e e i g h t p a r t i c i p a n t s w h o e x p r e s s e d d e n i a l c o n t i n u e d d o i n g s o , s t a t i n g t h a t t h e y t h o u g h t i t w o u l d b e " a p i e c e o f c a k e , e a s y , a c i n c h , m i n o r s u r g e r y . . . . " . T h e s e i n d i v i d u a l s l a t e r c o m m e n t e d t h a t t h e y h a d f a l s e p e r c e p t i o n s o f t h e p r o c e s s . "I w a s n o t q u i t e r a t i o n a l , i n t e r m s o f w h a t I w a s e x p e c t i n g . . . " . T w o i n d i v i d u a l s m a i n t a i n e d t h a t t h e h o s p i t a l a d m i s s i o n w a s e a s y . G e n e r a l l y , t h e g r o u p h a d a v e r y p o s i t i v e a t t i t u d e t o w a r d t h e s u r g e r y a n d r e c o v e r y . O n e w o m a n c o m m e n t e d "I w a s h a p p y t o g o a n d h a v e i t , b e c a u s e i t w a s g e t t i n g u n b e a r a b l e . . . " A n o t h e r w o m a n s t a t e d " t h e s u r g e o n i s g o i n g t o d o h i s p a r t a n d t h e n I ' v e g o t t o d o m i n e " . T h e p a r t i c i p a n t s w a n t e d t o h a v e t h e s u r g e r y , g o h o m e , b e w i t h t h e i r f a m i l i e s a n d r e c o v e r . T w o p a r t i c i p a n t s s t a t e d t h a t t h e y w e r e f e a r f u l o f , a n d c h o s e n o t t o v i e w t h e p r e - o p e r a t i v e v i d e o , b e l i e v i n g i t w o u l d p r o v i d e t h e m w i t h g r e a t e r i n f o r m a t i o n r e l a t e d t o t h e s u r g e r y t h a n t h e y e i t h e r w a n t e d o r p e r c e i v e d n e c e s s a r y . O n e w o m e n , a s e n i o r v i c e - p r i n c i p a l a t a n e l e m e n t a r y s c h o o l c o m m e n t e d : I t h o u g h t i t m i g h t b e l i k e s o m e o f t h e m e d i c a l t h i n g s o n T V w h e r e y o u ' r e g e t t i n g m o r e e d u c a t i o n t h a n y o u r e a l l y n e e d . I t p r o b a b l y n e e d s t o b e e x p l a i n e d t o s o m e o n e l i k e m y s e l f w h o w o u l d r e f u s e b e c a u s e o f t h e t h o u g h t o f t h e b l o o d a n d g o r e . W h e n a s k e d i f t h e y w e r e i n f o r m e d a s t o t h e c o n t e n t o f t h e v i d e o , b o t h p a r t i c i p a n t s r e p l i e d n o . W h e n t o l d w h a t t h e v i d e o d i d c o n t a i n ( i n f o r m a t i o n r e l a t e d t o w h o y o u w i l l m e e t , a n d t h e g e n e r a l p r o c e d u r e s p e r f o r m e d p r i o r t o h e a r t s u r g e r y ) b o t h p a r t i c i p a n t s s a i d t h a t h a d t h e y k n o w n t h i s , t h e y w o u l d h a v e b e e n w i l l i n g t o v i e w t h e t a p e . T h e y c o m m e n t e d t h a t t h i s s h o u l d h a v e b e e n m a d e c l e a r t o t h e m p r e - o p e r a t i v e l y . D i s c u s s i o n T h e p r e - o p e r a t i v e e m o t i o n a l r e s p o n s e s v a r i e d b u t a s n o t e d , a n x i e t y , f e a r , t h e f e a r o f d e a t h , s h o c k a n d a n g e r w e r e c o m m o n l y r e p o r t e d . T h e s e e m o t i o n s h a v e a l s o b e e n r e p o r t e d i n m u c h o f t h e p a s t a n d c u r r e n t r e s e a r c h l i t e r a t u r e . W h i l e m a n y o f t h e e m o t i o n s e x p r e s s e d w e r e c o m m o n t o m o r e t h a n o n e p e r s o n , t h e p a r t i c i p a n t s c l e a r l y s t a t e d t h a t t h e y p e r c e i v e d t h e i r s t o b e u n i q u e . I n t e r e s t i n g l y , t h e n e e d t o t e l l o n e ' s s t o r y a n d t h e p e r c e p t i o n t h a t i t i s u n i q u e h a v e a l s o b e e n c o m m o n l y r e p o r t e d i n t h e l i t e r a t u r e . B e i n g " b u m p e d " f r o m t h e w a i t i n g l i s t p l a c e d u n d u e s t r e s s a n d w o r r y o n p e o p l e w h o w e r e a l r e a d y v e r y i l l . O n e m a y l o o k t o t h e n e w s m e d i a f o r a p a r t i a l e x p l a n a t i o n f o r t h e w a i t i n g t i m e s t r e s s . T h e m e d i a r e p o r t o n s u r g i c a l w a i t i n g l i s t s w i t h o u t n e c e s s a r i l y p r e s e n t i n g t h e e n t i r e p i c t u r e . U n b a l a n c e d c o v e r a g e e x a c e r b a t e s p a t i e n t s p r e - o p a n x i e t i e s . S e c t i o n T h r e e : P o s t - O p e r a t i v e E x p e r i e n c e s D i s c h a r g e P r o c e s s E i g h t p a r t i c i p a n t s v o i c e d c o n c e r n s w i t h t h e p e r c e i v e d l a c k o f a s s i s t a n c e a n d o r g a n i z a t i o n i n t h e d i s c h a r g e p r o c e s s . F i v e s t a t e d t h a t t h e y w e r e d i s c h a r g e d t o o s o o n , t h a t t h e y r e m a i n e d u n w e l l , a n d w e r e n o t g i v e n p r o p e r n o t i c e t o m a k e s u i t a b l e t r a v e l o r d o m e s t i c a r r a n g e m e n t s . . . . t h e s p e c i a l i s t , h e t o l d me y o u h a v e t o g o h o m e . ' I s a y N O ! , I c a n n o t g o h o m e c a u s e I n o t f e e l g o o d . " N o " s a i d t h e s p e c i a l i s t , " Y o u h a v e t o g o b e c a u s e y o u a r e O K . " B u t I n o f e e l O K ! T h r e e p e o p l e v o i c e d t h e i r c o n c e r n s p e r t a i n i n g t h e l a c k o f a s s i s t a n c e p r o v i d e d w h e n l e a v i n g t h e h o s p i t a l . O n e , a r e t i r e d s u r g e o n , s t a t e d : . G o i n g h o m e , h u m , y o u g e t a l o t o f a t t e n t i o n w h e n y o u ' r e c o m i n g , b u t w h e n y o u ' r e l e a v i n g y o u m o r e o r l e s s a r e t o l d O K , g o h o m e ! N o f a n f a r e w h a t s o e v e r ! T h e y d i d n ' t o f f e r y o u a w h e e l c h a i r , n o t h i n g . M y w i f e a n d d a u g h t e r w e r e t h e r e . We h a d t o g o d o w n a n d g e t my v a l u a b l e s a n d l o o k a f t e r t h e b i l l f o r t h e r o o m a n d t h e n d o s o m e t h i n g a b o u t a c a r . B u t I t h o u g h t , n o h e l p ! D i s c u s s i o n 82 T h e p r o c e s s o f p h y s i c a l l y l e a v i n g t h e h o s p i t a l r e q u i r e s f u r t h e r c o n s i d e r a t i o n . I t i s p o s s i b l e t h a t h o s p i t a l d i s c h a r g e i s a p s y c h o l o g i c a l m i l e s t o n e w h i c h s o m e p a t i e n t s l o o k f o r w a r d t o , a n d w i s h t o c e l e b r a t e . H o w e v e r , o t h e r p a t i e n t s ( a n d t h e i r f a m i l i e s ) m a y t r u l y n o t b e p h y s i c a l l y o r m e n t a l l y p r e p a r e d T h i s m a y b e t h e r e s u l t o f t h e t r e n d t o w a r d f u n d i n g r e l a t e d , e a r l y h o s p i t a l d i s c h a r g e . S e e i n g o n l y o n e o f t h e p a r t i c i p a n t s w a s r e h o s p i t a l i z e d a f t e r d i s c h a r g e , i t i s r e a s o n a b l e t o s p e c u l a t e t h a t t h i s i s a n i s s u e p e r t a i n i n g t o p s y c h o l o g i c a l a d a p t a t i o n a n d n o t a n i s s u e r e l a t e d t o p h y s i c a l p r e p a r e d n e s s . F a t i g u e a n d W e a k n e s s T h e m o s t p r o m i n e n t t h e m e d e s c r i b e d b y a l l p a r t i c i p a n t s w a s o n e o f i n c r e d i b l e f a t i g u e a n d i t s r e s u l t i n g w e a k n e s s . T h i s w a s d e s c r i b e d a s b o t h u n e x p e c t e d a n d d i s c o u r a g i n g . I w a s a w a l k i n g d e a d m a n . I t h o u g h t I w o u l d b e h o t t o t r o t b y C h r i s t m a s . . . b u t I d i d n ' t r e a l i z e I w o u l d b e q u i t e s o t i r e d . . . I w a s d i s m a y e d . T h e w e a k n e s s e x p e r i e n c e d b y t h e p a r t i c i p a n t s w a s b e s t e x p r e s s e d b y t w o d i f f e r e n t w o m e n w h o s t a t e d : T h i n g s I w o u l d j u s t t a k e f o r g r a n t e d ' t h a t a r e s o e a s y , w e r e s o h a r d . L i k e t h e s e v i a l s t h a t I o p e n e d a m i l l i o n t i m e s a d a y , w e l l I. c o u l d n o t g e t i n t o t h e m . I c o u l d n ' t g e t i n t o my p i l l s ! I e v e n f o u n d a c o u p l e o f w e e k s a f t e r I w a s h o m e t o e v e n p e e l a p o t a t o w a s . a b i g e f f o r t a n d I h a d t o p u t t h e k n i f e d o w n a n d l o o k a t i t . I t h o u g h t t h i s i s r i d i c u l o u s . B u t y o u r m u s c l e s a r e j u s t l i k e j e l l y . O n l y o n e w o m e n s t a t e d t h a t s h e w a s . i n f o r m e d a b o u t t h e p o t e n t i a l 83 f o r p o s t - o p e r a t i v e , f a t i g u e w h i l e i n h o s p i t a l . W i t h o n e e x c e p t i o n , p a r t i c i p a n t s s t a t e d t h a t f a t i g u e a n d w e a k n e s s w e r e e x a c e r b a t e d b y p o s t - o p e r a t i v e s l e e p d i s t u r b a n c e s . S l e e p p a t t e r n s w e r e d i s t u r b e d b y c o u g h i n g , p a i n a n d t h e n e e d t o v o i d d u r i n g t h e n i g h t , "I h a d d i u r e t i c s f o r c o n g e s t i o n , a n d t h a t m e a n s a t r i p o r t w o t o t h e b i f f y t h r o u g h t h e n i g h t , r e g u l a r l y " . W h i l e a l l h a d b e e n p r e s c r i b e d s l e e p i n g p i l l s , f i v e r e p o r t e d n o t u s i n g a n y . T h r e e o f t h e s e w e r e b e c a u s e o f a l l e r g i e s a n d p r e v i o u s r e a c t i o n s t o s l e e p i n g m e d i c a t i o n s , w h i l e t w o f e l t t h e y c o u l d s i m p l y d o w i t h o u t t h e m . A l l 1 8 p a r t i c i p a n t s d e n i e d b e i n g p r o v i d e d w i t h i n f o r m a t i o n r e l a t e d t o r e s t a n d s l e e p p r o m o t i o n . T h e y w e r e s i m p l y g i v e n t h e s l e e p i n g p i l l s a s p a r t o f a l a r g e r p r e s c r i p t i o n b y t h e i r p h y s i c i a n s a n d i n s t r u c t e d t o t a k e t h e p i l l s a s n e e d e d . T h r e e p a r t i c i p a n t s v o i c e d c o n c e r n s r e g a r d i n g a d d i c t i o n t o t h e p i l l s a n d w o u l d h a v e l i k e d t h i s i s s u e r c l a r i f i e d . T h e r e s u l t i n g w e a k n e s s a n d f a t i g u e m a d e i t d i f f i c u l t f o r p a r t i c i p a n t s t o p e r f o r m t h e i r u s u a l d a i l y a c t i v i t i e s . T h e y h a d t r o u b l e w i t h , a n d n e e d e d i n f o r m a t i o n r e l a t e d t o p e r f o r m i n g a c t i v i t i e s s u c h a s d r e s s i n g , b a t h i n g , b r u s h i n g t e e t h , a n d s h a v i n g . M e n a n d w o m e n b o t h c o m m e n t e d o n h o w d i f f i c u l t i t w a s t o p u t o n s o c k s a n d s h o e s , b e c a u s e t h i s r e q u i r e d a b e n d i n g a n d p u l l i n g m o t i o n , w h i c h w a s u n c o m f o r t a b l e d u e t o t h e p r e s s u r e i t p l a c e d o n t h e i n c i s i o n . Women a d d e d n y l o n s , s t o c k i n g s , a n d t h e n e e d f o r a b r a ( d e p e n d i n g o n t h e i r b r e a s t s i z e ) t o t h e l i s t . I h a v e n e v e r b e e n e n v i o u s o f s m a l l b r e a s t e d w o m e n i n my l i f e ( l a u g h ) , b u t w i t h t h e s u r g e r y b e t w e e n t h e b r e a s t s , I t h i n k u g h , c h e s t y w o m e n s h o u l d b e a d v i s e d t o b r i n g s o m e t h i n g t o s l e e p i n , i n t h e w a y o f a s o f t s i d e d b r a o f s o m e s o r t . T h a t a l l o w e d me t o m o v e i n b e d w i t h s o m e d e g r e e o f c o m f o r t . F o u r p a r t i c i p a n t s r e p o r t e d t h a t o n c e h o m e , t h e y i m m e d i a t e l y s h o w e r e d o r b a t h e d b e c a u s e t h e y h a d n o t b e e n a l l o w e d t o d o s o i n h o s p i t a l . N i n e p a r t i c i p a n t s r e p o r t e d n o t b e i n g p r o v i d e d w i t h i n f o r m a t i o n p e r t a i n i n g t o b a t h i n g w h i c h r e s u l t e d i n f o u r p a r t i c i p a n t s g e t t i n g s t u c k i n t h e b a t h t u b . T h e f i r s t d a y I t o o k a b a t h , b i g m i s t a k e ! I c o u l d n ' t g e t o u t ! M y h a n d s w e r e s t r o n g b u t my a r m s w e r e s o w e a k . I d i d n ' t k n o w . F o u r p e o p l e r e p o r t e d d i f f i c u l t y w i t h t e e t h b r u s h i n g a n d s h a v i n g b e c a u s e t h i s r e q u i r e d t o o m u c h e f f o r t . T h e f i r s t f i v e d a y s a f t e r t h e o p e r a t i o n I d i d n ' t b r u s h my t e e t h o r s h a v e . I t w a s h a r d . I t w o u l d t a k e y o u h a l f a n h o u r . Y o u h a v e t o b r i n g i n t h e c h a i r t o s i t d o w n . D i s c u s s i o n . T h e m o s t c o m m o n l y d i s c u s s e d i m p a c t a s s o c i a t e d w i t h t h e s u r g i c a l e v e n t w a s a p h y s i c a l o n e . F a t i g u e h a s b e e n r e p o r t e d a s c o m m o n i n a v a r i e t y o f o t h e r s t u d i e s w i t h C A B G p a t i e n t s ( N e w t o n & K i l l i e n , 1 9 8 8 ; W i n g a t e , 1 9 8 7 ) . F a t i g u e w a s I n i t s e l f , a n i m p o r t a n t c o n t r i b u t i n g f a c t o r t o t h e m a n y n e e d s e x p r e s s e d . C o n s e q u e n t l y p a r t i c i p a n t s e x p r e s s e d a n e e d t o b e b e t t e r i n f o r m e d a b o u t t h e n a t u r e a n d e x t e n t o f t h e e x p e c t e d f a t i g u e a n d w e a k n e s s e n c o u n t e r e d , s o t h a t w h e n t h e s e w e r e e x p e r i e n c e d , t h e y w o u l d b e p e r c e i v e d a s a n a t u r a l p a r t o f r e c o v e r y . T h i s m a y i n t u r n r e d u c e s o m e o f t h e d i s i l l u s i o n 85 e x p e r i e n c e d p o s t - o p e r a t i v e l y . S l e e p p a t t e r n d i s t u r b a n c e s c o n t r i b u t e d t o f a t i g u e . T h i s i s a l s o a c o m m o n l y r e p o r t e d p r o b l e m i n t h e e a r l y p o s t - o p e r a t i v e d a y s a n d i n t h e l i t e r a t u r e . R e f u s i n g t o u s e s l e e p i n g m e d i c a t i o n c o n t r i b u t e d t o s l o w e d r e c o v e r y f o r m a n y p a r t i c i p a n t s a n d r e s u l t e d 1 i n p r o l o n g e d f a t i g u e a n d w e a k n e s s . T r o u b l e s w i t h , a n d t h e n e e d f o r i n f o r m a t i o n r e l a t e d t o s u c h a c t i v i t i e s a s d r e s s i n g , b a t h i n g , b r u s h i n g t e e t h , s h a v i n g a n d p u t t i n g o n s h o e s h a v e a l s o b e e n r e p o r t e d i n t h e l i t e r a t u r e . M o y n i h a n ( 1 9 8 4 ) f o u n d t h a t p a r t i c i p a n t s f o c u s e d o n t h e n e e d f o r m o r e i n f o r m a t i o n r e l a t e d t o t h e i r d a i l y a c t i v i t i e s d u r i n g . r e c o v e r y . S h e c o n c l u d e d t h a t " p a t i e n t s e x p r e s s e d a n e e d t o h a v e i n s t r u c t i o n s o n i t e m s w h i c h w o u l d f a c i l i t a t e t h e i r r e s u m p t i o n o f a n o r m a l l i f e s t y l e " . I t i s r e c o g n i z e d t h a t t h e d i f f i c u l t i e s e x p e r i e n c e d h e r e w e r e i n p a r t r e l a t e d t o f a t i g u e , b u t i t w o u l d s e e m t h a t m o t i v a t i o n a n d i n d e p e n d e n c e a l s o c o n t r i b u t e d t o e x p l a i n i n g t h e " r e c o v e r y " f r o m f a t i g u e . T h e f e w w h o d i d n o t w a n t t h e i r f a m i l i e s t o s e e t h e m l o o k i n g u n w e l l a n d h e l p l e s s r e p o r t e d m a k i n g a d d i t i o n a l e f f o r t s t o w a s h a n d c l e a n t h e m s e l v e s i n d e p e n d e n t l y . T h e i n c r e a s e d e f f o r t n a t u r a l l y r e s u l t e d i n g r e a t e r f a t i g u e . H o w e v e r , t h i s s a m e g r o u p p l a c e d l e s s e m p h a s i s o n t h e i r v a r i o u s n e e d s i n t h i s a r e a . A c c o m p l i s h m e n t o f e v e r y d a y t a s k s s u c h a s d r e s s i n g e n c o u r a g e d t h e m t o u n d e r t a k e o t h e r a c t i v i t i e s e a r l i e r i n t h e r e c o v e r y p r o c e s s . A l t h o u g h s p e c u l a t i v e , a p o s i t i v e c o r r e l a t i o n b e t w e e n accomplishment of a c t i v i t i e s and the confidence to try new ones has been reported i n the cardiac l i t e r a t u r e by Hertanu, Davis, Focseneanu, & Lahman (1986). The s p e c i f i c need to wear a bra, depending on chest size has not been previously reported. The use of a bra or support may provide comfort, and help reduce the problems associated with sternal wound dehiscence, which leads to infections and delayed healing. This also supports Mackenzie's (1993) research which suggested that women have dif f e r e n t learning needs, some of which have yet to be discovered. While s p e c i f i c information related to bathing i s i n the video, i t does not seem to be "retained" by the participants. It i s possible to speculate that participants should be encouraged to bathe while i n hospital. If they did, they might not f e e l the need to rush home and bathe. They would also encounter any potential problems with bathing while i n the safety of the hospital environment where there are q u a l i f i e d nursing s t a f f to as s i s t them i f needed. Mobility D i f f i c u l t y with mobilizing was the second most prevalent theme expressed by the participants. This was due to the sternal inc i s i o n , generalized pain, and the perception of sternal i n s t a b i l i t y , as well as general weakness and fatigue. In describing her chest i n s t a b i l i t y , one person said "You fee l 87 l i k e you are not together somehow you know. You f e e l l i k e you are cracked!" To cope with th i s , the participants stated that they simply listened and responded to their bodies, You got to slow down, you have to. It w i l l stop you anyway. You can only do so much and i t w i l l stop you! I recognize enough of my own c a p a b i l i t i e s to know that I have walked enough, I have done enough, I don't push myself beyond that. I do not do things I cannot do easil y . The physical l i m i t a t i o n are quite d e f i n i t e l y there and my body t e l l s me. I n a b i l i t y to mobilize resulted i n trouble getting i n and out of bed, chairs and cars, as well as reaching, l i f t i n g , turning, p u l l i n g , pushing, cleaning and driving. Many of these troubles were deemed general "hassles" because they impeded every day a c t i v i t i e s such as cooking and doing laundry. Participants stated that they were t o l d l i t t l e about the actual d i f f i c u l t i e s associated with moving. However the participants did report being well informed about how to get i n and out of bed. Their retention and understanding of this information was well described. In hospital, they have l i k e a rope hooked onto the bed frame. I made one out of e l e c t r i c a l cord. You have to have that to p u l l yourself up. It's much easier, a 100 times easier. i 1 We t i e d together a couple of neck t i e s ! My wife used a l l the horrible neck t i e s I own! The participants stated they were well informed about l i f t i n g , noting that they were not to l i f t anything over ten pounds. I am very careful about that. I do iron. I actually weighed the iron and i t i s not ten pounds, so (laugh). 88 W h i l e n o t s p e c i f i c a l l y t o l d a b o u t t h e t r o u b l e s e n c o u n t e r e d w i t h r e a c h i n g , p u s h i n g o r p u l l i n g , t h e y w e r e a b l e t o d i s c e r n t h e s e f o r t h e m s e l v e s , b y l i s t e n i n g t o t h e i r b o d i e s . S o m e t h i n g w o u l d b e t w o i n c h e s a w a y f r o m y o u r f a c e b u t i t w a s a l s o t w o i n c h e s h i g h e r t h a n y o u w e r e s u p p o s e t o r e a c h a n d y o u k n o w i f y o u r e a c h e d t h a t h i g h , i t ' s g o i n g t o h u r t . F u r t h e r e v i d e n c e t o s u g g e s t t h a t p a r t i c i p a n t s j u d g e d t h e i r o w n c a p a b i l i t i e s b y l i s t e n i n g a n d r e s p o n d i n g t o t h e i r b o d i e s w a s s e e n w h e n t h e p a r t i c i p a n t s d i s c u s s e d d r i v i n g . D e s p i t e a s t a t e m e n t i n t h e y e l l o w b o o k l e t n o t t o d r i v e f o r o n e m o n t h a f t e r t h e s u r g e r y , t w o p a r t i c i p a n t s o p t e d t o d r i v e s h o r t l y a f t e r t h e i r r e l e a s e f r o m h o s p i t a l . S e e m s t o me t h a t t h e r e w a s s o m e t h i n g i n t h i s b o o k a b o u t d r i v i n g a f t e r s u r g e r y , b u t u g h , I t h i n k i t w a s l e f t u p t o m e . I d r o v e a l m o s t i m m e d i a t e l y . . . I f e l t c o m f o r t a b l e d o i n g i t , a n d s o I w a s n ' t r e a l l y w o r r i e d . E i g h t p a r t i c i p a n t s c h o s e t o w a i t l o n g e r t h a n t h e p r e s c r i b e d 4 w e e k l i m i t . I s t a r t e d d r i v i n g t h i s w e e k w h i c h i s w o n d e r f u l . . . I t ' s g i v e n me a r e a l b o o s t . I w a i t e d a l i t t l e l o n g e r f o r t h e d r i v i n g , c a u s e I f e l t I w o u l d n ' t b e s o g o o d a t i t , a n d I w a n t e d t o b e s u r e . . . T h e y o u n g e r p a r t i c i p a n t s d r o v e o n o r a r o u n d t h e r e c o m m e n d e d d a t e s , w h i l e t h e o l d e r p a r t i c i p a n t s w a i t e d a l i t t l e l o n g e r . G e n e r a l l y , t h e p a r t i c i p a n t s w e r e t o l d b y t h e i r p h y s i c i a n s t o " t a k e i t e a s y " f o r t h e f i r s t w h i l e a f t e r t h e s u r g e r y . O n e p e r s o n a p t l y s t a t e d " T h e y d i d s a y t a k e i t e a s y , b u t t h a t d o e s n ' t m e a n a n y t h i n g ! " P a r t i c i p a n t s b o t h y o u n g a n d o l d w e r e a b l e t o d e s c r i b e o n e o r m o r e i n c i d e n t s i n w h i c h t h e y " o v e r d i d 89 i t " . T h e s e r e p o r t e d a c t s w e r e r o u t i n e a c t i v i t i e s a n d o c c u r r e d " b y a c c i d e n t . " R e g a r d l e s s o f h o w i t h a p p e n e d , t h e a c t i v i t y u n d e r t a k e n r e s u l t e d i n p a i n a n d d i s c o m f o r t . Y o u a r e s o u s e d t o a r o u t i n e a r o u n d t h e h o u s e , y o u s o r t o f f o r g e t . . . t h e n e x t t h i n g y o u k n o w y o u g r a b t h e v a c u u m c l e a n e r a n d y o u p i c k u p t h e . e n d o f a b e n c h a n d y o u k n o w , t h e n y o u p a y f o r i t l a t e r . H o w e v e r , m o s t o f t h e p a r t i c i p a n t s e x p r e s s e d t h e n e e d t o b e v e r y c a r e f u l , w i t h t w e l v e r e l a t i n g a s t o r y a b o u t t h e f e a r o f i n j u r i n g t h e m s e l v e s b y o v e r d o i n g i t . I w a s t o l d o f a p e r s o n w h o o v e r d i d i t a n d b r o k e t h e w i r e s a n d h a d t o g o i n a n d h a v e h i m s e l f c u t o p e n a n d r e - w i r e d . . . a n d t h a t w a s a l o t w o r s e t h a n t h e s u r g e r y . • • • O K , I w o n ' t l i f t t h a t I s a i d t o m y s e l f . T h i s s t o r y w a s m e n t i o n e d r e p e a t e d l y t o t h e r e s e a r c h e r . T h e a s s i s t a n t h e a d n u r s e o n t h e C a r d i a c S u r g e r y w a r d c o n f i r m e d t h a t a p a t i e n t h a d b e e n r e - a d m i t t e d o n t w o s e p a r a t e o c c a s i o n s f o r s t e r n a l r e - w i r i n g a f t e r h i s i n c i s i o n d e h i s c e d a t h o m e . T h i s e x p l a i n e d w h y s o m a n y o f t h e p a r t i c i p a n t s k n e w a b o u t t h i s p a r t i c u l a r i n c i d e n t , a n d m a y h a v e c o n t r i b u t e d t o t h e c a r e u n d e r t a k e n w h e n l i f t i n g . D i s c u s s i o n I s s u e s r e l a t e d t o m o b i l i z i n g h a v e b e e n w i d e l y r e p o r t e d i n t h e p o s t - o p e r a t i v e c a r d i a c l i t e r a t u r e . I t w o u l d s e e m t h a t w h i l e t h e p a r t i c i p a n t s e x p r e s s e d c o n c e r n w i t h m o b i l i z i n g a n d t h e l i m i t e d i n f o r m a t i o n r e c e i v e d p e r t a i n i n g t o t h i s , t h e y w e r e a b l e t o a d a p t q u i c k l y , m o s t p r o b a b l y b e c a u s e o f t h e " p e r c e i v e d 90 n e e d " t o d o s o . M a n y r e f e r r e d t o " l i s t e n i n g t o t h e i r b o d i e s " , a s t h e s i m p l e s t w a y t o a c c o m p l i s h a n y t h i n g . T h e f a c t t h a t p a r t i c i p a n t s w e r e a b l e t o " l i s t e n a n d l e a r n " f r o m a t t e m p t i n g a c t i v i t i e s s u c h a s l i f t i n g , p u l l i n g , d r i v i n g , a n d o t h e r d a i l y a c t i v i t i e s s u g g e s t s t h a t t h e y l e a r n e d a n d r e t a i n e d t h e i n f o r m a t i o n b e s t b y u n d e r t a k i n g a n a c t i o n o r a c t i v i t y w h i c h t o l d t h e i r b o d i e s " t h i s f e e l s o k " , o r " i t d o e s n ' t " . T h i s . a l s o h o l d s t r u e f o r o t h e r a r e a s . T h e p a r t i c i p a n t s w e r e a b l e t o s t a t e t h a t t h e y n e e d e d a r o p e a t t h e e n d o f t h e b e d , b e c a u s e i t f a c i l i t a t e d t h e m o b i l i z i n g p r o c e s s . U p o n d i s c h a r g e , p a r t i c i p a n t s w e r e o f t e n t o l d t o " t a k e i t e a s y " . P e r h a p s b e i n g t o l d t o " l i s t e n t o y o u r b o d y " w o u l d b e a m o r e m e a n i n g f u l g e n e r a l i z e d c o m m e n t . R e s u m p t i o n o f A c t i v i t i e s D u e t o t h e i r l i m i t e d m o b i l i t y , s e v e r a l p a r t i c i p a n t s s t a t e d t h e y n e e d e d t o m o d i f y t h e i r r o u t i n e s o r h o m e e n v i r o n m e n t t o m a k e t h e i r d a i l y a c t i v i t i e s e a s i e r t o u n d e r t a k e . T h i s i s w h y I am d o i n g e v e r y t h i n g a t t h e k i t c h e n s i n k , i t i s h i g h e r a n d I c a n r e s t my e l b o w s ( l a u g h ) . Two i n d i v i d u a l s a d d e d s i t d o w n , n o n - s l i p s h o w e r s e a t s t o t h e i r b a t h s w h i l e a n o t h e r a d d e d a n o n s l i p m a t . F a t i g u e , w e a k n e s s a n d l a c k o f m o b i l i t y d i c t a t e d a g r a d u a l r e s u m p t i o n o f a c t i v i t y f o r a l l p a r t i c i p a n t s . Y o u n g p a r t i c i p a n t s t e n d e d t o r e s u m e v a r i o u s a c t i v i t i e s s u c h a s 9 1 w a l k i n g g r e a t e r d i s t a n c e s a n d h o u s e h o l d w o r k , s o o n e r . O v e r t i m e , a l l t h e p a r t i c i p a n t s g r a d u a l l y r e s u m e d t h e i r v a r i o u s r o l e s a n d w o r k r e l a t e d a c t i v i t i e s . T h e t e n p a r t i c i p a n t s w h o w e r e s e e n a t t h e l a t t e r e n d o f t h e s t u d y r e l a t e d s i g n i f i c a n t i n c r e a s e s i n t h e i r r o u t i n e a c t i v i t i e s . S i n g l e w o m e n u n d e r t o o k m o r e a c t i v i t i e s s o o n e r t h a n m a r r i e d w o m e n o r m e n . M a r r i e d w o m e n r e s u m e d w h a t t h e y d e e m e d t h e i r r o l e r e l a t e d a c t i v i t i e s s o o n e r t h a n m e n . A l l t e n p a r t i c i p a n t s a d m i t t e d t o c o n t i n u i n g d i f f i c u l t i e s w i t h t h e r e s u m p t i o n o f t h e i r a c t i v i t i e s , d e s p i t e w a n t i n g t o d o m o r e . I n t h e k i t c h e n , I j u s t a c o o k a l i t t l e b i t a n d m y h u s b a n d w a s h t h e d i s h e s b e c a u s e i f I c o o k , I c a n n o t d o d i s h e s n o m o r e b e c a u s e I s t i l l f e e l v e r y v e r y w e a k . T h e f i r s t t h i n g I w a n t e d t o d o w a s s t a r t c l e a n i n g my h o u s e b e c a u s e a h u s b a n d a n d c h i l d r e n d o n ' t d o t h i n g s t h e s a m e w a y a w o m a n d o e s . A n d I s t i l l c a n ' t c l e a n m y h o u s e t h e s a m e w a y I n o r m a l l y d i d b e f o r e , a n d i t r e a l l y b o t h e r s me a l o t . T h e p a r t i c i p a n t s d e s c r i b e d t h e i r a c t i v i t y r e s u m p t i o n f r o m t h e i n - h o s p i t a l , e a r l y p o s t - o p e r a t i v e p e r i o d , b e g i n n i n g w i t h p h y s i o t h e r a p y . T h e p h y s i o t h e r a p y c l a s s e s w e r e p e r c e i v e d a s g o o d b y 1 1 o f t h e m . T h r e e p a r t i c i p a n t s t h o u g h t t h e c l a s s e s w e r e " n o t g r e a t " o r o f l i t t l e b e n e f i t t o t h e m . T h e r e m a i n i n g f o u r s t a t e d t h a t t h e c l a s s e s w e r e c o n d u c t e d t o o s o o n , n o t n e c e s s a r i l y f o r t h e m s e l v e s , b u t f o r o t h e r s . T h i s i n t u r n s l o w e d t h e r e s t o f t h e c l a s s a n d r e d u c e d i t s p o t e n t i a l b e n e f i t . T h e r e w a s s u c h a n a g e r a n g e a n d p h y s i c a l c a p a b i l i t y a n d m e n t a l a b i l i t y w i t h s o m e w h o w e r e n o t r e a l l y w i t h i t , s o t h a t I d o n ' t t h i n k t h e p h y s i o t h e r a p i s t m a d e t h e b e s t u s e o f h i s t i m e . 92 T h e p a r t i c i p a n t s p e r c e i v e d t h e t a k e h o m e e x e r c i s e h a n d o u t s a s g o o d f i r s t e x e r c i s e s b e c a u s e t h e y " g e t y o u g o i n g " . S e v e r a l p a r t i c i p a n t s r e p o r t e d d o i n g t h e s e e x e r c i s e s r e g u l a r l y , e v e n w i t h f r i e n d s a n d s p o u s e s . W h e n a s k e d a b o u t h i s a c t i v i t y l e v e l , o n e m a n r e s p o n d e d , " W e l l n o t a s m u c h a s I s h o u l d , b u t my w i f e g o e s t o t h e g y m ! " F o u r p a r t i c i p a n t s a d m i t t e d t o n o t r e s u m i n g o r a t t e m p t i n g t o p e r f o r m t h e l e v e l o f a c t i v i t y " p r e s c r i b e d " . T w o p e o p l e a d m i t t e d t h a t a s t h e p a t i e n t , t h e y h a d o v e r -p r o t e c t e d t h e m s e l v e s . T h e y e n c o u r a g e y o u t o e x e r c i s e . . . b u t r u n n i n g o u t a n d s u c k i n g c o l d a i r i n t o t h e s e t e n d e r l u n g s w a s n ' t t h e g r e a t e s t t h i n g i n t h e w o r l d ! . W h i l e d e s c r i b i n g t h e i r a c t i v i t y l e v e l s , 12 p a r t i c i p a n t s s t a t e d t h a t t h e i r s h o r t n e s s o f b r e a t h w a s o r h a d r e s o l v e d , a n d t h a t t h e y w e r e n o w w a l k i n g u p s l o p e s a n d h i l l s w i t h i n c r e a s i n g e a s e . T h i s w a s s i g n i f i c a n t , b e c a u s e i t w a s t h e m o s t c o m m o n s y m p t o m t h a t h a d m o t i v a t e d t h e m t o s e e k m e d i c a l a t t e n t i o n . C o n s e q u e n t l y , t h e y , p e r c e i v e d t h e i r h e a l t h a s i m p r o v i n g . S i x p a r t i c i p a n t s e x p r e s s e d a d e s i r e f o r m o r e i n f o r m a t i o n r e l a t e d t o e x e r c i s e i n o r d e r t o r e g a i n t h e i r p r e - i l l n e s s l e v e l s o f f i t n e s s , e n e r g y a n d s t a m i n a . T h i s r e q u e s t w a s m a d e f r o m b o t h m e n a n d w o m e n , i n d e p e n d e n t o f t h e n u m b e r o f w e e k s a f t e r t h e i r s u r g e r y o r t h e i r a g e . S o m e p a r t i c i p a n t s w e r e m o r e m o t i v a t e d t o a c t i v e l y p a r t i c i p a t e i n t h e r e c o v e r y p r o c e s s t h a n o t h e r s . D i s c u s s i o n 93 1 MacKenzie (1993), also reported that women engage i n various a c t i v i t i e s sooner than men. The reasons for this are speculative, but are thought to be linked to gender roles. Further investigation pertaining to gender differences and recovery continue. Overall, the exercises were perceived as being adequate beginning exercises. Previously published research has suggested that patients are often reluctant to resume or engage i n post-operative exercise programs (Allen, 1990; Certo, 1985; Stovsky & Dehner, 1994). While there was evidence of this, i t was encouraging to note that one t h i r d of the participants actually requested additional information pertaining to exercises they could undertake at home while convalescing. This may be p a r t i a l l y explained by the resolving shortness of breath and the perception of improved health. This re s u l t supports Wengers' (1986) assertion that patients with valve ' replacements can, and want to, safely p a r t i c i p a t e i n low lev e l exercises after hospital discharge.. Resumption of Sexual A c t i v i t y Ten participants stated that their l e v e l of sexual a c t i v i t y was affected during the early weeks of recovery. This was p a r t i c u l a r l y s i g n i f i c a n t for the younger participants who perceived that i t placed additional stress on the i r family support person and personal contact that they shared. I had a hard time with ugh, not being able to have the 94 c o n t a c t t h a t w i v e s a n d h u s b a n d s n o r m a l l y h a v e w i t h e a c h o t h e r . T h a t ' s o n e o f t h e b i g g e s t p r o b l e m s I h a d . B u t w e ' r e p a s t t h a t s t a g e n o w . I t b o t h e r e d h i m a n d i t b o t h e r e d m e , b e c a u s e h e w a s q u i t e w o r r i e d y o u k n o w , o n c e we g e t g o i n g h e w o u l d h u r t m e . B e c a u s e we d o g e t a c t i v e l i k e n o r m a l p e o p l e . . . . I t ' s l i k e D r . ' Z r e c o m m e n d e d , j u s t b e c a r e f u l n o t t o u s e y o u r a r m s a n d y o u k n o w , l i k e g e t c a r r i e d a w a y s o r t o f t h i n g . O n l y t h r e e p a r t i c i p a n t s s t a t e d t h a t t h e y h a d d i s c u s s e d s e x u a l a c t i v i t y w i t h t h e i r s u r g e o n s . T e n p a r t i c i p a n t s s t a t e d t h a t t h e y s i m p l y t r i e d t o e n g a g e i n s e x u a l a c t i v i t y w h e n a n d i f , t h e y f e l t r e a d y t o d o s o . T h e y g a v e me t o F e b r u a r y 4 t h b e f o r e . . . b u t h e y , I ' m h u m a n . I b a s i c a l l y s e t o u t a n d ugh, d i s c o v e r e d w h a t I c o u l d a n d c o u l d n ' t d o . . . Y o u d o y o u ' r e o w n t h i n g , r e g a r d l e s s o f w h a t y o u ' r e t o l d . F o u r p a r t i c i p a n t s s t a t e d t h a t s e x w a s n o l o n g e r a n i s s u e f o r t h e m a n d a s s u c h t h e y d i d n o t r e q u i r e i n f o r m a t i o n a b o u t t h i s , n o r w e r e t h e y p r o v i d e d w i t h a n y . N o , I h a d a r a d i c a l p r o s t a t e d o n e e i g h t o r n i n e y e a r s a g o f o r c a n c e r o f t h e p r o s t a t e a n d u g h , I h a v e b e e n p r e t t y -w e l l i m p o t e n t e v e r s i n c e . . . B u t t h e y w o u l d n ' t o f k n o w n t h a t I h a d h a d a r a d i c a l p r o s t a t e o r t h a t I w a s i m p o t e n t , s o t h e y j u s t d i d n ' t t a l k t o me a b o u t t h a t [ s e x ] . T h e p a r t i c i p a n t s w e r e a b l e t o s t a t e t h a t t h e y h a d n o t e d t h e r e c o m m e n d e d d a t e f o r r e s u m p t i o n o f s e x u a l a c t i v i t y i n t h e y e l l o w d i s c h a r g e b o o k . I n a d d i t i o n , f o u r p a r t i c i p a n t s s t a t e d t h a t i t w a s m e n t i o n e d i n p a s s i n g , i n t h e d i s c h a r g e v i d e o . T h r e e p a r t i c i p a n t s a d d e d t h a t t h e y h a d r e a d a b o u t i t i n o t h e r s o u r c e s . O n e 5 8 y e a r o l d w o m a n c o m m e n t e d : T h e l i t e r a t u r e s a y s i f y o u c a n c l i m b t w o f l i g h t s o f s t a i r s you can resume sexual a c t i v i t y , even though I am single, I must admit I checked out when I could do two f l i g h t s of s t a i r s ! The majority of participants stated they wanted.more i. information pertaining to the resumption of sexual a c t i v i t y p r i o r to hospital discharge. However, despite lacking the requisite information pertaining to the resumption of sexual a c t i v i t y , the participants proceeded when they deemed themselves ready to do so. Discussion The resumption of sexual a c t i v i t y , despite being well reported i n the l i t e r a t u r e as a concern, remained a topic poorly discussed between the patient and the physician or nurse. Despite being discussed i n the video and discharge booklet, more information was desired. Nonetheless, the participants were able to " l i s t e n to the body" and resumed intimate a c t i v i t y at a time when they f e l t most comfortable. Due to this, health care professionals may question i f sexual a c t i v i t y needs to be openly discussed with patients. The participants responses to the question indicate that i t should be. The fact that information was provided, but the participants s t i l l f e l t inadequately prepared, suggests that in-hospital patient education programs may not be able to provide the "complete solution" to the questions encountered during the early weeks of r e h a b i l i t a t i o n . This author suggests, as did Stanton et a l . (1984) that patients require p o s t - h o s p i t a l f o l l o w u p a n d r e i n f o r c e m e n t o f t h e i r l e a r n i n g _ P a i n a n d M e d i c a t i o n s A t h o r o u g h u n d e r s t a n d i n g o f t h e p e r c e i v e d l e v e l s o f p a i n a n d i t s m a n a g e m e n t a r e i m p o r t a n t b e c a u s e i t w a s r e p o r t e d t h a t p a i n d e t e r r e d s l e e p a n d i n h i b i t e d a c t i v i t i e s . P a i n w a s d e s c r i b e d a s w e l l m a n a g e d i n o n l y f i v e i n d i v i d u a l s , " Y o u k n o w , y o u c u t y o u r s e l f a n d y o u f e e l p a i n . I h a d p r a c t i c a l l y n o p a i n . " S t e r n a l i n c i s i o n s w e r e d e s c r i b e d a s s o r e , t e n d e r a n d q u i t e u n c o m f o r t a b l e ( m o d e r a t e p a i n ) b y s i x i n d i v i d u a l s . T h e s e i n d i v i d u a l s v e r b a l i z e d s o m e k n o w l e d g e p e r t a i n i n g t o p a i n c o n t r o l a n d t r e a t m e n t w i t h t h e i r p a i n r e l i e v i n g m e d i c a t i o n s . I d o n ' t t a k e i t u n l e s s I n e e d i t , a n d t h e y s a i d i t w a s b e t t e r t o h a v e i t a n d n o t b e i n p a i n , s o t h a t s u i t s me f i n e . T h e r e m a i n i n g s e v e n d e s c r i b e d t h e i r p a i n a s i n t e n s e , t r e m e n d o u s , a n d i n c r e d i b l e ( s e v e r e ) . T h r e e A s i a n p a r t i c i p a n t s ( t w o m e n a n d o n e w o m a n ) w h o w e r e y o u n g e r t h a n f i f t y f i v e , w e r e m o s t e x p r e s s i v e a n d d e s c r i p t i v e a b o u t t h e i r u n c o n t r o l l e d , l o n g l a s t i n g p a i n . I t h u r t s , e v e n t o p u l l t h e d o o r o p e n i s h a r d . I t h u r t s e v e r y t i m e y o u , e v e r y t i m e y o u m o v e , i t h u r t s s o d a r n e d • m u c h ! T h e y s h o u l d h a v e g i v e n me m o r e d r u g s , m o r e d r u g s . T h e y s h o u l d h a v e g i v e n a l l o f u s m o r e d r u g s . O f t h e s e v e n w h o r e p o r t e d h i g h l e v e l s o f p e r c e i v e d p a i n , o n l y o n e h a d b e e n p r o v i d e d w i t h i n f o r m a t i o n i n h o s p i t a l p e r t a i n i n g t o t h e u s e o f p a i n r e l i e v i n g m e d i c a t i o n . T h i s h a d b e e n p r o v i d e d b y t h e s u r g e o n , b u t o n l y a f t e r h e s u f f e r e d t h r o u g h a 97 r e a c t i o n t o c o d e i n e . I n t o t a l , f i v e p a r t i c i p a n t s r e p o r t e d h a v i n g b e e n p r o v i d e d w i t h s p e c i f i c i n f o r m a t i o n r e l a t e d t o p a i n m a n a g e m e n t a n d t h e u s e o f p a i n m e d i c a t i o n s . E v e n o n e p a r t i c i p a n t w h o w a s a h e a l t h c a r e p r o v i d e r s t a t e d : I t ' s k i n d o f c o n f u s i n g a b o u t p a i n m e d i c a t i o n . T h e y s h o u l d h a v e e x p l a i n e d i t b e t t e r I t h i n k . Y o u k n o w , s o m e k i n d o f a g u i d e l i n e . I k n o w e v e r y b o d y i s d i f f e r e n t b u t i t ' s s o i m p o r t a n t . . . F i v e o l d e r p a r t i c i p a n t s d i s c u s s e d r e f e r r e d p a i n , a n d d i s c o m f o r t i n t h e i r s h o u l d e r s , b a c k s a n d o u t e r c h e s t w a l l s . S i n c e t h e s e a r e a s a r e n o t d i r e c t l y i n l i n e w i t h t h e s t e r n a l i n c i s i o n s , t h r e e o f t h e m w e r e u n s u r e . i f t h e i r a c h e s w e r e r e l a t e d t o t h e s u r g e r y . A d i s c u s s i o n r e l a t e d t o p a i n a n d p a i n m a n a g e m e n t w o u l d h a v e b e e n o f b e n e f i t t o t h e s e p a r t i c i p a n t s . W h e n d i s c u s s i n g p a i n a n d t h e . m e d i c a t i o n s t o . t r e a t i t , ' o t h e r m e d i c a t i o n s w e r e a l s o m e n t i o n e d . O f t h e 1 3 w h o w e r e taking a n anticoagulant (warfarin or Coumadin), s e v e n p a r t i c i p a n t s s t a t e d t h a t t h e y w e r e n o t g i v e n e n o u g h o r a n y i n f o r m a t i o n p e r t a i n i n g t o t h e d r u g a n d i t s u s e . T h e y d i d n ' t e x p l a i n a w h o l e l o t . T h e y a s s u m e d I a l r e a d y k n e w b e c a u s e I w a s a p h a r m a c i s t . . . b u t t h e r e w a s a l o t o f s p e c i f i c s I d i d n ' t k n o w . . . O f t h e s e v e n , s i x . c o m m e n t e d t h a t m o r e i n f o r m a t i o n w o u l d h a v e b e e n h e l p f u l a n d w o u l d h a v e e a s e d t h e a d j u s t m e n t p r o c e s s . O n e 7 6 y e a r o l d w o m a n h a d n o u n d e r s t a n d i n g o f t h e w a r f a r i n t h e r a p y o t h e r t h a n t h a t i t w a s " t o h e l p p r e v e n t c l o t s " . S h e w a s c o n f u s e d w h e n a s k e d i f h e r P T o r I N R r a t i o w a s b e i n g c o n v e y e d t o h e r , - s t a t i n g t h a t s h e h a d n e v e r e v e n h e a r d t h e w o r d s b e f o r e . 98 D e s p i t e b e i n g i n h o s p i t a l f o r 1 9 d a y s , n o o n e h a d d i s c u s s e d h e r m e d i c a t i o n s w i t h h e r . B l o o d t e s t s w e r e d o n e r e g u l a r l y b y a l a b t e c h n i c i a n w h o c a m e t o h e r h o m e , b u t s h e w a s u n s u r e w h y . T h i s p e r s o n w a s 3 6 d a y s p o s t - d i s c h a r g e a t t h e t i m e o f t h e i n t e r v i e w a n d h a d a P u b l i c . H e a l t h N u r s e p e r f o r m f o u r h o m e v i s i t s t o a s s e s s h e r n e e d s . S h e h a d b e e n d i s c h a r g e d f r o m t h e s e r v i c e a f e w d a y s p r i o r t o t h e i n t e r v i e w . . A p a r t f r o m t h e w o m a n p r e v i o u s l y d e s c r i b e d , t h e p a r t i c i p a n t s w h o p e r c e i v e d t h e y w e r e n o t p r o v i d e d w i t h e n o u g h i n f o r m a t i o n w e r e a b l e t o o b t a i n t h e r e q u i s i t e k n o w l e d g e f r o m t h e i r l o c a l p h a r m a c i s t s . S o m e a l s o a s k e d t h e f a m i l y p h y s i c i a n w h o w a s i n r e g u l a r c o n t a c t , c a l l i n g d a i l y t o p r e s c r i b e m e d i c a t i o n d o s a g e s . I n t h e h o s p i t a l t h e y d i d n ' t t e a c h me v e r y ' m u c h , b u t w h e n my d a u g h t e r w e n t t o g e t t h e m a t t h e d r u g s t o r e , t h e y g a v e me a l o n g p i e c e o f p a p e r a b o u t t h e m e d i c a t i o n , w h a t i t d o e s f o r y o u , c o m p l i c a t i o n s . . . T h o s e p a r t i c i p a n t s w h o w e r e m o t i v a t e d t o s e e k i n f o r m a t i o n d i d s o p r e d o m i n a n t l y b e c a u s e t h e y w e r e h a v i n g d i f f i c u l t y w i t h r e g u l a t i n g t h e d r u g l e v e l s . O n e m a n , w h o h a d w h a t h e d e s c r i b e d a s a m i l d s t r o k e ( p o s t - o p e r a t i v e l y ) s t a t e d : I ' m o n t h e b l o o d t h i n n e r s , a n d a t t h a t t i m e I w a s j u s t h o m e n o t l o n g a n d my b l o o d w a s r e a l l y t h i n , s o t h e y t h o u g h t t h a t m i g h t b e t h e p r o b l e m , a n d t h e n w i t h t h i s e y e t h i n g , t h e b l o o d w a s t o o t h i c k , s o t h e y t h o u g h t i t w a s m a y b e n o t e n o u g h b l o o d g e t t i n g i n o r s o m e t h i n g . . . D r u g i n t e r a c t i o n s w i t h t h e a n t i c o a g u l a n t w e r e r e p o r t e d l y n o t w e l l m o n i t o r e d , a f f e c t i n g t h e p a r t i c i p a n t s I N R l e v e l s . O n e m a n w a s p r e s c r i b e d a d r u g t o h e l p r e l i e v e h e a r t b u r n , h o w e v e r , i t 99 g r e a t l y r e d u c e d h i s I N R r a t i o . A n o t h e r p e r s o n h a d h e r d i g i t a l i s r e d u c e d w h i c h i n t u r n a f f e c t e d h e r I N R r a t i o . I t t o o k h e r s e v e r a l d a y s t o d e t e r m i n e t h e c a u s e , a n d h a d s h e n o t b e e n a h e a l t h c a r e p r o f e s s i o n a l h e r s e l f , t h e c a u s e m a y h a v e r e m a i n e d u n k n o w n . I n t o t a l f o u r s u c h i n c i d e n t s o c c u r r e d . H o w e v e r , t h e p a r t i c i p a n t s l e a r n e d f r o m t h e s e , a n d w e r e a b l e t o l i s t s u c h t h i n g s a s v i t a m i n K , d i e t , a l c o h o l a n d o t h e r m e d i c a t i o n s t h a t w o u l d a f f e c t t h e i r a n t i c o a g u l a n t l e v e l . T h e y e m p h a s i z e d t h e p r o v i s i o n o f i n f o r m a t i o n r e l a t e d t o d i e t a n d w a r f a r i n a s e s s e n t i a l . T h e s i x p a r t i c i p a n t s w h o r e p o r t e d a d e q u a t e k n o w l e d g e p e r t a i n i n g t o t h e i r b l o o d t e s t s a n d a n t i c o a g u l a t i o n t h e r a p y r e p o r t e d t h a t t h e i n f o r m a t i o n h a d b e e n p r o v i d e d t o t h e m i n h o s p i t a l p r e d o m i n a n t l y i n b o o k l e t f o r m b y t h e i r n u r s e s , a n d t o s o m e e x t e n t p r e - o p e r a t i v e l y b y t h e i r p h y s i c i a n s . S i x p a r t i c i p a n t s r e p o r t e d a n e m o t i o n a l a t t a c h m e n t t o t h e a d j u s t m e n t o f t h e a n t i c o a g u l a n t . F r u s t r a t i o n w a s e x p r e s s e d w h e n t h e r e s u l t s w e r e n o t a s e x p e c t e d , a n d s a t i s f a c t i o n w a s n o t e d w h e n i t w a s . O n e w o m e n s t a t e d . " W h e n I t ' s p e r f e c t y o u ' r e a l l e x c i t e d a n d t h e n e x t d a y y o u ' r e p t h t h t h t h , d o w n h i l l ! " I n c o n s i d e r i n g a l l o f t h e p a r t i c i p a n t s o n m e d i c a t i o n s o f a n y k i n d , t e n i n d i c a t e d t h e y w e r e n o t a d e q u a t e l y i n f o r m e d a b o u t v a r i o u s a s p e c t s o f t h e m e d i c a t i o n s . P a r t i c i p a n t s e x p r e s s e d a n e e d f o r i n f o r m a t i o n r e l a t e d t o a d d i c t i o n ( s l e e p i n g p i l l s ) , s i d e e f f e c t s , h o w t o e f f e c t i v e l y u s e t h e d r u g , a n d w h e n a n d h o w 100 t o s t o p t a k i n g t h e m . T h e y t o o w e r e a b l e t o o b t a i n t h e r e q u i s i t e i n f o r m a t i o n f r o m t h e i r p h a r m a c i s t , f a m i l y d o c t o r o r c a r d i o l o g i s t . Two o l d e r p a r t i c i p a n t s ( o n e m a n , o n e w o m a n ) s t a t e d t h e y h a d b e e n p r o v i d e d w i t h t e a c h i n g , b u t w h a t t h e y s a i d i n d i c a t e d t h a t t h e y d i d n o t u n d e r s t a n d t h e i n f o r m a t i o n p r o v i d e d , n o r t h e u s e a n d s i g n i f i c a n c e o f t h e i r m e d i c a t i o n s . . . . t h e h e a r t p i l l s . [ s h o w i n g a b o t t l e o f s o t a c o r ] . . T h e y t o l d me t h e y r e g u l a t e my h e a r t . H o w l o n g s h o u l d I t a k e 1 t h e m ? T h e f i r s t w e e k w h e n I c a m e h o m e , q u i t e a f e w t i m e s I h a d v e r y l o w h e a r t b e a t s a n d s o m e t i m e s v e r y q u i c k . S o I w a s w o n d e r i n g , s h o u l d I r e g u l a t e my h e a r t b e a t s w i t h t h e s e ? I w a s g i v e n a p a m p h l e t t h a t e x p l a i n s e a c h m e d i c a t i o n , b u t I w a s d o p e y w h e n I l e f t t h e h o s p i t a l , s o I d i d n ' t r e a d t h e m a t f i r s t . T h i s o n e d o e s s a y t o a v o i d a b r u p t c e s s a t i o n o f t h e d r u g . . . M y s o t a c o r i s t o s t o p i n n i n e d a y s , I f e e l I c a n d o w i t h o u t i t . . . I t w a s e a s y t o c o n c l u d e t h a t t h e p a r t i c i p a n t s d i d n o t a l w a y s u n d e r s t a n d t h e i n f o r m a t i o n p r o v i d e d , a n d t h a t t h e y r e q u i r e d m o r e i n f o r m a t i o n r e l a t i n g t o t h e i r v a r i o u s m e d i c a t i o n s . T h e n e e d t o c a r r y i d e n t i f i c a t i o n o r a M e d i c - A l e r t ® b r a c e l e t w a s v o i c e d b y f i v e p a r t i c i p a n t s . T h i s w a s d e e m e d e s p e c i a l l y r e l e v a n t f o r t h o s e w h o h a d a m e c h a n i c a l v a l v e a n d w e r e u n d e r g o i n g w a r f a r i n t r e a t m e n t . T h i s i n f o r m a t i o n w a s v o l u n t e e r e d d u r i n g t h e i n t e r v i e w , p e r h a p s b e c a u s e t h e r e s e a r c h e r w o r e a m e d i c a l - a l e r t ® b r a c e l e t . O f t h e f i v e w h o d i d . . m e n t i o n i t , f o u r s a i d t h e y h a d b e e n t o l d b y t h e i r d o c t o r s t h a t t h e y w o u l d r e c e i v e a n i d e n t i f i c a t i o n c a r d t o p u t i n t h e i r w a l l e t s , w h i c h i n d i c a t e d t h a t t h e y h a d a n a r t i f i c i a l v a l v e . A l l f i v e s t a t e d t h e y h a d o b t a i n e d o r w e r e g e t t i n g m e d i c - a l e r t ® 1 0 1 b r a c e l e t s . O n e p a r t i c i p a n t h a d b e e n g i v e n a n i n f o r m a t i o n p a m p h l e t p e r t a i n i n g t o m e d i c - a l e r t ® b r a c e l e t s w h i l e a t t h e s u r g e o n ' s o f f i c e , b u t a l l f i v e f e l t i t w a s i m p o r t a n t t o o f f e r t h e p a m p h l e t s w h i l e i n h o s p i t a l . M y d a u g h t e r c a l l e d a l l my d o c t o r s a n d t h e y t o l d h e r w h a t t o g e t p u t o n i t a n d s h e d i d . B u t i t w a s a n a f t e r t h o u g h t . I k n o w I s h o u l d c a r r y i t [ i d e n t i f i c a t i o n ] , b u t i f I w a s n ' t . t o l d a n d I w a s a n o r d i n a r y p e r s o n , I m a y n o t k n o w . B u t b e i n g a h e a l t h p r o f e s s i o n a l , I k n e w a b o u t t h e m e d i c a l e r t ® a n d I p i c k e d u p t h e a p p l i c a t i o n i n t h e d o c t o r ' s o f f i c e . T h a t w a s s o m e t h i n g t h a t c o u l d h a v e b e e n d o n e i n t h e h o s p i t a l s o I h a d t i m e t o t h i n k a b o u t i t a n d a s k w h a t g o e s o n i t •' D i s c u s s i o n M u c h c o n f u s i o n r e m a i n e d a t t h e t i m e o f f o l l o w u p . r e g a r d i n g p a i n a n d i t s m a n a g e m e n t . D e s p i t e b e i n g w e l l r e p o r t e d i n t h e l i t e r a t u r e a s a t r a d i t i o n a l l e a r n i n g n e e d ( T a c k & G i l l i s s 1 9 9 0 ) , t h i s r e m a i n e d a n a r e a w h i c h r e q u i r e d a d d i t i o n a l e d u c a t i o n f o r m o s t p a r t i c i p a n t s . B e c a u s e i t w a s n o t p r o v i d e d , t h e p a r t i c i p a n t s e x p e r i e n c e d a n u n n e c e s s a r y d e g r e e , o f d i s c o m f o r t . A d d i t i o n a l e d u c a t i o n i s a l s o r e q u i r e d t o a l l e v i a t e a n x i e t y a n d f e a r r e l a t e d t o a d d i c t i o n a n d d e p e n d e n c e . P a r t i c i p a n t s p e r c e i v e d t h e i r m e d i c a t i o n s t o b e i m p o r t a n t , b u t r e p o r t e d b e i n g i l l p r e p a r e d t o m a n a g e t h e i r r e g i m e n s . T h i s h a s a l s o b e e n d o c u m e n t e d b y S t a n t o n e t a l . (1984). T h e l a c k o f u n d e r s t a n d i n g r e l a t i n g t o m e d i c a t i o n s i n g e n e r a l , a n d m o r e s p e c i f i c a l l y t h e a n t i c o a g u l a n t s , g a v e c a u s e f o r c o n c e r n . T h e g r o u p w h o c o m m e n t e d t h a t t h e y d i d u n d e r s t a n d t h e i r a n t i c o a g u l a n t s s t a t e d t h e y r e c e i v e d t h e i r i n f o r m a t i o n f r o m a .102 n u r s e . T h i s w o u l d s u g g e s t t h e r e a r e i n d i v i d u a l n u r s e d i s c r e p a n c i e s i n t h e p o s t - o p e r a t i v e t e a c h i n g p r o c e s s , a n d t h a t b e c a u s e o f a l a c k o f n u r s i n g a c t i o n ( i e . n u r s e s a r e n o t e d u c a t i n g p a t i e n t s a b o u t t h e i r a n t i c o a g u l a n t s ) p a t i e n t s a r e p o t e n t i a l l y ( a n d u n k n o w i n g l y ) p u t t i n g - t h e m s e l v e s a t r i s k o f • d r u g i n t e r a c t i o n s a n d t h r o m b o l y t i c c o m p r o m i s e . T h e n u r s e s h o u l d r e v i e w t h e p u r p o s e o f t h e a n t i c o a g u l a n t , i t s s i d e e f f e c t s , d i e t r e s t r i c t i o n s , c o n t r a i n d i c a t e d m e d i c a t i o n s a n d g e n e r a l s a f e t y , m e a s u r e s w i t h t h e p a t i e n t ( S t o v s k y , .& D e h n e r , 1994). T h e s e r e s u l t s a r e s u p p o r t e d b y F i t z p a t r i c k a n d M c C o n e (1991) a s w e l l a s F i n k e l m e i e r e t a l . (1989) w h o c a l l e d f o r a n i n c r e a s e d e m p h a s i s o n p a t i e n t e d u c a t i o n b y t h e n u r s e a n d i m p r o v e d a f t e r c a r e b y t h e h e a l t h - c a r e t e a m o n c e t h e p a t i e n t i s d i s c h a r g e d f r o m h o s p i t a l . D o d g e .(1969) n o t e d t h a t p a t i e n t s d i d n o t c o n c e r n . t h e m s e l v e s w i t h t h i n g s , , t h e y d i d n o t u n d e r s t a n d . - W h i l e . t h i s m a y b e t r u e f o r o t h e r a r e a s , - i t d o e s n o t h o l d t r u e h e r e . - T h e p a r t i c i p a n t s w h o s t a t e d t h e y h a d t r o u b l e w i t h t h e i r a n t i c o a g u l a n t s v i s i t e d t h e i r p h a r m a c i s t s a n d c o n t i n u a l l y r e -r e a d t h e i r m e d i c a t i o n h a n d o u t s i n a n a t t e m p t t o u n d e r s t a n d t h e a n t i c o a g u l a t i o n r e g i m e n . T h e n e e d f o r a M e d i c - A l e r t ® b r a c e l e t , o r s o m e f o r m o f i d e n t i f i c a t i o n w a s a c c o r d e d m u c h i m p o r t a n c e b y m a n y o f t h e p a r t i c i p a n t s . T h i s i n f o r m a t i o n , w h i l e a v a i l a b l e i n h o s p i t a l w a s o f t e n n o t p r o v i d e d . T h i s p o i n t s t o d i s c r e p a n c i e s , i n 1 0 3 c o n s i s t e n c y a n d c o n t e n t o f t e a c h i n g . M o r e i m p o r t a n t l y , t h i s i n c o n s i s t e n c y m e a n s t h a t m a n y h e a r t v a l v e r e c i p i e n t s d o n o t c a r r y v i s i b l e f o r m s o f i d e n t i f i c a t i o n , w h i c h c o u l d c o m p r o m i s e t h e i r h e a l t h c a r e i n e m e r g e n c y s i t u a t i o n s . V a l v e C l i c k i n g T w e l v e p a r t i c i p a n t s h a d o n e o r m o r e m e c h a n i c a l v a l v e s i n s e r t e d . S e v e n r e p o r t e d b e i n g t o l d t h a t t h e v a l v e w o u l d c l i c k w i t h v a r y i n g d e g r e e s o f i n t e n s i t y , w h i l e f i v e r e p o r t e d n o t k n o w i n g t h i s . A l l f i v e r e p o r t e d s u r p r i s e a n d f e a r w h e n t h e y f i r s t h e a r d t h e c l i c k i n g s o u n d . I t s c a r e d t h e h e l l o u t o f me w h e n I c a m e h o m e b e c a u s e i t e c h o e d s o l o u d . I t w a s l i k e s o m e b o d y d r o p p e d a T i m e x i n t h e r e . T h e f i r s t n i g h t , I a h h e a r d t h i s n o i s e a n d I am s c a r e d s o m u c h . I s a y o h my G o d , w h a t i s t h i s ? F o u r o f t h e f i v e e x p e r i e n c e d d i f f i c u l t i e s a d j u s t i n g t o t h e c o n t i n u a l s o u n d o f t h e v a l v e c l i c k i n g . T h e c l i c k i n g , i t ' s e n o u g h t o d r i v e a p e r s o n w i l d a n d i t d i d ! M y d o c t o r s a i d y o u w i l l g e t u s e d t o i t . B u t w h a t d o y o u d o n o w ? T h e s e f o u r a d j u s t e d t o t h e v a l v e b y t u r n i n g t h e t e l e v i s i o n o r r a d i o o n t o " d r o w n o u t " t h e s o u n d a t n i g h t . O n e m a n s a i d " W h e n i t b o t h e r s me a n d I c a n ' t s l e e p I w i l l c o u n t t h e t i c k s , a n d g r a d u a l l y I w i l l f a l l a s l e e p , l i k e c o u n t i n g s h e e p " . M o s t o f t h e 12 p a r t i c i p a n t s m a d e j o k e s a b o u t t h e v a l v e , 1 0 4 s t a t i n g t h a t t h e i r f r i e n d s a n d f a m i l y c o m m e n t e d t h a t t h e y c o u l d . h e a r i t c l i c k i n g . O n e w o m e n s a i d h e r f r i e n d s c o u l d h e a r h e r t w o . f e e t a w a y , s o s h e t o l d t h e m s h e w a s a " t i c k i n g t i m e b o m b " . O t h e r c o m m e n t s i n c l u d e d : S h e [ n i e c e ] w a s s i t t i n g n e x t t o me a n d w e w e r e r e a d i n g a n d s h e s a i d " A u n t y y o u t i c k " S o we d e c i d e d I w a s r e l a t e d t o t h e c r o c o d i l e i n P e t e r P a n ! ( l a u g h ) P e o p l e h a v e s a i d o h m y . G o d , y o u h a v e t w o m e c h a n i c a l , v a l v e s , y o u ' l l h a v e y o u r o w n c o n c e r t g o i n g y o u k n o w ! T h e j o k e s m a y h a v e b e e n o n e w a y o f c o p i n g w i t h t h e v a l v e s o u n d , a n d t h e r e s u l t a n t a t t e n t i o n , a l t h o u g h t h i s w a s n e v e r v e r i f i e d -w i t h t h e . p a r t i c i p a n t s . D i s c u s s i o n A d j u s t i n g t o t h e s o u n d o f t h e v a l v e c l i c k i n g i s a p o o r l y d o c u m e n t e d i s s u e t o d a t e i n c a r d i a c l i t e r a t u r e ( J e n k i n s e t a l . 1 9 8 3 ) . H o w e v e r , t h e f a c t t h a t o n l y h a l f o f t h e p a r t i c i p a n t s c o u l d r e m e m b e r b e i n g t o l d t h e i r m e c h a n i c a l v a l v e s w o u l d c l i c k l o u d l y s e r v e s t o r e i n f o r c e t h a t p a r t i c i p a n t s w e r e p o o r l y i n f o r m e d a b o u t t h e n a t u r e o f t h e v a l v e . T h i s i n f o r m a t i o n w a s m o s t p r o b a b l y n o t p r o v i d e d b e c a u s e w h e n t h e v a l v e d i d c l i c k , t h e p a r t i c i p a n t s e x p r e s s e d f e a r a n d d i d n o t r e m e m b e r d i s c u s s i n g ' t h i s p r e - o p e r a t i v e l y . A g a i n , h a d i n f o r m a t i o n o f t h i s n a t u r e b e e n p r o v i d e d i n a t a n g i b l e f o r m , - t h e p a r t i c i p a n t s c o u l d h a v e r e f e r r e d t o i t , a n d b e e n r e a s s u r e d t h a t w h a t t h e y w e r e e x p e r i e n c i n g w a s n o r m a l . T h e I n c i s i o n 1 0 5 F o u r p a r t i c i p a n t s r e p o r t e d n o t b e i n g g i v e n a n y i n s t r u c t i o n p e r t a i n i n g t o t h e c a r e o f t h e i r i n c i s i o n , w h i l e a n a d d i t i o n a l n i n e s t a t e d t h a t t h e v i d e o i n f o r m e d t h e m n o t t o l e t s h o w e r w a t e r s p r a y d i r e c t l y o n i t , b e c a u s e t h i s w o u l d h u r t . T h e r e m a i n i n g f i v e s t a t e d t h e y h a d b e e n t o l d h o w t o c a r e f o r t h e i r i n c i s i o n s , f o u r b e c a u s e t h e y h a d a s k e d t h e i r n u r s e s o r p h y s i c i a n s a n d a n o t h e r b e c a u s e s h e w e n t h o m e w i t h a d r e s s i n g o n , w h i c h r e q u i r e d d a i l y c a r e . I n c i s i o n c a r e v a r i e d c o n s i d e r a b l y . S o m e w a s h e d i t w i t h a c l o t h , w h i l e o t h e r s d i d n o t h i n g . O n e w o m a n b o i l e d w a t e r a n d p o u r e d i t o v e r a c l o t h b e f o r e w i p i n g t h e i n c i s i o n , b e l i e v i n g s h e w a s h e l p i n g h e r s e l f a v o i d i n f e c t i o n s . S e v e n o f t h e p a r t i c i p a n t s p u t v i t a m i n E o r s i m i l a r c r e a m s o n t h e i n c i s i o n r e g u l a r l y . T h i s a c t i o n w a s o f t e n s u g g e s t e d b y a t h i r d p a r t y . "I w a s t o l d b y g o o d o l d mom, v i t a m i n E . " D e s p i t e t h e o b v i o u s v a r i a t i o n i n i n c i s i o n c a r e , a n d t h e l a c k o f i n f o r m a t i o n p r o v i d e d , o n l y t h r e e s t a t e d t h a t t h e y w o u l d h a v e l i k e d a d d i t i o n a l i n f o r m a t i o n . F i v e p a r t i c i p a n t s r e p o r t e d n e e d i n g a n t i b i o t i c s d u e t o m i n o r p r o b l e m s a s s o c i a t e d w i t h w o u n d h e a l i n g . T h e p r e s c r i p t i o n s w e r e p r o v i d e d b y t h e s u r g e o n s . I n t e r e s t i n g l y p a r t i c i p a n t s c a l l e d o n t h e i r s u r g e o n s a t t h i s t i m e r a t h e r t h a n t h e i r f a m i l y p h y s i c i a n s , b u t w e r e n o t a s k e d w h y . A l l p a r t i c i p a n t s h a d w e l l h e a l e d i n c i s i o n s a t t h e t i m e o f t h e i n t e r v i e w s . T h e l e v e l o f k n o w l e d g e r e l a t i n g t o p r o p h y l a c t i c a n t i b i o t i c .-'106 use for dental work was assessed when discussing i n c i s i o n care. Fifteen participants stated they were informed about the need for a n t i b i o t i c s p r i o r to dental work, either through their surgeons or because i t was i n the discharge booklet provided. More than half of those who were aware of this had known before the surgery and1 had been using a n t i b i o t i c s . The other three stated they did not know this, and were referred to their discharge booklets for more information. Nine participants (four men and five women) commented on how they f e l t about the in c i s i o n . This was unsolicited information. Three men perceived the i n c i s i o n to be "beautiful" or "clean" and made jokes about i t , " I ' l l t e l l a l l i t i s an enduring scar from my days at Heidelberg!" These men were oyer the age of f i f t y and were 8 to 10 weeks post-hdspitalization. The 29 year old man who was four weeks post-ho s p i t a l i z a t i o n did not l i k e the incision, stating "Scars don't look a l l that at t r a c t i v e . . . I am a b i t insecure when we're ugh, intimate." Women found the i n c i s i o n to be unappealing at f i r s t , but tended to accept i t over time. One 65 year old woman who was 7 weeks post-discharge commented: I burst into tears, and I said to my husband "Look what he did to me!" you know l i k e the surgeon. "Did he have to make such a mess of me?" But now I think, who cares, I am not going to walk around with a b i k i n i on at my age ,anyway. ' The young female participant who was fi v e weeks post-discharge also found the scar unappealing, stating that her friends did 107 a s w e l l . T h e s e n i n e p a r t i c i p a n t s a l s o m a d e c o m m e n t s a b o u t t h e i r p e r s o n a l a p p e a r a n c e w h e n f i r s t r e c o v e r i n g f r o m t h e s u r g e r y . O n e m a n s a i d "I am s u r e I w a s a s a d l o o k i n g s a c k w h e n I d r a g g e d my t a i l i n t h e d o o r " a n d o n e w o m e n s t a t e d " Y o u k n o w my h u s b a n d d o e s n ' t w a n t t o c o m e h o m e a n d s e e me l i k e t h a t w i t h m y h a i r u g l y a n d e v e r y t h i n g " . I t w a s i m p o r t a n t f o r t h e s e i n d i v i d u a l s t o a t t e m p t t o d r e s s , b a t h e , a n d b e p r e s e n t a b l e e v e n w h e n t h e y w e r e v e r y w e a k a n d f a t i g u e d . T w e l v e p a r t i c i p a n t s d i s c u s s e d t e m p e r a t u r e c h a n g e s e x p e r i e n c e d d u r i n g t h e e a r l y w e e k s a f t e r s u r g e r y . . T h e s e w e r e d e s c r i b e d i n a d d i t i o n t o f e e l i n g c o l d i n t h e e a r l y h o u r s a f t e r s u r g e r y . T h r e e p a r t i c i p a n t s d e s c r i b e d b e i n g v e r y h o t . O n e w o m a n d e s c r i b e d i t a s m e n o p a u s a l n i g h t s w e a t s . T h e r e m a i n i n g n i n e s t a t e d t h e y w e r e v e r y c o l d . " Y e a h , I w a s c o l d a l o t . C o l d e v e n i n b e d . I h a d a n e l e c t r i c b l a n k e t a n d h a d i t t u r n e d u p t o t h e t o p m o s t o f t h e t i m e . . . " . T h e m o s t c o m m o n r e a s o n g i v e n f o r m e n t i o n i n g t h i s w a s t h a t t h e y w o r r i e d t h e y w e r e c a t c h i n g c o l d , d e v e l o p i n g a n i n f e c t i o n i n t h e i r i n c i s i o n , o r b e c o m i n g i l l . O n e p e r s o n b o u g h t a t h e r m o m e t e r a n d m e a s u r e d h i s t e m p e r a t u r e s e v e r a l t i m e s a d a y , a n d i n f o r m e d h i s s u r g e o n a b o u t h i s t e m p e r a t u r e v a r i a t i o n s . H e w a s r e a s s u r e d b y t h e s u r g e o n t h a t a l l w a s w e l l . F o u r p a r t i c i p a n t s w h o w e r e c o n c e r n e d a b o u t b o d y t e m p e r a t u r e f l u c t u a t i o n s w e r e i n t h e g r o u p o f f i v e w h o w e r e g i v e n p o s t - o p e r a t i v e a n t i b i o t i c s ; t h i s s u g g e s t e d t h a t t h e 1 0 8 p a r t i c i p a n t s w e r e i n t o u c h w i t h ( o r c l o s e l y m o n i t o r i n g ) t h e i r b o d i e s a n d t h e v a r i a t i o n s i n c u r r e d . D i s c u s s i o n T h e r e w a s t r e m e n d o u s v a r i a t i o n i n i n c i s i o n c a r e n o t e d . U n l i k e o t h e r s t u d i e s , t h e p a r t i c i p a n t s d i d n o t r e q u e s t a d d i t i o n a l t e a c h i n g i n t h i s a r e a , d e s p i t e - t h e i r w o r r i e s a b o u t t e m p e r a t u r e f l u c t u a t i o n s a n d p o t e n t i a l i n f e c t i o n s . T h i s m a y b e b e c a u s e t h e y h a d b e e n h o m e f o r a m i n i m u m o f f o u r w e e k s a n d h a d a l r e a d y d e a l t w i t h t h e c a r e o f t h e i r i n c i s i o n s . T h i s , i s n o t t o s a y t h a t t h e i n c i s i o n c a r e p r o v i d e d p r o m o t e d o p t i m a l h e a l i n g , o n l y t h a t t h e y w e r e s a t i s f i e d w i t h t h e i r h e a l i n g p r o c e s s , h a d r e m a i n e d i n f e c t i o n f r e e , a n d d i d n o t r e q u i r e a d d i t i o n a l i n f o r m a t i o n i n t h i s , a t r a d i t i o n a l l y r e p o r t e d p r o b l e m a r e a . I t w a s e n c o u r a g i n g t o n o t e t h a t m o s t p a r t i c i p a n t s h a d b e e n i n f o r m e d a b o u t t h e n e e d f o r p r o p h y l a c t i c . a n t i b i o t i c u s e w h e n h a v i n g d e n t a l w o r k d o n e . T h e s e r e s u l t s a r e f a v o u r a b l e i n c o m p a r i s o n t o t h e s t u d y u n d e r t a k e n b y F i . t z p a t r i c k a n d M c C o n e ( 1 9 9 1 ) w h o s u g g e s t e d t h a t 25% o f t h e i r s t u d y p a r t i c i p a n t s w e r e u n a w a r e o f t h e n e e d , f o r p r o p h y l a c t i c a n t i b i o t i c u s e . T h i s s u g g e s t s t h a t s o m e t e a c h i n g h a d b e e n p r o v i d e d ( b y w h o m . r e m a i n s u n k n o w n ) , a n d t h a t p a r t i c i p a n t s d i d r e t a i n p e r t i n e n t i n f o r m a t i o n . N u t r i t i o n A l l b u t t h r e e p a r t i c i p a n t d e s c r i b e d a s i g n i f i c a n t l o s s o f a p p e t i t e i n t h e e a r l y p o s t - o p e r a t i v e d a y s . 1 0 9 I l o s t e i g h t p o u n d s b u t I c o u l d n ' t r e a l l y s p a r e i t , b u t I j u s t h a d n o a p p e t i t e . . . T h e q u a l i t y o f t h e f o o d w a s f r i g h t f u l . I f y o u e v e n h a d t h e s p i r i t t o t a k e t h e l i d o f f t o h a v e a l o o k o r h a v e a s m e l l , w e l l e v e r y t h i n g s e e m e d t o s m e l l t h e s a m e . T h e y c o u l d h a v e j u s t f o r g o t t e n a b o u t g i v i n g me a t r a y c a u s e I d i d n ' t e a t a n y t h i n g . T h e p a r t i c i p a n t s u n i v e r s a l l y s t a t e d t h a t t h i s w a s n o t s o m e t h i n g t h a t h a d b e e n d i s c u s s e d w i t h t h e m p r e - o p e r a t i v e l y , n o r w a s i t e x p e c t e d , t h e y j u s t " d i d n ' t t h i n k a b o u t i t " . T h e l o s s o f a p p e t i t e w a s a t t r i b u t e d t o p a i n , n a u s e a , w e a k n e s s , a n d l a c k o f a c t i v i t y . W h i l e t h i s w a s n o t s o m e t h i n g t h e p a r t i c i p a n t s w a n t e d m o r e i n f o r m a t i o n a b o u t , t h e y d i d r e q u e s t i n f o r m a t i o n p e r t a i n i n g t o c o n s t i p a t i o n a n d t h e i r s p e c i f i c n u t r i t i o n a l n e e d s . E l e v e n p a r t i c i p a n t s r e p o r t e d s o m e d e g r e e o f p o s t - o p e r a t i v e c o n s t i p a t i o n . T h e y b e l i e v e d t h i s w a s a t t r i b u t a b l e t o a l a c k o f a c t i v i t y , c o d e i n e , r e d u c e d a p p e t i t e , i r o n s u p p l e m e n t s a n d r e d u c e d w a t e r i n t a k e i n t h e e a r l y p o s t - o p e r a t i v e p e r i o d . O n e p e r s o n s a i d : • I r o n i s n o t o r i o u s f o r a c t i n g l i k e c e m e n t s o . . . u g h , I h a d my w i f e p i c k u p s o m e p r u n e s . . . t h a t h e l p e d a s m u c h a s a n y t h i n g . A l l t h e p a r t i c i p a n t s s t a t e d t h e y w e r e a s k e d i n h o s p i t a l b y t h e n u r s e s i f t h e y r e q u i r e d l a x a t i v e s . T h o s e w h o d i d w e r e s u p p l i e d w i t h t h e m . " T h e y g a v e u s a l i t t l e u g h , m i l k s h a k e t o c h e e r u s u p . T h a t c l e a r e d t h i n g s u p " . T h e r e w a s l i t t l e a d d i t i o n a l f o l l o w u p . F o u r p a r t i c i p a n t s w e n t h o m e c o n s t i p a t e d d e s p i t e b e i n g p r o v i d e d w i t h t h e " m i l k s h a k e " . T h r e e w e r e s u c c e s s f u l i n t r e a t i n g t h e m s e l v e s , w h i l e t h e f o u r t h h a d a s s i s t a n c e f r o m t h e 110. P u b l i c H e a l t h N u r s e . T h i r t e e n p a r t i c i p a n t s r e p o r t e d b e i n g o n a r e g u l a r d i e t , t h e r e f o r e n o t r e q u i r i n g s p e c i f i c n u t r i t i o n a l i n f o r m a t i o n . T h e r e m a i n i n g f i v e w e r e p l a c e d o n s a l t f r e e d i e t s b y t h e i r s u r g e o n s o r f a m i l y p h y s i c i a n . A l l f i v e r e q u e s t e d s p e c i f i c i n f o r m a t i o n r e l a t e d t o t h e i r d i e t s . I w a n t e d t o k n o w b e t t e r a b o u t t h e f o o d I e a t y o u k n o w b e c a u s e , y o u k n o w t h e y j u s t g i v e a b o o k , b u t y o u k n o w t h e y d o n ' t s a y t o o m u c h t o me a n d I w a n t e d t o k n o w w h a t f o o d s I h a v e t o e a t , w h a t - i s b e t t e r f o r m e . . . O n l y t h e p r e g n a n t w o m a n , w h o w a s i n h o s p i t a l f o r a l m o s t t h r e e m o n t h s , r e p o r t e d t a l k i n g w i t h a h o s p i t a l n u t r i t i o n i s t . T h i s t o o k p l a c e p r i o r t o t h e h e a r t s u r g e r y , a t a d i f f e r e n t h o s p i t a l . I w a s g i v e n a p a m p h l e t o f f o o d s I c a n o r c a n n o t h a v e s o r t o f t h i n g , a n d t h i s w a s p r i o r t o t h e s u r g e r y . I d o h a v e i t s o m e w h e r e a r o u n d t h e h o u s e , b u t s h e e x p l a i n e d i t w e l l e n o u g h s o t h a t b a s i c a l l y I j u s t , w h e n I g o g r o c e r y . s h o p p i n g , I j u s t w a t c h t o s e e h o w m u c h s a l t c o n t e n t a n d c h o l e s t e r o l t h e r e i s i n w h a t I am b u y i n g , a n d t r y a n d b u y t h e l o w e s t a m o u n t . O n e i n d i v i d u a l ' r e p o r t e d r e c e i v i n g c o n f l i c t i n g , i n f o r m a t i o n " i n r e l a t i o n t o h e r d i e t a n d h o w t o m a n a g e i t . S h e w a s a l o n e p o s t - o p e r a t i v e l y a n d h a d t o p r e p a r e h e r o w n m e a l s . N O , n o n u t r i t i o n i n f o r m a t i o n a t a l l ! N o n e . I e v e n a s k e d t o s p e a k t o a d i e t i t i a n t o o b e c a u s e I w a s q u i t e c o n f u s e d . I am o n a n o s a l t d i e t , t h e n t h e y t o l d me I c o u l d n ' t c o o k . T h e y t o l d me t h a t t h e T V d i n n e r s y o u b u y i n a s t o r e a r e f i n e . . B u t t h e y a r e f u l l o f s a l t a n d . p r e s e r v a t i v e s . S o I g o t c o n f l i c t i n g i n f o r m a t i o n . T h e c a r d i a c s u r g e r y u n i t d o e s h a v e r e g u l a r l y s c h e d u l e d n u t r i t i o n c l a s s e s o n T u e s d a y a n d F r i d a y a f t e r n o o n s , h o w e v e r t h e p a r t i c i p a n t s w e r e n o t a s k e d i f t h e y w e r e m a d e a w a r e o f t h e s e . I l l T h e c l a s s e s a r e w e l l a d v e r t i s e d i n t h e h o s p i t a l h a l l w a y s , b u t f r o m t h e p a r t i c i p a n t s r e s p o n s e s , i t i s c l e a r t h a t t h e f i v e w h o w o u l d h a v e b e n e f i t e d f r o m t h e c l a s s e s w e r e n o t i n a t t e n d a n c e . D i s c u s s i o n C o n s t i p a t i o n a n d a l a c k o f a p p e t i t e d u r i n g r e c o v e r y h a v e b e e n c o m m o n l y r e p o r t e d i n t h e l i t e r a t u r e w i t h c a r d i a c p a t i e n t s , a n d w a s a l s o s e e n i n t h i s s t u d y . T h e p a r t i c i p a n t s d i d n o t p e r c e i v e t h i s a s a n a r e a r e q u i r i n g a d d i t i o n a l e d u c a t i o n . O n l y t h o s e f i v e w h o w e r e o n s p e c i f i c d i e t s p r e s c r i b e d b y t h e i r d o c t o r s e x p r e s s e d s p e c i f i c l e a r n i n g n e e d s i n t h i s a r e a . T h e f a c t t h a t n o n e o f t h e f i v e p a r t i c i p a n t s h a d a t t e n d e d t h e n u t r i t i o n c l a s s e s o f f e r e d o n T u e s d a y a n d F r i d a y a f t e r n o o n s s u g g e s t s t h a t t h i s s e r v i c e i s b e i n g u n d e r - u t i l i z e d , o r t h a t t h e p a r t i c i p a n t s w e r e s i m p l y n o t i n f o r m e d t h a t t h e s e r v i c e w a s a v a i l a b l e . I t i s a l s o p o s s i b l e t h a t m o r e p e o p l e w o u l d a t t e n d m o r n i n g n u t r i t i o n c l a s s e s r a t h e r t h a n a f t e r n o o n c l a s s e s , w h i c h a r e s c h e d u l e d a t a t i m e w h e n p a t i e n t s a r e r e s t i n g . P o s t - O p e r a t i v e C o m p l i c a t i o n s A w i d e v a r i e t y o f p o s t - o p e r a t i v e c o m p l i c a t i o n s w e r e e x p e r i e n c e d b y t h e g r o u p . F i v e p a r t i c i p a n t s r e p o r t e d h a v i n g t r o u b l e w i t h r e g u l a t i n g t h e i r h e a r t r a t e o r r h y t h m s . O n e p e r s o n r e q u i r e d c a r d i o v e r s i o n , w h i l e t h e o t h e r f o u r w e r e r e g u l a t e d w i t h m e d i c a t i o n s . V i s u a l d i s t u r b a n c e s i n c l u d i n g s e e i n g s p o t s , b l u r r e d v i s i o n , a n d t h e i n a b i l i t y t o f o c u s w e r e . 1 1 2 ' r e p o r t e d b y f i v e p e o p l e . H y p o t e n s i o n r e s u l t i n g i n i m b a l a n c e w a s d e s c r i b e d b y f o u r p a r t i c i p a n t s . W h i l e t h i s r e s o l v e d s p o n t a n e o u s l y , o n e w o m a n h a d a f a l l w h i l e i n h o s p i t a l . T w o p a r t i c i p a n t s r e p o r t e d w h a t t h e y t e r m e d " m i l d s t r o k e s " p o s t - . o p e r a t i v e l y . T h e p r e g n a n t w o m e n a l s o h a d w h a t s h e d e s c r i b e d a s a m i l d s t r o k e p r e - o p e r a t i v e l y . N o n e o f t h e m s u s t a i n e d - r e s i d u a l e f f e c t s . A t o t a l o f 13 p a r t i c i p a n t s r e p o r t e d t h e a b o v e n o t e d c o m p l i c a t i o n s w h i c h o c c u r r e d b e f o r e s u r g e r y ( o n e ) o r d u r i n g t h e f i r s t t h r e e w e e k s a f t e r s u r g e r y ( 1 2 ) . W h i l e t h e h e a r t r h y t h m t r o u b l e s a n d h y p o t e n s i o n c o m m o n l y o c c u r r e d i n h o s p i t a l , v i s u a l d i s t u r b a n c e s a n d m i l d s t r o k e s d i d n o t . S i n c e t h e s e o c c u r r e d a t h o m e w i t h o u t a n y w a r n i n g , f a m i l y s t r e s s a n d a n x i e t y w e r e e x p e r i e n c e d . I f t h e p a t i e n t w a s t o l d t h a t t h i n g s l i k e t h a t c o u l d h a p p e n , t h e y w o u l d n ' t b e s o s c a r e d w h e n i t d i d h a p p e n . I h a v e , h a d s o m e p r e t t y h o r r i f y i n g e x p e r i e n c e s . F o r i n s t a n c e , . I h a v e b e e n d o w n t o e m e r g e n c y b e c a u s e m y . h e a r t w a s r a c i n g . T h e p a r t i c i p a n t s c l e a r l y p e r c e i v e d a l a c k o f i n f o r m a t i o n i n . r e l a t i o n t o p o t e n t i a l p o s t - o p e r a t i v e c o m p l i c a t i o n s . R e t u r n t o W o r k . O f t h e e i g h t p a r t i c i p a n t s w h o w e r e n o t r e t i r e d , f i v e . e x p r e s s e d a f e a r o f r e t u r n i n g t o t h e i r e m p l o y m e n t , s t a t i n g t h e y h a d b e e n g i v e n l i t t l e o r no - i n f o r m a t i o n p e r t a i n i n g t o t h i s . I ' m d e f i n i t e l y n o t g o i n g t o g o b a c k . t o my t y p e o f j o b . I d o c u s t o d i a l w o r k a t t h e s c h o o l . S o t h e r e i s a l o t o f c a r r y i n g a r i d l i f t i n g o f g a r b a g e , v a c u u m i n g , d a m p - m o p p i n g , a n d n o w w e h a v e t h a t g i a n t m a c h i n e ! 1 1 3 W e l l n o b o d y t o l d me a n y t h i n g a b o u t i t . I w a s t o l d I w o u l d b e o f f f o r a b o u t t h r e e m o n t h s a n d t h a t w a s a b o u t a l l . T w o m e n s t a t e d t h a t t h e y h a d l o s t t h e i r j o b s d u e t o t h e p h y s i c a l e x e r t i o n r e q u i r e d a n d t h e i r p e r c e i v e d i n a b i l i t y t o d o t h i s p o s t - o p e r a t i v e l y . O n e m a n w a s a c a r p e n t e r a n d t h e o t h e r a r e s t a u r a n t m a n a g e r . O n e w o m a n w a s e a g e r t o r e t u r n t o w o r k , b e c a u s e s h e f e l t c a p a b l e o f d o i n g s o a f t e r b e i n g o f f w o r k f o r o n l y s e v e n w e e k s . S h e s a i d " S c h o o l s t a r t e d t o d a y , w e l l , I s h o u l d b e t h e r e . Y o u k n o w I am j u s t s i t t i n g a r o u n d n o w ! " D e s p i t e t h e s o c i a l s a f e t y n e t s o f C a n a d i a n s o c i e t y , f i v e p a r t i c i p a n t s d e s c r i b e d t h e s i g n i f i c a n t f i n a n c i a l i m p a c t t h e p r o c e s s p l a c e d o n t h e m . F i n a n c i a l l y a r o u n d h e r e w e a r e n o t d o i n g s o h o t e i t h e r , ' c a u s e o f a l l t h i s I h a v e n ' t b e e n w o r k i n g . W e ' r e g o i n g d o w n f r o m m a k i n g u g h , y o u k n o w 3 - 4 g r a n d a m o n t h t o 1 2 0 0 a m o n t h , w e l f a r e . T h e f i r s t m o n t h , y o u k n o w , we w e r e g o i n g t h r o u g h s u c h a b a d t i m e f i n a n c i a l l y a n d e v e r y t h i n g , s o t h e r e w a s a d d e d s t r e s s c o m i n g f r o m t h a t . A s e l f - e m p l o y e d a c c o u n t a n t s t a t e d t h a t h e s t a r t e d w o r k i n g a g a i n w h i l e i n h o s p i t a l . H e s t a t e d h i s c l i e n t s h a d g o v e r n m e n t t a x d e a d l i n e s t o m e e t , w h i c h w e r e n o t f l e x i b l e . F u r t h e r m o r e , h e h a d a m o r t g a g e t o p a y a n d n o o n e e l s e w a s g o i n g t o d o t h i s f o r h i m ! I f y o u d o n ' t w o r k t h e r e i s n o m o n e y c o m i n g i n . . . I c a n ' t s e e i f i t m a k e s a l o t o f d i f f e r e n c e i f I w o r k o r n o t . I r e a d a b o o k a n d t h a t i s a n e x p e n d i t u r e o f e n e r g y , n o m o r e s o t h a n r e a d i n g a l e d g e r . 1 1 4 D i s c u s s i o n W i t h v a l v u l a r h e a r t d i s e a s e b e i n g a c h r o n i c i l l n e s s , i t w a s n o t s u r p r i s i n g t h a t o n l y . e i g h t p a r t i c i p a n t s , w e r e w o r k i n g , -a n d t h a t m u l t i p l e a d v e r s e e v e n t s w e r e e n c o u n t e r e d a f t e r s u r g e r y . T h a t f e w k n e w a b o u t t h e p o t e n t i a l a d v e r s e e v e n t s a g a i n c a l l s i n t o q u e s t i o n t h e . i s s u e o f i n f o r m e d c o n s e n t . T h i s a u t h o r i s o f t h e o p i n i o n t h a t t h o s e w h o a r e s c h e d u l e d f o r o p e n h e a r t s u r g e r y s h o u l d h a v e r e f e r e n c e i n f o r m a t i o n p r o v i d e d p r e -o p e r a t i v e l y . T h e s t a t e m e n t s i n d i c a t i n g u n c e r t a i n t y p e r t a i n i n g t o t h e a b i l i t y t o r e t u r n t o w o r k s u p p o r t t h e r e s e a r c h d o n e b y C l a n c y e t a l . ( 1 9 8 4 ) , a n d A l l e n ( 1 9 9 0 ) . T h e y h a v e p r e v i o u s l y n o t e d t h a t p e r c e p t i o n s o f h e a l t h s t a t u s a c t - a s a s i g n i f i c a n t . i n d i c a t o r o f r e t u r n t o w o r k a f t e r C A B G s u r g e r y . I t i s n o t k n o w n a t t h e t i m e o f w r i t i n g w h e t h e r t h e s e p a r t i c i p a n t s -r e t u r n e d t o w o r k . H o w e v e r , n o n e o f t h e e i g h t m a d e m e n t i o n o f e n g a g i n g i n a n y o r g a n i z e d r e h a b i l i t a t i o n p r o g r a m , w h i c h w o u l d a s s i s t i n p r e p a r i n g t h e m f o r t h e i r r e t u r n . T h e f i n a n c i a l b u r d e n p l a c e d o n i n d i v i d u a l s a s a r e s u l t o f t h e s u r g e r y i s a p o o r l y d o c u m e n t e d p r o b l e m i n C a n a d i a n c a r d i a c l i t e r a t u r e . T h e s o c i a l s a f e t y n e t h a s t r a d i t i o n a l l y m e a n t t h a t . t h i s i s n o t a c o n s i d e r a t i o n f o r m o s t , b e c a u s e t h e r e a r e n o d i r e c t c o s t s ( s u c h a s h o s p i t a l b i l l s ) i n c u r r e d . B e c a u s e f i v e p a r t i c i p a n t s c l e a r l y n o t e d t h i s a s a c o n c e r n , : i t i s b e c o m i n g i n c r e a s i n g l y e v i d e n t t h a t c h a n g e s t o t h e s o c i a l s y s t e m w i l l 1 1 5 f i n a n c i a l l y a f f e c t t h e a v e r a g e s u r g i c a l c a n d i d a t e . W h i l e t h i s p r o b l e m i s i n i t s i n f a n c y , i t n e e d s t o b e m o n i t o r e d a s t h e p r o c e s s o f e c o n o m i c c h a n g e c o n t i n u e s . E m o t i o n s V a r i o u s e m o t i o n s w e r e d e s c r i b e d b a s e d o n t h e e x p e r i e n c e s e n c o u n t e r e d . T h r e e p a r t i c i p a n t s e x p e r i e n c e d a c t i v e p o s t - J o p e r a t i v e h a l l u c i n a t i o n s , r e q u i r i n g p s y c h i a t r i c i n t e r v e n t i o n a n d m e d i c a l t r e a t m e n t . T h e p a r t i c i p a n t s f o u n d t h e h a l l u c i n a t i o n s t o b e d i s t r e s s i n g , s t a t i n g t h e y h a d n o t b e e n t o l d t h i s w a s a p o t e n t i a l o r e x p e c t e d c o m p l i c a t i o n f r o m t h e s u r g e r y . We [ t h e p a r t i c i p a n t a n d t h e m a n i n t h e b e d n e x t t o h i m ] h a d h a l l u c i n a t i o n s , d i s o r i e n t a t i o n f o r s e v e r a l d a y s t h a t w e r e r e a l l y q u i t e s e v e r e . We h a d n ' t b e e n w a r n e d a b o u t t h i s a t a l l . . . I d i d n ' t k n o w w h e r e I w a s a n d c o u l d n ' t f i g u r e o u t w h y I w a s t h e r e . I t w a s q u i t e a l a r m i n g y o u k n o w . U p o n q u e s t i o n i n g , t h e p a r t i c i p a n t s a g r e e d t h a t h a d t h e y a n d t h e i r f a m i l i e s b e e n t o l d o f t h i s p o t e n t i a l r e a c t i o n t o t h e p r o c e d u r e , i t w o u l d h a v e m a d e c o p i n g w i t h a n d u n d e r s t a n d i n g i t , m u c h e a s i e r , e s p e c i a l l y f o r t h e i r f a m i l i e s . T h e o t h e r 1 5 p a r t i c i p a n t s e x p e r i e n c e d a m o r e " r o u t i n e " r e c o v e r y . A l l t h e p a r t i c i p a n t s d e s c r i b e d a t l e n g t h t h e e m o t i o n s t h e y h a d e x p e r i e n c e d i n t h e w e e k s f o l l o w i n g t h e i r d i s c h a r g e f r o m h o s p i t a l . T h e e m o t i o n s m o s t c o m m o n l y e x p r e s s e d i n c l u d e d f e a r o r b e i n g s c a r e d , w o r r y , a n x i e t y , d e p r e s s i o n , r e l i e f , g r a t i t u d e a n d e u p h o r i a . 116 Fear was most commonly discussed i n r e l a t i o n to the heart valve, i t s potential for f a i l u r e and the need for repeat surgery. This was' discussed by 11 participants. I don't wanna go a back again [to hospital].. I'm tod old. How long i s the valve r e a l l y good?. Ten or 15 years, then • what? I know i f the c l i c k doesn't sound, then I'd better go [to hospital], i f I am able to go... Along with general fear, a s p e c i f i c fear of death was expressed by the majority of the participants. This was not related to valve type: I have the fear of the blood c l o t . They say that i f i t does b u i l d up and a piece does go, i t could end up anywhere, some place where i t ' s harmless but then again i t could end up i n my brain and I could have a stroke, or you know... So I have to deal with that. I was worried about the pig valve, because i t sort of puts a lease on my l i f e . It i s not very strong. ...my doctor didn't l i k e to discuss i t with me very much. He just said i t would be fine. I hope I don't have to go again. Three participants expressed concern about overexertion and how this would affect the valve. This was not valve type s p e c i f i c . There i s no work that I haven't been able to do around the house. But w i l l I get hurt or ugh, make my valve'more weak i f I work that way again l i k e I did? Do I have to keep back? W i l l i t r e a l l y do something to my valve i f I,, l e t ' s say i i f t up something, what happens? ' Can I hurt myself? A l l reported being scared, worried or anxious post-operatively. My doctor thought he heard regurgitation i n the valve and that scared me. I thought oh, I got a bad valve! Four participants worried about having had blood transfusions. 117 I hope my blood i s not tainted. I t o l d them I wanted a guarantee! It's just that that's the thing i n the news a l l the time. You are scared a l i t t l e b i t to get the blood because you are reading so many things, tainted blood, a l l kinds of sickness... When Dr. comes to the hospital I say to him, you sure I got the right blood? The woman with the newborn voiced worry pertaining to her baby getting used to "kind of l i k e a new heartbeat". Her c h i l d was being cared for by her mother because she could not l i f t her; consequently she had not yet been permanently reunited. Several participants were scared to climb the s t a i r s i n their own homes, despite having done so i n hospital p r i o r to the i r d i s charge. I go and half way and stop then go. I just stop because I want to stop to be sure, I scared. Eleven participants stated they were worried about and f e l t the need to protect their sternal incisions. Like when my l i t t l e grandson comes running and wants to give me a hug. I am so scared about him coming and touching me i n the chest. It's t e r r i b l e , I don't know how long that w i l l l a s t . . . Feeling down, or depression was experienced by 12 of the participants. However, only three were not t o l d this would happen. The other 15 stated that this information was provided in the video, books they had read, or by their nurse or physician. They were to l d i t was normal and that i t would pass. Three men and four women admitted to crying uncontrollably and for no apparent reason during their "down 118. d a y s " . M a n , I c r i e d l i k e a l i t t l e b a b y s i n c e I h a v e b e e n o u t o f h o s p i t a l ! I t s t o p p e d n o w b u t f o r t h e f i r s t f e w w e e k s I c o u l d n ' t s t o p t h e t e a r d u c t s f r o m g o i n g . E i g h t p a r t i c i p a n t s e x p r e s s e d g r a t i t u d e a n d r e l i e f t h a t t h e p r o c e s s w a s u n d e r t a k e n a n d n o w o v e r w i t h . T h e t w o y o u n g e s t p a r t i c i p a n t s m o s t c l e a r l y e x p r e s s e d t h i s . I t ' s b e e n h a r d , b u t h e y , I g e t t o w a t c h my k i d s g r o w u p , I w o u l d n ' t g e t t o o t h e r w i s e , a n d f o r t h a t I am t h a n k f u l . I ' m 2 9 , a n d I j u s t w a n t e d t h i s o v e r w i t h , n o w i t i s . F r o m t h e s e d e s c r i p t i o n s , i t i s e v i d e n t t h a t d e s p i t e h a v i n g b e e n t h r o u g h t h e s u r g e r y s u c c e s s f u l l y , t h e p a r t i c i p a n t s c o n t i n u e d t o h a v e o n g o i n g f e a r s , a n x i e t y , w o r r y . a n d d e p r e s s i o n . T h r o u g h o u t t h e i n t e r v i e w s , a l l 1 8 p a r t i c i p a n t s e x p r e s s e d t h e i d e a a n d h o p e t h a t t h e f u t u r e w o u l d b e b r i g h t e r a n d b e t t e r t h a n t h e p a s t . T h e y b e l i e v e d t h e y , w o u l d e v e n t u a l l y h a v e m o r e e n e r g y a n d p l a n n e d f u t u r e e v e n t s s u c h a s t r a v e l , m o v i n g t o n e w e r o r s m a l l e r h o m e s , d i n n e r p a r t i e s , o r n e w e m p l o y m e n t , o p p o r t u n i t i e s . T h r e e t o f o u r m o n t h s d o w n t h e r o a d I w i l l f e e l l i k e I w a s 16 a g a i n h e a l t h w i s e . I f o c u s o n . t h a t . I ' m h o p i n g f o r t h e e n e r g y o f a y o u n g p e r s o n . S o m a n y p e o p l e h a v e s a i d t h i s w i l l h a p p e n . M i x e d i n ' w i t h t h e " d o w n d a y s " , i t w o u l d a p p e a r t h a t , t h e r e c o v e r y p r o c e s s b r o u g h t w i t h i t a h o p e f o r i m p r o v e d q u a l i t y o f l i f e i n t h e f u t u r e . T h e p a r t i c i p a n t s w e r e e a g e r t o o f f e r u n s o l i c i t e d o p i n i o n s 1 1 9 a b o u t t h e h o s p i t a l p h y s i c i a n s a n d s t a f f . E l e v e n p a r t i c i p a n t s s t a t e d t h e i r s u r g e o n s w e r e s a t i s f a c t o r y . H e i s g o d l i k e ! I t w a s j u s t s u c h a b l e s s i n g t o h a v e t h e s u r g e r y d o n e w i t h D r . X ' s h e a l i n g h a n d s ! T h r e e p a r t i c i p a n t s w e r e a n g r y w i t h t h e i r f a m i l y p h y s i c i a n s o r c a r d i o l o g i s t s f o r h a v i n g m i s d i a g n o s e d t h e m , a n d o n e s i m p l y d i s l i k e d t h e s u r g e o n . D e s c r i p t i o n s o f t h e n u r s e s w e r e m o r e v a r i e d . T e n p a r t i c i p a n t s p r a i s e d t h e n u r s e s a n d t h e c a r e r e c e i v e d : I t h i n k i t ' s t e n d e r l o v i n g c a r e a r o u n d t h e r e , y e s . . . I m u s t h o n e s t l y s a y I t h i n k we a r e f o r t u n a t e t o h a v e t h e g r o u p o f n u r s e s w e h a v e t h e r e . T h e y m u s t b e c h o s e n t o g o t h e r e , t h e y a r e s p e c i a l y o u k n o w ! T h r e e p a r t i c i p a n t s n o t e d v a r i a t i o n s i n t h e s e r v i c e s r e c e i v e d , d e p e n d i n g o n t h e n u r s e f o r t h e s h i f t a n d t h a t n u r s e ' s c a s e l o a d . F o u r b e l i e v e d n u r s e s w o r k e d t o o h a r d . O n l y t w o p a r t i c i p a n t s d i d n o t l i k e t h e n u r s i n g p e r s o n n e l . T h e y s a i d : T h e y n e v e r c o m e a n d s e e y o u . S o m e b o d y b r i n g s y o u f o o d a n d l e a v e s i t t h e r e . I f my w i f e w a s n ' t t h e r e I w o u l d n ' t e a t a n y t h i n g a t a l l . N o b o d y c h e c k e d o n h o w m u c h I a t e , d r a n k o r w h a t e v e r . Two p o s i t i v e c o m m e n t s w e r e r e c e i v e d i n p r a i s e o f t h e n u r s i n g s e r v i c e s p r o v i d e d i n B l o c k A ( s t e p - d o w n u n i t ) a n d t h e C a r d i a c S u r g e r y I n t e n s i v e C a r e U n i t ( C S I C U ) E s p e c i a l l y d o w n i n t h e s l a u g h t e r h o u s e , t h e C S I C U , y e a h , t h e y w e r e f a n t a s t i c d o w n t h e r e . D i s c u s s i o n 120 Crohin (1990) noted that patients who displayed signs of emotional i n s t a b i l i t y at the time of diagnosis were more l i k e l y to experience complications post-operatively.. This trend was not observed; however, this conclusion i s based solely on what the participants t o l d the researcher. The fact that only three participants experienced delirium post-operatively was surprising. This i s lower than the s t a t i s t i c s reported i n other research, such as that undertaken by Kloosterman (1991), who reported a 24% to 72% rate of post-operative delirium. The reasons for this are unknown. The three who did experience delirium requested that i n the future, information about delirium be provided to participants and their families pre-operatively. This has been suggested i n the li t e r a t u r e (Kloosterman, 1991) but appears to have been poorly implemented, to date. While Cronin (1990), MacKenzie (1993), and Raleigh & Odtohan (1987), have reported anxiety to be a common psychological response to the surgery, the various fears s p e c i f i c a l l y r e l a t i n g to valve f a i l u r e have been under-reported in the l i t e r a t u r e (Jenkins et a l . 1983). As Finkelmeier et a l . (1989) noted, once the valve i s in, the potential for valve related morbidity i s present for l i f e . Consequently, the participants concerns were not unfounded. Some anxiety w i l l undoubtedly remain, even with the provision of information and education related to the valve and i t s l i f e expectancy. 121 Fears related to the blood transfusions might again best be explained by the news media. An inquiry into the Canadian "tainted~blood scandal" of the early 1980's was being conducted and publicizedTa't^the time of the research. This could explain why this has not been a previously reported concern for cardiac surgery patients. A discussion pertaining^^d^"cne"ihx<sfc--' blood transfusions might be used during the surgery should be undertaken as part of the routine pre-operative instruction. Patients have a right to refuse blood transfusions and this needs to be noted as part of the informed consent process. Emotions such as crying, depression and r e l i e f were reported i n this study and are common to cardiac patients i n general (Jenkins, Stanton, Savageau, Ockene, Denlinger, & Kleine, 1983; Rankin, 1990). The participants d i d not request additional information pertaining to emotional adjustments, stating they had been well informed through th e i r nurses and the video. This suggests that patients do retain some of the information provided p r i o r to discharge. Along with wanting to resume a normal l i f e s t y l e , the participants had hope for the future. Some were s t i l l attempting to discover what impact the surgical event would have on the i r l i v e s . Consequently, the rate of psychological recovery varied. It has been well documented i n the l i t e r a t u r e that a sense of euphoria and elation are common post-operatively. T h e r e f o r e , ' i t w a s h o t s u r p r i s i n g t o h a v e p a t i e n t s p r a i s e t h e h o s p i t a l s t a f f . ' . N o a t t e m p t w a s ' m a d e t o s p e c i f i c a l l y m e a s u r e o r c o m p a r e " the p a r t i c i p a n t s f u n c t i o n a l s t a t u s w i t h p s y c h o l o g i c a l o u t c o m e s d u r i n g t h e i n t e r v i e w s . W h i l e .some o f t h e p a r t i c i p a n t s d e s c r i b e d t h e m s e l v e s a s p h y s i c a l l y a n d p s y c h o l o g i c a l l y h e a l t h y , o t h e r s d i d n o t . A f e w p a r t i c i p a n t s e x p r e s s e d t h e . t h o u g h t t h a t t h e d a y s w h e n t h e y w e r e m o r e e n e r g e t i c , t h e y w e r e a l s o i n a b e t t e r m o o d . H o w e v e r , t h e y o u n g e s t a n d f i t t e s t p a r t i c i p a n t / a s e l f - p r o c l a i m e d " b o d y b u i l d e r " , d e s c r i b e d h i m s e l f a s a . " p s y c h o l o g i c a l m e s s " s i n c e t h e s u r g e r y , d e s p i t e h a v i n g m o r e -e n e r g y . W h i l e n o t s p e c i f i c a l l y s t u d i e d , t h e f i e l d n o t e s , o b s e r v a t i o n s a n d i n t e r v i e w s ' f r o m t h i s s t u d y s u p p o r t G r e e n l a n d ( 1 9 8 8 ) a n d B e n g t s s o n ( 1 9 8 3 ) a s s e r t i o n t h a t t h e r e i s n o p r o v e n c o r r e l a t i o n b e t w e e n e x e r c i s e , f u n c t i o n a l s t a t u s a n d p s y c h o l o g i c a l o u t c o m e s f o r t h e s e p a r t i c i p a n t s . •' S u p p o r t D u e t o f a t i g u e , a n d a l a c k o f e n e r g y a n d m o b i l i t y , t h e -p a r t i c i p a n t s r e q u i r e d e x t r a s u p p o r t t o h e l p m a n a g e t h e i r ; r o u t i n e a c t i v i t i e s . T h e p a r t i c i p a n t s , u n i v e r s a l l y s t a t e d t h a t t h i s , h a d b e e n m a d e c l e a r t o t h e m b y t h e i r s u r g e o n s p r i o r t o t h e e v e n t . .'., . . • • ; . ' • ' . • " ' "-' • I w a s t o l d I - w o u l d h a v e t o h a v e s o m e o n e t h e r e t o t a k e c a r e o f m e , m o r e o r l e s s b a b y s i t me i s w h a t i t b o i l s d o w n t d . A n d I w a s n ' t t o o t h r i l l e d a b o u t t h a t , a s I am a s t r o n g w i l l e d , s t u b b o r n , I r i s h w o m a n . . 1 2 3 M o s t p a r t i c i p a n t s s t a t e d t h a t a d a p t i n g t o t h i s w a s d i f f i c u l t a n d t h a t a t s o m e p o i n t d u r i n g t h e i r r e c o v e r y , t h e y p e r c e i v e d a l o s s o f i n d e p e n d e n c e . T h i s w a s m o s t e m p h a s i z e d b y p a r t i c i p a n t s w h o h a d n o p a r t n e r s . T h e y c o m m e n t e d : I t i s r e a l l y h a r d f o r s o m e o n e i n d e p e n d e n t t o b e c o m e t o t a l l y d e p e n d e n t . T h a t i s w h a t I f e l t , t o t a l l y d e p e n d e n t . W h e n y o u 1 v e b e e n i n d e p e n d e n t a l o n g t i m e a n d t h a t i n d e p e n d e n c e i s t a k e n a w a y f r o m y o u , i t ' s v e r y h a r d t o a d j u s t . E i g h t p a r t i c i p a n t s s t a t e d t h a t t h e y h a d a l s o f e l t " o v e r -p r o t e c t e d " o r " o v e r - s u p p o r t e d " b y t h e i r p a r t n e r s o r f a m i l y m e m b e r s d u r i n g t h e i r r e c o v e r y . H e w a s j u s t s o d a m n e d h e l p f u l t h a t i t w a s i r r i t a t i n g . . . h e i s r i g h t t h e r e , J o h n n y o n t h e s p o t a n d i t ' s l i k e g o a w a y , l e t me b r e a t h e ! I f e l t l i k e a n i n v a l i d b e c a u s e e v e r y b o d y w a s d o i n g e v e r y t h i n g f o r m e , y o u k n o w i t ' s n o t l i k e I d o n ' t h a v e a r m s a n d l e g s . I f o u n d i t a r e a l p a i n i n t h e a s s , b u t I k n o w i t ' s b e c a u s e h e l o v e s m e . D e s p i t e t h i s , t h e p a r t i c i p a n t s m a r r i e d o r s i n g l e , u n i v e r s a l l y a g r e e d o n t h e n e e d f o r s u p p o r t f r o m f a m i l y o r f r i e n d s d u r i n g t h e r e c o v e r y p r o c e s s . C o m m e n t s i n c l u d e d : I am n o t s u r e w h a t I w o u l d h a v e d o n e i f I d i d n ' t h a v e s o m e o n e s t a y i n g w i t h m e . . . Y o u c a n ' t l e t a p e r s o n g o h o m e a n d b e a l o n e . O n l y o n e w o m a n w a s a l o n e d u r i n g t h e r e c o v e r y p r o c e s s . S h e p u r p o r t s t o h a v e t o l d h e r c a r d i o l o g i s t t h a t h e r r e c o v e r y w a s h i n d e r e d b e c a u s e s h e h a d b e e n l i v i n g a l o n e a f t e r d i s c h a r g e . I s a i d t o my d o c t o r , p e o p l e w h o l i v e a l o n e o f t e n d o n ' t r e c o v e r a s f a s t b e c a u s e o f a l a c k o f s u p p o r t . T h e f i v e u n m a r r i e d p a r t i c i p a n t s a r r a n g e d t o h a v e f r i e n d s s t a y " 1 2 4 w i t h t h e m d u r i n g r e c o v e r y . . T h e . w o m a n w h o w a s a l o n e h a d a r r a n g e d f o r s o m e o n e t o s t a y , b u t t h e p e r s o n w a s u n a b l e t o a t t h e l a s t m i n u t e . T h o s e w h o w e r e m a r r i e d a r r a n g e d f o r b r o t h e r s , s i s t e r s , s i b l i n g s o r f r i e n d s t o a s s i s t w h e r e a n d w h e n n e e d e d . E i g h t p a r t i c i p a n t s n o t e d t h e i r f r i e n d s h a d b e e n i n s t r u m e n t a l d u r i n g t h e r e c o v e r y p r o c e s s . M y f r i e n d i s a c a r d i o l o g i s t i n M o n t r e a l a n d h e h e l p e d . H e ' w a s i n c o n s t a n t c o n t a c t . H e t o l d u s w h a t q u e s t i o n s t o a s k , w h e n a n d h o w t o a s k s o we d i d n ' t a l i e n a t e a n y o n e . H e w a s a v e r y i m p o r t a n t p e r s o n f o r u s . F o u r t e e n p a r t i c i p a n t s e x p r e s s e d t h e n e e d f o r r e a s s u r a n c e a n d v a l i d a t i o n f r o m t h e i r s u p p o r t p e r s o n s a b o u t t h e i r r e c o v e r y . T h i s w a s . m o s t o f t e n s o u g h t f r o m f a m i l y a n d f r i e n d s , a n d o c c a s i o n a l l y t h e i r p h y s i c i a n s . W e l l y o u l o o k f o r w a r d t o t h e f a m i l y v i s i t i n g e v e r y d a y a n d i f t h e y c a n ' t g e t t h e r e f o r s o m e r e a s o n i t i s a • d i s a p p o i n t m e n t , e v e n i f y o u a r e f e e l i n g w e l l . B e c a u s e y o u l i k e t o b e r e a s s u r e d t h a t e v e r y t h i n g i s g o i n g w e l l . I s a i d " A r e y o u q u i t e p l e a s e d w i t h me D r . X ? " a n d h e r e a s s u r e d me h e w a s . E l e v e n p a r t i c i p a n t s c o m p a r e d t h e i r r e c o v e r y p r o c e s s t o t h a t o f o t h e r s t h e y h a d k n o w n , o r m e t w h i l e i n h o s p i t a l . T h i s p r o c e s s p r o v i d e d a d d i t i o n a l r e a s s u r a n c e t h a t a l l w a s w e l l . I k e p t i n t o u c h w i t h t w o w o m e n f r o m W h i t e R o c k w h o h a d t h e s a m e t h i n g a s m e . T h a t w a s g o o d . I t d i d n ' t m a k e y o u f e e l l i k e y o u w e r e a n o d d p e r s o n o u t , t h a t y o u s h o u l d b e g e t t i n g o v e r t h i s q u i c k e r . S t r a n g e l y e n o u g h , I t h i n k I w a s i n b e t t e r s h a p e t h a n m o s t o f t h e o t h e r s o n t h e w a r d . . . I n e v i t a b l y y o u c o m p a r e y o u r s e l f t o t h e o t h e r s o n t h e w a r d . I f e l t s m u g a n d s u p e r i o r b e c a u s e .1 w a s - i n g o o d s h a p e i n c o m p a r i s o n . O n l y o n e p a r t i c i p a n t , t h e w o m a n w h o w a s a l o n e d u r i n g r e c o v e r y , 1 2 5 s t a t e d t h a t c o m p a r i n g h e r p r o g r e s s h a d a n e g a t i v e i m p a c t . I p h o n e d [ t h e P a c i f i c O p e n H e a r t A s s o c i a t i o n ] t o a s k i f w h a t w a s h a p p e n i n g t o me w a s n o r m a l a n d s h e c o m p a r e d me t o h e r s e l f . S h e h a d b y p a s s . S h e w a s o f f h e r T y l e n o l #3 i n t h r e e o r f o u r d a y s . S h e d o n e a l l t h i s e x e r c i s e . I t k i n d o f m a d e me f e e l l i k e g e e , I a l m o s t w i s h I h a d n ' t c a l l e d . A v a r i e t y o f s u p p o r t s w e r e n e e d e d b y t h e p a r t i c i p a n t s . A d d i t i o n a l a s s i s t a n c e w a s s o u g h t b y m o s t o f t h e p a r t i c i p a n t s f o r b a t h i n g , g r o c e r y s h o p p i n g , c o o k i n g , o b t a i n i n g m e d i c a t i o n s , d r e s s i n g , d o i n g l a u n d r y , m o b i l i z i n g a n d g e t t i n g t o a n d f r o m a p p o i n t m e n t s . E i g h t p a r t i c i p a n t s u t i l i z e d v a r i o u s c o m m u n i t y s e r v i c e s , i n c l u d i n g m e a l s o n w h e e l s , h o m e - c a r e , l a b o n w h e e l s , a n d t h e P u b l i c H e a l t h N u r s e s . I f e e l I h a v e h a d v e r y g o o d s u p p o r t f r o m t h e M e t r o p o l i t a n H e a l t h U n i t h e r e . I h a v e a h o m e - m a k e r n o w , a n d t h e n u r s e s c o m e i n , a g i r l c o m e s t o t a k e m y b l o o d t o o . . . . I f i n d t h i s h a s b e e n a g r e a t h e l p . T h e f e m a l e p a r t i c i p a n t w h o w a s a l o n e c o m m e n t e d t h a t d e s p i t e b e i n g i n h o s p i t a l f o r t e n d a y s , s h e d i d n o t m e e t w i t h t h e s o c i a l w o r k e r t o a r r a n g e t h e r e q u i s i t e s e r v i c e s u n t i l t h e d a y o f d i s c h a r g e . B e c a u s e t h e d i s c h a r g e w a s h a s t i l y a r r a n g e d , s h e f e l t s h e h a d r e c e i v e d l e s s t h a n o p t i m a l s e r v i c e a n d c a r e . I t w o u l d h a v e h e l p e d i f I k n e w s o o n e r a b o u t t h e d i f f e r e n t k i n d s o f h o m e m a k i n g s e r v i c e s t h a t w e r e a r o u n d a n d w h a t t h e y d i d a n d h o w m u c h t h e y a r e a n d w h a t e v e r k i n d o f h e l p t h e r e i s , f o r a t h o m e . I ' m p a y i n g f o r t h i s a n d a l l I am g e t t i n g i s s o u p ! I t w a s e v i d e n t t h a t a l l t h e p a r t i c i p a n t s p e r c e i v e d t h e n e e d f o r g e n e r a l a s s i s t a n c e d u r i n g r e c o v e r y . T h o s e w i t h o u t p a r t n e r s o r s i g n i f i c a n t o t h e r s w e r e m o s t r e l i a n t o n t h e c o m m u n i t y s e r v i c e s a v a i l a b l e . , F a m i l y p r o v e d t o b e a n i n t e g r a l p a r t o f t h e s u p p o r t p r o c e s s . T h e p a r t i c i p a n t s w h o h a d f a m i l y m a d e i t c l e a r t h a t t h e y w e r e c o n s c i o u s o f t h e s t r a i n t h e i r s u r g e r y h a d p l a c e d o n t h e i r f a m i l y m e m b e r s . C o m m e n t s i n c l u d e d : T h e y t o l d me a o r t i c s t e n o s i s c a n h a v e . a g e n e t i c b a s i s . I h a v e a d a u g h t e r t h a t i s m a r r i e d a n d l i v e s i n F r a n c e . S h e w a s q u i t e u p s e t a t t h e p r o s p e c t o f b e i n g f a c e d w i t h t h i s a t s o m e p o i n t i n t i m e . B u t t h e r e i s s o m e g e n e t i c p r e -d i s p o s i t i o n f o r t h i s I g u e s s , s o I h a d t o t e l l h e r . Y o u w a n t t o c u d d l e a n d p l a y b u t y o u c a n ' t b e c a u s e t h e y [ y o u n g c h i l d r e n ] b o u n c e a r o u n d a n d t h a t . I h a v e a l r e a d y b e e n n a i l e d b y t h e m a c o u p l e t i m e s . . . S o . t h e y g o t u p a n d w e n t a n d c u d d l e d w i t h my b u d d y . . . t h a t s o r t o f t h i n g , i t r e a l l y i s h e a r t b r e a k i n g . T h e p e r c e i v e d s t r a i n t h a t t h e s u r g e r y p l a c e d o n t h e f a m i l y r e l a t i o n s w a s v a l i d a t e d b y t h e w i f e o f o n e p a r t i c i p a n t w h o w a n t e d t o l i s t e n i n o n t h e i n t e r v i e w . W h e n t h e i n t e r v i e w w i t h ' h e r h u s b a n d w a s o v e r , s h e c o m m e n t e d : O n e n i g h t t h e r e w a s a f i r e d o w n t h e l a n e , a n d I w o n d e r e d \ h o w I w a s g o i n g t o e v a c u a t e h i m q u i c k l y i f I n e e d e d t o . I w o r r i e d a l o t a b o u t t h i n g s l i k e t h a t . •i A s i d e f r o m f a m i l y a n d f r i e n d s , s u p p o r t w a s a l s o a c q u i r e d i n t h e f o r m o f r e l i g i o u s a n d s p i r i t u a l a f f i l i a t i o n s . O n l y t w o p a r t i c i p a n t s s t a t e d t h e y h a d v i s i t s f r o m t h e i r m i n i s t e r s w h i l e i n h o s p i t a l , o r r e c o v e r i n g a t h o m e . F o u r p a r t i c i p a n t s s t a t e d t h a t t h e y w o u l d h a v e l i k e d t o h a v e s o m e o n e v i s i t t h e m , b u t t h e y w e r e n o t m a d e a w a r e t h a t s u c h a . s e r v i c e w a s a v a i l a b l e i n h o s p i t a l . I am i n t h e p r o c e s s o f , I ' m n o t a s p i r i t u a l g i a n t o r a n y t h i n g , b u t I am i n t h e p r o c e s s o f g o i n g a l o n g w i t h t h e s p i r i t u a l l i n e s o f l i f e a s o p p o s e d t o b e i n g a n a s s h o l e i n 127 l i f e , so a v i s i t from a minister would have been good, yeah. The remaining participants stated they had no r e l i g i o u s a f f i l i a t i o n s , and as such did not require s p e c i f i c services. I am agnostic. I went through f i v e years of the war without needing the Lord at my side, so I would be a hypocrite to c a l l on him there. However, nine stated that they were not asked about th e i r r e l i g i o u s or s p i r i t u a l needs as part of the admission procedure. While only a few participants expressed needs i n this area, i t can be surmised that r e l i g i o u s and s p i r i t u a l needs for this patient population were poorly assessed i n hospital, and were generally not responded to. Discussion The need for support, the loss of independence, the need to compare oneself to others and the feeling of being over-protected are a l l commonly reported i n the cardiac l i t e r a t u r e previously reviewed. Family and acquaintance support were ca l l e d on to provide reassurance, val i d a t i o n and a s s i s t with d a i l y a c t i v i t i e s such as grocery shopping, which i s also well documented i n the cardiac l i t e r a t u r e . The fact that single people perceived a greater need for support services, but sometimes found i t d i f f i c u l t to f i n d and access these i s s i g n i f i c a n t . One person who did not benefit from community so c i a l support admittedly recovered at a slower rate, both emotionally and physically. The study by Zyzanski et a l . (1981) 1 2 8 s u p p o r t e d a r e l a t i o n s h i p b e t w e e n p o s t - o p e r a t i v e p s y c h o s o c i a l f u n c t i o n i n g a n d p h y s i c a l s t a t u s . W h i l e m o s t o f t h e p a r t i c i p a n t s r e c e i v e d t h e n e c e s s a r y s e r v i c e s , _ . t h e f a c t t h a t o n e d i d n o t g e n e r a t e s t h e q u e s t i o n " w h y ? " O n t h i s s p e c i f i c w a r d , t h e a s s e s s m e n t f o r t h e s e s e r v i c e s i s u n d e r t a k e n b y t h e s o c i a l w o r k e r a n d s o m e t i m e s t h e n u r s e . G i v e n t h e n o t e d d e f i c i e n c i e s , t h e q u a l i t y o f t h e a s s e s s m e n t p r o c e s s w a r r a n t s r e v i e w . I t m u s t a l s o b e r e m e m b e r e d t h a t s u p p o r t s e r v i c e s i n c l u d e s p i r i t u a l o r r e l i g i o u s o r d e r s . . W h i l e t h i s i s b e l i e f r e l a t e d , i t w a s g e n e r a l l y p o o r l y a d d r e s s e d i n t h i s p a t i e n t p o p u l a t i o n . W h i l e f e w p e o p l e e x p r e s s e d a n e e d i n r e l a t i o n t o t h i s i s s u e , t h o s e w h o d i d n o t h a v e t h e i r n e e d s f u l f i l l e d i n h o s p i t a l e x p r e s s e d t h e i r d i s a p p o i n t m e n t t h a t s e r v i c e s w e r e a v a i l a b l e a n d t h e y w e r e n o t m a d e a w a r e . S e c t i o n S u m m a r y T h i s s t u d y d i d n o t c o n s t i t u t e a n e v a l u a t i o n o f t h e d i s c h a r g e t e a c h i n g p r o g r a m . A s a r e s u l t i t i s d i f f i c u l t t o c o m m e n t o n r e t e n t i o n a n d u n d e r s t a n d i n g o f m a t e r i a l p r e s e n t e d t o t h e p a r t i c i p a n t s p r i o r t o . d i s c h a r g e . W h a t i s r e l e v a n t i s t h a t t h e m a j o r i t y p e r c e i v e d p a r t s o f t h e d i s c h a r g e t e a c h i n g t o b e i n a d e q u a t e . H o w e v e r , t h e f a c t t h a t t h e y w e r e a b l e t o r e m e m b e r s p e c i f i c i n f o r m a t i o n r e l a t i n g t o s u c h t h i n g s a s I n c i s i o n c a r e , s h o w e r s , d r i v i n g , a n d m o b i l i z i n g i n a n d o u t o f b e d , s u g g e s t s t h a t f o r m a l i z e d l e a r n i n g r e l e v a n t t o t h e i r n e e d s d i d t a k e p l a c e t h r o u g h t h e p l a n n e d e d u c a t i o n a l p r o g r a m . 1 2 9 S e c t i o n F o u r : A d d r e s s i n g L e a r n i n g N e e d s P o s t - O p e r a t i v e E d u c a t i o n F o u r t e e n p a r t i c i p a n t s a g r e e d f u r t h e r p o s t - o p e r a t i v e o r p o s t - h o s p i t a l p a t i e n t e d u c a t i o n w o u l d h a v e b e e n h e l p f u l . O n e p e r s o n c o m m e n t e d " Y e s , b e c a u s e y o u c a n ' t a s k a v i d e o t a p e a q u e s t i o n ! " T e n p a r t i c i p a n t s o f f e r e d u n s o l i c i t e d c o m m e n t s i n d i c a t i n g t h a t t h e y w e r e " f u z z y " , " d i d n ' t r e m e m b e r " , o r " c o u l d n ' t k e e p t h e i n f o r m a t i o n i n " a t t h e t i m e o f h o s p i t a l d i s c h a r g e . W h e n y o u ' r e j u s t a b o u t t o b e d i s c h a r g e d y o u ' r e n o t a l l c o h e r e n t e i t h e r . . . S o m e o f t h e s t u f f f r o m w h e n I l e f t h o s p i t a l i s a l i t t l e b i t f u z z y y o u k n o w . O n e w o m a n c o m m e n t e d t h a t t h e d i s c h a r g e i n s t r u c t i o n s p r o v i d e d w e r e g i v e n t o t h e w r o n g p e r s o n ! O n d i s c h a r g e , t h e n u r s e r a m b l e d a b u n c h o f t h i n g s t o my s i s t e r i n - l a w a n d I t h o u g h t s h e s h o u l d n ' t h a v e d o n e t h a t . M y s i s t e r i n - l a w h a s o n l y b e e n h e r e t h e d a y s h e b r o u g h t me h o m e . S h e s h o u l d h a v e t o l d me t h e s t u f f , s o I w o u l d h a v e k n o w n ! T w o p a r t i c i p a n t s c o m m e n t e d t h a t w h i l e t h e y d i d r e c e i v e i n f o r m a t i o n p e r t a i n i n g t o w h a t n o t t o d o , t h e y d i d n o t r e c e i v e i n f o r m a t i o n p e r t a i n i n g t o w h a t t h e y w e r e a l l o w e d t o d o , t o a s s i s t w i t h t h e i r r e c o v e r y . T h e y d i d n ' t e x p l a i n a l o t o f t h e t h i n g s I w a s a l l o w e d t o d o t o h e l p my r e c o v e r y . W h e n I l e f t t h e r e I k i n d o f w i s h I h a d s o m e i d e a o f w h a t I c o u l d d o , n o t o f w h a t I c o u l d n ' t d o . O f t h e f o u r p a r t i c i p a n t s w h o p e r c e i v e d t h e d i s c h a r g e p r o c e s s t o b e a d e q u a t e , o n e w a s t h e p r e g n a n t w o m a n w h o h a d s p e n t t h r e e • 1 3 0 m o n t h s i n h o s p i t a l a n d h a d r e c e i v e d a n a b u n d a n c e o f " o n e o n o n e " e d u c a t i o n . A n o t h e r w a s t h e a c c o u n t a n t w h o c o n t i n u a l l y d e n i e d h i s i l l n e s s ( c a l l i n g i t a s i m p l e m e c h a n i c a l d e f e c t ) , a n d h a d n o d e s i r e t o c h a n g e h i s l i f e s t y l e . T h e o t h e r t w o , d e s p i t e s a y i n g t h e y d i d n o t n e e d a d d i t i o n a l i n f o r m a t i o n w e r e t h e t w o w h o d i d n o t k n o w w h a t . t y p e o f v a l v e t h e y h a d i m p l a n t e d a n d w e r e g e n e r a l l y i l l - i n f o r m e d w h e n a s k e d q u e s t i o n s p e r t a i n i n g t o t h e i r i l l n e s s . A l l 1 8 p a r t i c i p a n t s a s k e d q u e s t i o n s o f t h e r e s e a r c h e r p e r t a i n i n g t o i n f o r m a t i o n t h e y w o u l d h a v e l i k e d t o h a v e r e c e i v e d d u r i n g t h e i r r e c o v e r y p r o c e s s . T h i s i n i t s e l f i n d i c a t e d t h a t s o m e f o r m o f f o l l o w u p w a s w a r r a n t e d w i t h a l l 1 8 p a r t i c i p a n t s . ' .-E d u c a t i o n a l M a t e r i a l s D e s p i t e n o t b e i n g a s k e d t o s p e c i f i c a l l y e v a l u a t e t h e e d u c a t i o n a l m a t e r i a l s p r o v i d e d , m o s t o f t h e p a r t i c i p a n t s m a d e c o m m e n t s p e r t a i n i n g t o t h e u t i l i t y o f t h e d i s c h a r g e b o o k l e t s , t h e d i s c h a r g e v i d e o , a n d t h e o t h e r f o r m s o f l i t e r a t u r e . T h e d i s c h a r g e b o o k l e t w a s p e r c e i v e d a s " g o o d " , b y a l l b u t o n e o f t h e p a r t i c i p a n t s . T h i s w o m a n c o u l d n o t r e a d h e r s u r g e o n ' s w r i t i n g , w h i c h r e n d e r e d t h e i n f o r m a t i o n p r o v i d e d " u s e l e s s " . D e s p i t e u n i v e r s a l a g r e e m e n t t h a t t h e b o o k s w e r e i n f o r m a t i v e , s e v e r a l c o n c e r n s w e r e r a i s e d a b o u t t h e i r u s e . Two p e o p l e ( o n e m a n a n d o n e woman) c o m m e n t e d t h a t t h e y w e r e n o t a b l e t o r e a d . H a d t h e i r s p o u s e s n o t b e e n a b l e t o , t h e b o o k l e t s w o u l d h a v e b e e n o f n o v a l u e t o . t h e m . B o t h p a r t i c i p a n t s v o l u n t e e r e d t h i s i n f o r m a t i o n , b e c a u s e t h e y b e l i e v e d t h a t t h o s e w h o d o n o t r e a d a r e e m b a r r a s s e d t o a d m i t t o i t . C o n s e q u e n t l y t h e a b i l i t y t o r e a d E n g l i s h n e e d s t o b e a s s e s s e d i n h o s p i t a l p r i o r t o p r o v i d i n g p a t i e n t s w i t h t h e d i s c h a r g e b o o k l e t . T w o p a r t i c i p a n t s d i s c u s s e d b l u r r e d v i s i o n f o r w e e k s a f t e r t h e s u r g e r y a n d b e l i e v e d t h a t t h e y w e r e n o t a b l e t o r e a d t h e b o o k l e t s p r o p e r l y . T w o p e o p l e c o m m e n t e d . t h a t t h e b o o k s w e r e f a i r l y b a s i c a n d c o u l d h a v e i n c l u d e d m o r e i n f o r m a t i o n , w h i l e t w o o f t h e A s i a n p a r t i c i p a n t s c o m m e n t e d t h a t t h e r e a d i n g l e v e l w a s d i f f i c u l t f o r t h e m . T h e o t h e r s d i d n o t c o m m e n t o n t h i s s p e c i f i c a l l y . F r o m t h i s i t c a n b e s u r m i s e d t h a t t h e r e a d i n g l e v e l w a s a d e q u a t e f o r t h o s e w h o r e a d E n g l i s h , b u t t h a t i t w a s d i f f i c u l t f o r t h o s e w h o s t r u g g l e w i t h w r i t t e n E n g l i s h . O n e w o m a n t o o k i s s u e w i t h t h e b o o k " p r e s c r i b i n g " d a t e s f o r . t h e r e s u m p t i o n o f v a r i o u s a c t i v i t i e s . S i x w e e k s y o u s h o u l d d o t h i s , e i g h t w e e k s y o u s h o u l d d o t h a t . B u t t h e n , I k n o w e v e r y o n e i s d i f f e r e n t , b u t i t ' s i n b l a c k a n d w h i t e t h e r e i n t h e . b o o k , w h a t i f y o u ' r e n o t u p . . . t o i t t h e n ? : .' • • • • •-. S e v e r a l p a r t i c i p a n t s c o m m e n t e d t h a t t h e y r e - r e a d t h e d i s c h a r g e b o o k l e t s o r t h e Coumadin b o o k l e t s p e r i o d i c a l l y . . T h e y f o u n d t h i s v e r y u s e f u l . T h e y a l s o g a v e me o n e o n Coumadin t h a t I r e - r e a d e v e r y s o o f t e n t o m a k e s u r e I u n d e r s t a n d w h a t i s g o i n g o n . F o u r p a r t i c i p a n t s w e r e g i v e n a c c e s s t o , o r h a d p u r c h a s e d b o o k s f r o m , t h e P r i t c h e t t a n d H u l l s e r i e s o f e d u c a t i o n a l , 132 c a r t o o n b a s e d b o o k s , p e r t a i n i n g t o r e c o v e r y f r o m c a r d i a c i l l n e s s e s . T h e y a l l b e l i e v e d t h e s e b o o k s t o b e o f g r e a t b e n e f i t t o t h e m a n d r e c o m m e n d e d t h a t t h e y b e a v a i l a b l e t o t h o s e u n d e r g o i n g o p e n h e a r t s u r g e r y . T h a t b o o k i s v e r y g o o d . T h e b o o k d o e s n ' t e x p l a i n a l l t h e u n n e c e s s a r y s t u f f f o r p a t i e n t s t o k n o w . B e c a u s e we a r e n o t d o c t o r s , t h e r e f o r e w e d o n ' t u n d e r s t a n d . . . I t g i v e s u s n a m e s , a n d w h a t t o d o . . . I t i s v e r y e d u c a t i o n a l , a s i t t e l l s y o u w h a t y o u c a n d o a f t e r s o m a n y w e e k s . I t i s a g o o d g u i d e l i n e f o r r e c o v e r y , a s i t t e l l s me w h a t I s h o u l d . d o ! T h e h o s p i t a l d o e s o w n a s e r i e s - o f t h e s e b o o k s , b u t t h e y a r e n o t a v a i l a b l e t o t a k e h o m e . T h e y a r e f o r s a l e i n t h e h o s p i t a l ' s g i f t s h o p f o r u n d e r $.7 C D N . I t w o u l d s e e m o n l y a f e w . o f t h e p a r t i c i p a n t s w e r e m a d e a w a r e o f t h i s u s e f u l r e s o u r c e . T h e d i s c h a r g e v i d e o w a s p r a i s e d a n d d e s c r i b e d a s i n f o r m a t i v e a n d u s e f u l b y 16 p a r t i c i p a n t s . O n e p e r s o n s t a t e d t h a t " I t s o r t o f i m p r e s s e s i t o n y o u m o r e t h a n j u s t r e a d i n g t h i n g s " . A n o t h e r p e r s o n b e l i e v e d i t ' w o u l d h a v e b e e n h e l p f u l i f t h e v i d e o w a s a v a i l a b l e o n a l o a n o r p u r c h a s e b a s i s . H e s t a t e d t h a t i t w a s e a s y t o f o r g e t w h a t t h e v i d e o s a i d , a n d t h a t i f h e c o u l d h a v e t a k e n i t h o m e a n d r e p e a t e d l y w a t c h i t , h e w o u l d h a v e l e a r n e d m o r e a b o u t h i s r e c o v e r y . H e a d d e d t h a t h e w a s w i l l i n g t o b u y t h e v i d e o f o r a n o m i n a l f e e . A s i n g l e w o m a n c o m m e n t e d t h a t t h e v i d e o w a s p r o d u c e d w i t h m a r r i e d c o u p l e s i n m i n d . S h e s t a t e d t h a t t h i s w a s n o l o n g e r t h e n o r m i n t h e L o w e r M a i n l a n d a s t h e g r e a t m a j o r i t y o f o l d e r . p e o p l e l i v e a l o n e . S h e b e l i e v e d a v i d e o o h h o w t o m a n a g e o n y o u r o w n , o r w i t h l i m i t e d s u p p o r t w o u l d b e h e l p f u l , a n d t h a t i t s h o u l d c o n t a i n i n f o r m a t i o n r e l a t i n g t o t h e c o m m u n i t y s e r v i c e s a v a i l a b l e t h r o u g h o u t t h e L o w e r M a i n l a n d a n d h o w t o a c c e s s t h e s e . D i s c u s s i o n T h o s e p a r t i c i p a n t s w h o w e r e l i t e r a t e i n E n g l i s h r e p o r t e d r e a d i n g t h e d i s c h a r g e b o o k l e t s a n d t h i s s e e m e d t o b e t h e i r p r i n c i p a l ( a n d o f t e n o n l y ) s o u r c e o f p o s t - o p e r a t i v e e d u c a t i o n a l m a t e r i a l . T h i s r e s u l t i s t r e m e n d o u s l y e n c o u r a g i n g f o r t h o s e w h o s p e n d t h e t i m e a n d e f f o r t i n c r e a t i n g s u c h e d u c a t i o n a l m a t e r i a l . H o w e v e r , n u r s e s m u s t r e m e m b e r t h a t p r o v i d i n g t h e p a t i e n t w i t h a b o o k d o e s n o t r e l i e v e t h e m o f t h e i r d u t y t o t a i l o r p a t i e n t e d u c a t i o n t o . t h e i n d i v i d u a l n e e d s e x p r e s s e d b y t h e p a t i e n t . N u r s e s m u s t m a k e p a t i e n t s a w a r e o f t h e l e a r n i n g r e s o u r c e s a v a i l a b l e o n t h e w a r d , s u c h a s t h e " P r i t c h e t t a n d H u l l " s e r i e s o f b o o k s ( b y G a s s e r t & B u r r o w s , 1 9 9 3 ) , t h e n u t r i t i o n c l a s s e s , a n d t h e v i d e o . T h e v i d e o w a s p r a i s e d b y a l l t h e p a r t i c i p a n t s . S o m e o f t h e i n f o r m a t i o n i n t h e v i d e o w a s n o t r e m e m b e r e d a t t h e t i m e o f t h e i n t e r v i e w s . A s a r e s u l t , p a t i e n t s w h o r e q u i r e i t s h o u l d b e s e n t h o m e w i t h a c o p y o f t h e v i d e o , o r a n a u d i o - t a p e d v e r s i o n o f t h e i n f o r m a t i o n p r o v i d e d . T h e y c o u l d t h e n w a t c h t h e v i d e o o r l i s t e n t o t h e t a p e a t a l a t e r d a t e w h e n t h e y a r e l e s s " f u z z y " a n d m o t i v a t e d t o l e a r n . T h i s m a y a l s o p r o v e b e n e f i c i a l 1 3 4 t o f a m i l y m e m b e r s . ' T h e c o s t o f s u c h a n e x e r c i s e c o u l d b e p a s s e d o n t o t h e c o n s u m e r , o r i t c o u l d b e m a d e p o s s i b l e w i t h t h e a s s i s t a n c e o f t h e P a c i f i c O p e n H e a r t A s s o c i a t i o n . M o r e i m p o r t a n t l y , i t m u s t b e r e c o g n i z e d t h a t t h e v i d e o , w h i l e a r e a s o n a b l y e f f e c t i v e e d u c a t i o n a l t o o l , w a s n o t a b l e t o m e e t a l i . t h e e d u c a t i o n a l n e e d s , a n d i s t h e r e f o r e o n l y o n e o f m a n y m e d i u m s r e q u i r e d f o r c o m p r e h e n s i v e p a t i e n t e d u c a t i b n . T h i s l e n d s f u r t h e r c r e d e n c e t o t h e h e e d f o r a l t e r n a t i v e f o r m s o f p o s t - o p e r a t i v e e d u c a t i o n a n d f o l l o w u p o n c e d i s c h a r g e d f r o m h o s p i t a l . E n c o u n t e r i n g L e a r n i n g N e e d s T h e s t o r i e s t o l d p r o v i d e d a c l e a r i n d i c a t i o n a s t o w h e n t h e l e a r n i n g n e e d s a r o s e . P a r t i c i p a n t s d i s c u s s e d m a n y o f t h e i r d i f f i c u l t i e s ' i n h o s p i t a l , a n d h o w i t w a s h a r d t o a d j u s t i n t h e e a r l y d a y s a n d w e e k s a t h o m e . T h e f i r s t t h r e e w e e k s a f t e r t h e s u r g e r y w e r e t h e ' m o s t d i f f i c u l t , b e c a u s e i t ' s a l l n e w a n d y o u h a v e t o a d j u s t . T h e . f i r s t t w o w e e k s w a s b a d , a n d t h e f i r s t w e e k i n h o s p i t a l w a s h a r d t o o . I t w a s e v i d e n t t h a t a l l 1 8 p a r t i c i p a n t s f o u n d t h e w e e k / i n h o s p i t a l a n d . t h e f i r s t t w o t o t h r e e w e e k s a f t e r d i s c h a r g e t o b e w h e n t h e y e n c o u n t e r e d m o s t o f t h e i r l e a r n i n g n e e d s . T h e a n s w e r t o " w h e n " w o u l d b e a n a p p r o p r i a t e t i m e f o r a d d i t i o n a l d i s c h a r g e t e a c h i n g v a r i e d . O n l y t h r e e p a r t i c i p a n t s b e l i e v e d a d d i t i o n a l f o l l o w u p , d o n e a f t e r t h e y w e r e d i s c h a r g e d f r o m t h e h o s p i t a l w o u l d b e b e n e f i c i a l . T h e i r r a t i o n a l e w a s t h a t t h e y w e r e n o t c o h e r e n t w h e n t h e y l e f t t h e h o s p i t a l , a n d g i v e n a f e w d a y s , t h e i r r e t e n t i o n a n d u n d e r s t a n d i n g w o u l d i m p r o v e . T h e r e m a i n i n g p a r t i c i p a n t s s t a t e d t h a t i f t h e r e w e r e t o b e a d d i t i o n a l t e a c h i n g u n d e r t a k e n i t s h o u l d h a p p e n w h i l e i n h o s p i t a l . T h e y p e r c e i v e d t h a t t h e y h a d a m p l e t i m e i n h o s p i t a l , a n d t h a t t h e i n f o r m a t i o n p r o v i d e d w o u l d b e r e q u i r e d b e f o r e o n e i s d i s c h a r g e d . • W e l l , g e t t i n g i t a c o u p l e o f d a y s b e f o r e y o u ' r e d i s c h a r g e d . I h a d l o t s o f t i m e w h i l e I ' w a s i n t h e r e ; I w a s b o r e d s i l l y . T h e y b e l i e v e d t h a t p o s t - o p e r a t i v e e d u c a t i o n s h o u l d b e u n d e r t a k e n p r i o r t o t h e d a y o f d i s c h a r g e , w i t h s e v e n p a r t i c i p a n t s n o t i n g t h a t t h e y c o u l d h a v e b e e n g i v e n a d d i t i o n a l t e a c h i n g o n " m o v i n g d a y " w h e n t h e y w e r e t r a n s f e r r e d f r o m B l o c k A ( s t e p - d o w n u n i t ) t o W e s t 10A ( g e n e r a l w a r d ) . W h e n a s k e d w h y t h e y w e r e s o s p e c i f i c i n s u g g e s t i n g t h i s d a y , t h e p a r t i c i p a n t s r e p l i e d t h a t r e c e i v i n g t h e i n f o r m a t i o n s e v e r a l d a y s b e f o r e h o s p i t a l d i s c h a r g e w o u l d g i v e t h e m t i m e t o d i g e s t t h e , i n f o r m a t i o n o r r e a d ' t h r o u g h t h e p a m p h l e t s , a n d f o r m u l a t e a n y q u e s t i o n s t h e y m i g h t h a v e . T h e y c o u l d t h e n a s k t h e i r d o c t o r , p h y s i o t h e r a p i s t , n u t r i t i o n i s t o r n u r s e a b o u t o u t s t a n d i n g i s s u e s D i s c u s s i o n D e t e r m i n i n g w h e n t h e l e a r n i n g n e e d s a r o s e p r o v e d t o b e r e l a t i v e l y e a s y d e s p i t e t h e p a r t i c i p a n t s n o t p r o v i d i n g e x a c t d a t e s a s t o w h e n t h e y f i r s t n o t i c e d a l a c k o f r e l e v a n t i s s u e -s p e c i f i c m a t e r i a l o r i n f o r m a t i o n . T h e d a y s i n h o s p i t a l a n d t h e f i r s t f e w w e e k s a t h o m e w e r e t h e m o s t d i f f i c u l t t o a d a p t t o , a n d w e r e m o s t c o m m o n l y d i s c u s s e d . C o n s e q u e n t l y , t h i s i s t h e . t i m e w h e n m o s t n e e d s w e r e r e a l i z e d a n d e x p r e s s e d . T h i s h a s -b e e n n o t e d t o b e c o m m o n i n t h e c a r d i a c l i t e r a t u r e , a n d h a s b e e n i n v e s t i g a t e d s o m e w h a t b y B e c k i e , ( 1 9 8 9 ) a n d T a c k & G i l l i s s , ( 1 9 9 0 ) . T h e m a j o r i t y w e r e a b l e t o c h o o s e a s p e c i f i c t i m e a n d d a y " m o v i n g d a y " , f o r t h e d i s c h a r g e t e a c h i n g . H o w e v e r , t e n p a r t i c i p a n t s n o t e d t h a t t h e y w e r e " f u z z y " o n t h e d a y o f t h e i r d i s c h a r g e . T h e s e r e s u l t s a r e t h e r e f o r e c o n f l i c t i n g . W h a t i s i n f e r r e d i s t h a t i f p a t i e n t e d u c a t i o n i s t o b e u n d e r t a k e n w h i l e i n h o s p i t a l , " m o v i n g d a y . " i s p r o b a b l y t h e b e s t d a y t o d o i t . T h e p a r t i c i p a n t s w e r e n o t s p e c i f i c a l l y a s k e d i f t h e y w o u l d h a v e b e n e f i t e d f r o m f o l l o w - u p a t h o m e , b e c a u s e t h i s w o u l d h a v e b e e n l e a d i n g t h e d i s c u s s i o n . H o w e v e r , t h e m a n y d i f f i c u l t i e s e n c o u n t e r e d p o s t - o p e r a t i v e l y ( s u c h a s t h e a n t i c o a g u l a t i o n m a n a g e m e n t ) a n d t h e f a c t t h a t p a t i e n t s a r e n o t a w a r e o f a l l o f t h e i r p o t e n t i a l l e a r n i n g n e e d s p r i o r t o d i s c h a r g e , s u g g e s t s t h e t h a t f o l l o w - u p e d u c a t i o n c o u l d b e r e q u i r e d o n c e d i s c h a r g e f r o m h o s p i t a l . W h i l e t h i s h a s b e e n , s u g g e s t e d b y a n u m b e r o f r e s e a r c h e r s i n c l u d i n g , B e c k i e , ( 1 9 8 9 ) , S t a n t o n , J e n k i n s , ' 137 Savageau, Harken & Aucoin (1984), Tack & G i l l i s s , (1990), i t was not s p e c i f i c a l l y sought by this patient group. Education: Transferring Knowledge The participants were asked "how" they believed health care professionals could'best address their learning needs. Seven participants suggested that "one on .one" discussion with someone who was not perceived as too busy would be best. A l i t t l e b i t of actual talking and t e l l i n g "is often better than a book or something you know. It's.very reassuring. The lowest pupil teacher relationship i n the world i s one to one and that's frequently what works best.. I guess because i t i s so intensely personal. The participants recognized that this suggestion was not necessarily p r a c t i c a l , and so proposed a number of other suggestions. Six participants suggested seeing the video, and being provided with the discharge booklet at the same time. Even i f the doctor had not f i l l e d i n the booklet, being provided with them simultaneously would provide reinforcement •of the material presented i n the video. This way, they would also be thinking about, and planning for their return home. : Four participants suggested that the Pritchett and Hull books be made more available while i n hospital. Again these" would help patients by answering many of th e i r questions. The books provide common guidelines, such as most, people heal i n x number of weeks, and you should start walking x blocks each day. .' '• 138 O n e w o m a n s u g g e s t e d a n a u d i o - t a p e b e m a d e a v a i l a b l e f o r p e o p l e t o t a k e h o m e . W h i l e n o t e v e r y o n e h a s a V C R , s h e . b e l i e v e d m o s t w o u l d h a v e a c a s s e t t e p l a y e r . T h e t a p e c o u l d b e r e - p l a y e d p e r i o d i c a l l y f o r r e i n f o r c e m e n t o f t h e h o s p i t a l t e a c h i n g . S h e b e l i e v e d t h i s w o u l d b e o f a d d i t i o n a l b e n e f i t f o r t h e b l i n d a n d t h o s e w h o c o u l d n o t r e a d v e r y w e l l . T w o p a r t i c i p a n t s a s k e d f o r . a n i n f o r m a t i o n l i n e o r n u m b e r , s o t h e y c o u l d c a l l i n a n d a s k q u e s t i o n s . T h i s w o u l d n o t n e c e s s a r i l y b e r u n b y t h e h o s p i t a l . T h e y b e l i e v e d t h e v o l u n t e e r -h e a r t a s s o c i a t i o n w a s a l l t h a t w a s r e q u i r e d , b e c a u s e t h e v o l u n t e e r s c o u l d t a l k t o p a t i e n t s b a s e d o n t h e i r o w n p e r s o n a l . e x p e r i e n c e s . T h i s w o u l d a l s o b e a n a c c e s s i b l e f o r m o f . r e a s s u r a n c e a n d v a l i d a t i o n f o r t h e p a t i e n t . •. I r e a l l y t h i n k t h a t y o u s h o u l d h a v e a v o l u n t e e r n u m b e r f o r h e a r t p a t i e n t s . . . t o g i v e t o o t h e r h e a r t p a t i e n t s . . . S o t h a t t h e y c a n c o n t a c t s o m e b o d y t h e r e a n d s a y t h i s i s w h a t I am g o i n g t h r o u g h . T h e o t h e r p e r s o n c a n s a y , d o n ' t w o r r y . . a b o u t i t , i t ' s p a r t o f r e c o v e r y . . W h e n a s k e d w h o s h o u l d d o t h e t e a c h i n g , t h e p a r t i c i p a n t s g a v e a v a r i e t y o f a n s w e r s ' . S e v e n p a r t i c i p a n t s w a n t e d t h e i r s u r g e o n s t o d o t h e t e a c h i n g . S e v e n p a r t i c i p a n t s s a i d t h a t ' n u r s e s o r n u r s e s p e c i a l i s t s w o u l d b e c a p a b l e e d u c a t i n g t h e m . O n e o f t h e s e p a r t i c i p a n t s s u p p o r t e d h i s c h o i c e w i t h t h i s r a t i o n a l e : T h e n u r s e . T h e y a r e d o i n g t h e w o r k i n t h e f a c i l i t y s o t h e y h a v e t h e b e s t i n f o r m a t i o n . A n o r d i n a r y n u r s e w i l l n o t k n o w a s m u c h a b o u t h e a r t o p e r a t i o n s . . Y o u n e e d s o m e o n e w h o w i l l k n o w a b o u t i t . L e t s a y u g h , s o m e b o d y h a s t o e x p l a i n w h a t i s i n t h e c h e s t e r f i e l d , y o u d o n ' t g o t o t h e b u t c h e r b e c a u s e h e i s n o t m u c h h e l p ! S o s o m e b o d y t h a t ' 1 3 9 w o r k s i n t h e h e a r t o p e r a t i o n s p l a c e , t h e y k n o w w h a t i s g o i n g o n a n d c a n e x p l a i n w h a t i s t h e b e s t f o r y o u . O f t h e s e s e v e n , t w o c h o s e t h e n u r s e b e c a u s e t h e y p e r c e i v e d t h e d o c t o r t o b e t o o b u s y a n d a s s u c h s h o u l d n o t b e e x p e c t e d t o d e a l w i t h t h i s . : . • .. D o c t o r s a r e t o o b u s y , y o u c a n ' t e x p e c t t h e m t o , s o w h o w o u l d y o u t u r n t o n e x t ? Y o u r n u r s e ! T h e a u t h o r w o n d e r e d i f s o m e o f t h e p a r t i c i p a n t s m a y h a v e c h o s e n n u r s e s b e c a u s e t h e r e s e a r c h e r h a d i d e n t i f i e d h i m s e l f a s a n u r s e a t t h e b e g i n n i n g o f " t h e s t u d y . T h i s i d e n t i f i c a t i o n m a y h a v e i n f l u e n c e d s o m e p a r t i c i p a n t s , ' . ; d e c i s i o n s . Two p a r t i c i p a n t s s t a t e d t h a t ' t e a c h i n g s h o u l d b e d o n e b y w h o m e v e r w a s t h e e x p e r t i n t h e a r e a . F o r . i n s t a n c e n u t r i t i o n a l c o u n s e l l i n g s h o u l d b e d o n e b y a d i e t i t i a n o r n u t r i t i o n i s t . T h e y s a i d t h e y w o u l d a s k n u r s e s -some q u e s t i o n s a n d d o c t o r s o t h e r s . Two p a r t i c i p a n t s s a i d t h e y w e r e n o t - s u r e w h o t o a s k b e c a u s e t h e d o c t o r s w e r e t o o b u s y , a n d t h e n u r s e d e f e r r e d t o t h e d o c t o r s . I am n o t s u r e a l l t h e n u r s e s r e a l l y h a d a l l t h e i n f o r m a t i o n y o u - k n o w . I f t h e y d i d h a v e i t t h e y d i d n ' t w a n t t o m a k e s t a t e m e n t s w h i c h w e r e t r a n s g r e s s i n g o n t h e d o c t o r ' s w o r d . S o t h e y s a i d y o u h a v e t o a s k t h e d o c t o r a l o t . T h e y d i d n ' t w a n t t o g i v e i n f o r m a t i o n c o n t r a r y t o w h a t t h e d o c s a i d , b u t t h e d o c s w e r e s e l d o m a v a i l a b l e . F r o m t h e r e s p o n s e s , i t i s e v i d e n t t h a t t h e p a r t i c i p a n t s s o u g h t e i t h e r a d o c t o r , o r a n u r s e w h o w a s d e e m e d a n e x p e r t i n t h e a r e a o f c a r d i a c c a r e t o a d d r e s s t h e i r . l e a r n i n g n e e d s . T h i s p e r s o n m u s t n o t b e p e r c e i v e d a s b e i n g i n a r u s h a n d m u s t a p p e a r 140 c o m p e t e n t D i s c u s s i o n A l l p a r t i c i p a n t s , r e q u e s t e d a d d i t i o n a l e d u c a t i o n d u r i n g t h e r e c o v e r y p r o c e s s . T h e m a j o r i t y v i e w e d t h e i r p h y s i c i a n s , c a r d i o l o g i s t s a n d f a m i l y d o c t o r s a s t h e i r p r i m a r y , s o u r c e o f i n f o r m a t i o n a n d v a l i d a t i o n . L e s s t h a n h a l f o f . t h e p a r t i c i p a n t s a c k n o w l e d g e d t h e n u r s e a s t h e p r i m e e d u c a t o r . K a r l i c k a n d Y a r c h e s k i ( 1 9 8 7 ) r e p o r t e d s i m i l a r r e s u l t s . C o n s e q u e n t l y , i t i s p r o b a b l e t h a t u n t i l p a t i e n t e d u c a t i o n i s u n d e r t a k e n v i s - a - v i s : t h e r o l e o f t h e n u r s e a s a p a t i e n t e d u c a t o r , a n a t t i t u d i n a l s h i f t w i l l n o t o c c u r , . ^ l e a v i n g t h e p h y s i c i a n s a s t h e " t r u s t e d " e d u c a t o r . T h e f a m i l y p h y s i c i a n ' s r o l e , w h i l e n o t s p e c i f i c a l l y e v a l u a t e d , m a y h a v e p r o v i d e d m u c h e d u c a t i o n , r e a s s u r a n c e a n d v a l i d a t i o n t o t h e p a r t i c i p a n t s . T h o s e o n a n a n t i c o a g u l a n t w e r e i n t h e c l o s e s t c o n t a c t w i t h t h e i r p h y s i c i a n s , b e c a u s e t h e y c a l l e d d a i l y t o a d j u s t t h e m e d i c a t i o n d o s e . T h i s i s , s i g n i f i c a n t f o r t h e p o s t o p e r a t i v e e d u c a t i o n p r o c e s s . F a m i l y p h y s i c i a n s m a y c u r r e n t l y b e u n d e r - u t i l i z i n g t h e i r r o l e v i s - a -v i s p o s t - o p e r a t i v e h e a r t v a l v e , r e p l a c e m e n t p a t i e n t e d u c a t i o n a n d r e h a b i l i t a t i o n . . T h e s t u d y ' s r e s u l t s l e n d c r e d e n c e t o t h e i d e a t h a t p a t i e n t p r e f e r e n c e s n e e d t o b e a s s e s s e d a n d v a l i d a t e d b e f o r e a n y e d u c a t i o n i s u n d e r t a k e n . T h e m a j o r i t y s t a t e d t h e y w o u l d p r e f e r d n e - o n - o n e t e a c h i n g , i f a t a l l p o s s i b l e . S m a l l g r o u p t e a c h i n g , s u c h a s t h e t y p e u n d e r t a k e n i n t h e n u t r i t i o n c l a s s e s n e e d s t o b e r e c o n s i d e r e d a s t h i s m e t h o d w a s p r o v e n t o b e i n e f f e c t i v e , s i m p l y a s a r e s u l t o f t h e l a c k o f d e s i r e t o a t t e n d . V a n c o u v e r i s a m u l t i c u l t u r a l c i t y , w i t h d i v e r s e e t h n i c p o p u l a t i o n s . E n g l i s h w a s n o t t h e f i r s t l a n g u a g e o f m a n y o f t h e p a r t i c i p a n t s , s o a l t e r n a t i v e m e t h o d s o f p a t i e n t e d u c a t i o n i n o t h e r l a n g u a g e s a n d t h r o u g h o t h e r m e d i u m s m u s t b e c o n s i d e r e d . H e n d e r s o n ' s F r a m e w o r k : H e n d e r s o n ' s p h i l o s o p h y ( 1 9 6 1 ) w a s u s e d a s a c o n c e p t u a l g u i d e f o r t h e p a t i e n t i n t e r v i e w s i n t h i s s t u d y . H e n d e r s o n ' s f o u r t e e n n e e d s w e r e s p e c i f i c a l l y u s e d a s p r o m p t s f o r t h e -p a r t i c i p a n t i n t e r v i e w s . A s ' s e e n , t h e p r o m p t s - p r o v e d u s e f u l b e c a u s e t h e y p r o v i d e d a g e n e r a l f r a m e w o r k f o r f u l l y e x p l o r i n g t h e p r o c e s s o f l i v i n g t h r o u g h h e a r t v a l v e , r e p l a c e m e n t s u r g e r y . T h e y e n c o u r a g e d p a t i e n t s t o p o n d e r i s s u e s t h e y h a d n o t y e t d i s c u s s e d w i t h t h e i n t e r v i e w e r , a n d a i d e d i n d i s c o v e r i n g n e w i n f o r m a t i o n a n d i s s u e s r e l e v a n t t o t h e r e c o v e r y p r o c e s s : t h e t r o u b l e e n c o u n t e r e d w i t h s l e e p d u e t o t h e h e a r t ' v a l v e c l i c k i n g , t h e h e e d t o p r o t e c t o n e ' s s t e r n a l i n c i s i o n f r o m o t h e r s , f e m a l e p a r t i c i p a n t s n e e d f o r b r e a s t s u p p o r t a n d s u c h i s s u e s a s b o d y t e m p e r a t u r e f l u c t u a t i o n s . T h e r e s u l t s o f t h e s t u d y l e n d c r e d e n c e t o H e n d e r s o n ' s c l a i m t h a t p e o p l e w i l l i n d e p e n d e n t l y u n d e r t a k e t h e r e q u i s i t e a c t i v i t i e s t o m e e t t h e i r v a r i o u s n e e d s i f t h e y h a v e t h e .142 "necessary strength, w i l l or knowledge" ; to do so (1991, p.21). A good example of this was observed with the participants resumption of driving. . During recovery, some participants reported not having the strength and confidence to drive, and so delayed this a c t i v i t y , while others engaged i n this a c t i v i t y sooner than even recommended by their, physicians as they f e l t ready to do so. 'In addition as Henderson proposed, most participants stated they required assistance with their recovery because they were incredibly fatigued and lacking i n strength. The need to learn, or acquire knowledge (need 14) and the motivation to. meet this and other needs, which Henderson stated leads to "normal" health, was evidenced i n the various needs expressed by the participants. Many of the needs related s p e c i f i c a l l y to knowledge acquisition, how to obtain the requisite knowledge, and the subsequent behaviour: changes.. -For example, the participants required information, confirmation and v a l i d a t i o n of which a c t i v i t i e s they were allowed to. undertake to improve their physical state, as well as education related to medications, anticoagulation therapy and pain management, a l l of which assisted i n attaining the goal of independence. The nurse, as the "prime helper" (1991, p.24) during recovery assisted the participants i n obtaining.this > requisite knowledge. The overall goal expressed by the 1 participants was that of returning to a normal l i f e s t y l e , which. i s c o n g r u e n t w i t h H e n d e r s o n ' s p h i l o s o p h y . ' W h i l e H e n d e r s o n d o e s n o t s p e c i f i c a l l y a d d r e s s t h e i s s u e o f t i m i n g w h e n d i s c u s s i n g t h e p r o v i s i o n . o f e d u c a t i o n , h e r p h i l o s o p h y s t a t e s t h a t t h e p a t i e n t w i l l r e q u i r e t e a c h i n g a n d l e a r n i n g w h e n a n e w n e e d d e v e l o p s . T h e m a j o r i t y o f t h e , p a r t i c i p a n t s v a l i d a t e d t h i s b y s t a t i n g t h a t a d d i t i o n a l f o l l o w u p w h i l e i n h o s p i t a l , d u r i n g t h e t i m e t h e y w e r e e x p e r i e n c i n g t h e i r " a c u t e " e v e n t , w o u l d b e h e l p f u l . I t c a n b e i n f e r r e d t h a t t h e r e q u i s i t e t e a c h i n g o r p r o c e s s e s r e q u i r e d f o r k n o w l e d g e a c q u i s i t i o n a n d b e h a v i o u r c h a n g e s h o u l d o c c u r w h e n r e q u e s t e d a n d r e q u i r e d b y t h e p a t i e n t . S u m m a r y T h e l e a r n i n g n e e d s e x p r e s s e d b y t h e 1 8 p a r t i c i p a n t s w e r e r e f l e c t i v e o f t h e i r i n d i v i d u a l s i t u a t i o n s a n d e x p e r i e n c e s f r o m d i a g n o s i s t o r e c o v e r y . T h e p a r t i c i p a n t s w e r e e x p r e s s i v e i n t h e i r p e r c e i v e d l a c k o f c h o i c e a s i t p e r t a i n e d t o t h e s u r g e r y a n d t h e t y p e o f v a l v e t h e y h a d i m p l a n t e d . T h e y e x p r e s s e d s u r p r i s e a n d c o n c e r n w i t h t h e l a c k o f i n f o r m a t i o n g i v e n a b o u t t h e l o n g s t a n d i n g f a t i g u e a n d w e a k n e s s , e x p e r i e n c e d p o s t -o p e r a t i v e l y . T h e i r r e p o r t e d l e a r n i n g n e e d s c e n t r e d a r o u n d m o b i l i t y i s s u e s s u c h a s l i f t i n g , r e a c h i n g , p u l l i n g , p u s h i n g . a n d d r i v i n g ; r e s u m p t i o n o f g e n e r a l a c t i v i t i e s i n c l u d i n g e x e r c i s e s w h i c h w o u l d a s s i s t w i t h g e n e r a l f i t n e s s ; p a i n c o n t r o l ; m e d i c a t i o n s , s p e c i f i c a l l y a n t i c o a g u l a t i o n t h e r a p y ; e m o t i o n a l 1 4 4 i s s u e s f r o m t h e t i m e o f d i a g n o s i s t o r e c o v e r y ; t h e n e e d f o r s u p p o r t f r o m f a m i l y a n d f r i e n d s a n d t h e n e e d f o r c o m m u n i t y s u p p o r t f o r t h o s e w h o w e r e s i n g l e ; g e n e r a l a d j u s t m e n t s r e q u i r e d i n c l u d i n g v a l v e n o i s e s , i n c i s i o n c a r e , b o d y i m a g e , a p p e t i t e a n d n u t r i t i o n , p o t e n t i a l c o m p l i c a t i o n s a n d e m p l o y m e n t . T i m e b r o u g h t w i t h i t a h o p e f o r t h e f u t u r e a n d t h e g r a d u a l • r e s u m p t i o n o f r o u t i n e a n d s e x u a l a c t i v i t i e s . . T h e p r e - a n d p o s t - o p e r a t i v e . t e a c h i n g r e c e i v e d b y t h e p a r t i c i p a n t s v a r i e d . H o w e v e r , m o s t b e l i e v e d t h e i n f o r m a t i o n f r o m t h e i r d o c t o r s , n u r s e s , v i d e o s a n d b o o k s t o b e b e n e f i c i a l t o t h e i r r e c o v e r y . Some p a r t i c i p a n t s m o r e e a g e r l y e n g a g e d t h e r e c o v e r y p r o c e s s b y t a k i n g a n a c t i v e r o l e i n t h e i r l e a r n i n g , e i t h e r t h r o u g h d i s c u s s i o n s w i t h f r i e n d s , r e a d i n g b o o k s o r a s k i n g q u e s t i o n s . O v e r a l l t h e p a r t i c i p a n t s b e l i e v e d a d d i t i o n a l f o l l o w - u p , p r e d o m i n a n t l y w h i l e i n h o s p i t a l , w o u l d h a v e a s s i s t e d i n t h e r e c o v e r y p r o c e s s . T h e m a j o r i t y b e l i e v e d t h i s s h o u l d b e . d o n e o n a o n e t o o n e b a s i s , p r e f e r a b l y w i t h s o m e o n e d e e m e d a n e x p e r t i n t h e a r e a o f c a r d i a c c a r e . T h i s c h a p t e r h a s p r e s e n t e d a g e n e r a l d e s c r i p t i o n a n d d i s c u s s i o n o f t h e l e a r n i n g n e e d s o f 1 8 p a t i e n t s w h o u n d e r w e n t s u r g i c a l h e a r t v a l v e r e p l a c e m e n t s . C h a p t e r f i v e w i l l l o o k a t t h e c o n c l u s i o n s t o b e d r a w n f r o m t h e s t u d y , a n d t h e i m p l i c a t i o n s t h e y h o l d 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 , r e s e a r c h a n d o t h e r h e a l t h c a r e p r o f e s s i o n a l s . • •. . C H A P T E R F I V E . 1 4 5 I n t h i s f i n a l c h a p t e r , r e l e v a n t c o n c l u s i o n s a r e d r a w n , a n d t h e i m p l i c a t i o n s t h e s t u d y h a 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 , r e s e a r c h , a n d o t h e r h e a l t h c a r e p r o f e s s i o n a l s a r e h i g h l i g h t e d . C o n c l u s i o n s A s a n t i c i p a t e d , s o m e o f t h e l e a r n i n g n e e d s f o r h e a r t v a l v e r e p l a c e m e n t p a t i e n t s w e r e s i m i l a r t o t h o s e p f C A B G o r M I p a t i e n t s . Common l e a r n i n g n e e d s i n c l u d e d : t h e n e e d f o r i n f o r m a t i o n a n d e d u c a t i o n r e l a t e d t o f a t i g u e , . m o b i l i t y , p a i n m a n a g e m e n t , d i e t , l a c k o f a p p e t i t e , c o n s t i p a t i o n , e m o t i o n s , a n d i n c i s i o n c a r e . O v e r a l l , t h e s p e c i f i c n e e d s . e x p r e s s e d b y t h e p a r t i c i p a n t s v a r i e d , a s d i d t h e i r d e s i r e t o l e a r n a b o u t s p e c i f i c a s p e c t s o f t h e i r r e c o v e r y . P a r t i c i p a n t s s o u g h t i n f o r m a t i o n a n d e d u c a t i o n s p e c i f i c a l l y r e l a t e d t o . t h e i r i n d i v i d u a l n e e d s ( s u c h a s r e g u l a t i o n o f a n t i c o a g u l a n t s ) w h i c h l e n d s c r e d e n c e t o K n o w l e s ( 1 9 8 5 ) t h e o r y o f a d u l t l e a r n i n g w h i c h s u g g e s t s t h a t a d u l t l e a r n e r s w i l l l e a r n b e s t w h e n t h e y p e r c e i v e a n e e d . P a r t i c i p a n t s w e r e w i l l i n g t o m a k e s o m e a d j u s t m e n t s t o t h e i r l i f e s t y l e s i n a r e a s t h e y v i e w e d a s i m p o r t a n t b u t s e t l i m i t s o n t h e e x t e n t o f t h e a d j u s t m e n t s . S o m e o f t h e u s u a l t o p i c s i n c a r d i a c e d u c a t i o n i n c l u d i n g t h e a n a t o m y o f t h e h e a r t , g e n e r a l m e d i c a t i o n s , a l c o h o l a n d s m o k i n g c e s s a t i o n w e r e b a r e l y m e n t i o n e d b y t h e p a r t i c i p a n t s . .146 F r o m t h i s i t i s p o s s i b l e t o c o n c l u d e t h a t p a t i e n t s w i t h h e a r t v a l v e r e p l a c e m e n t s e x p e r i e n c e d i f f e r e n t l e a r n i n g n e e d s p o s t -o p e r a t i v e l y . T h i s s t u d y d i d n o t c o n s t i t u t e a n " e v a l u a t i o n " o f t h e t e a c h i n g c a r r i e d o u t , h e n c e i t . i s n o t p o s s i b l e t o c o n c l u d e t h a t a d d i t i o n a l i n f o r m a t i o n w a s n o t r e q u i r e d i n t h e s e , a r e a s , o n l y t h a t t h e p a r t i c i p a n t s d i d n o t f i n d t h e m I m p o r t a n t e n o u g h t o m e n t i o n a s e s s e n t i a l d u r i n g e a r l y r e h a b i l i t a t i o n . P a t i e n t s r e q u i r e m o r e i n f o r m a t i o n a n d e d u c a t i o n p r e -o p e r a t l v e l y a b o u t t h e v a l v e t y p e s , t h e . s u r g e r y a n d t h e p o t e n t i a l c o m p l i c a t i o n s . T h e y w o u l d p r e f e r t h a t t h i s % i n f o r m a t i o n b e p r o v i d e d b y t h e i r s u r g e o n . I t w o u l d b e b e n e f i c i a l t o h a v e " t a n g i b l e " i n f o r m a t i o n ( s u c h a s a v i d e o o r p a m p h l e t ) p r o v i d e d d u r i n g t h e s u r g i c a l c o n s u l t . T h i s - w o u l d 1 a l l o w p a t i e n t s t o r e f e r t o t h e i n f o r m a t i o n a t a l a t e r d a t e , a n d w o u l d a s s i s t i n c l a r i f y i n g m i s u n d e r s t o o d o r f o r g o t t e n b u t r e l e v a n t i s s u e s a f t e r t h e i n i t i a l c o n s u l t a t i o n . O v e r a l l i t w o u l d r e i n f o r c e t h e e d u c a t i o n a l p r o c e s s a n d a s s i s t t h e s u r g i c a l c a n d i d a t e i n p r o v i d i n g i n f o r m e d c o n s e n t . C o n s i s t e n c y i n t h e e d u c a t i o n a l p r o c e s s n e e d s t o b e a d d r e s s e d b y t h e h e a l t h c a r e p r o f e s s i o n a l s p r o v i d i n g t h e t e a c h i n g . W h i l e t h i s s t u d y a c k n o w l e d g e s t h a t p a r t i c i p a n t s h a v e , u n i q u e l e a r n i n g n e e d s , s o m e p a r t i c i p a n t s w e r e n o t e v e n p r o v i d e d w i t h b a s i c i n f o r m a t i o n p e r t a i n i n g t o s u c h t h i n g s a s t h e i r m e d i c a t i o n s a n d p a i n c o n t r o l . : H e a l t h c a r e p r o f e s s i o n a l s c o n t i n u e t o f i n d i t ' v e r y 147; d i f f i c u l t t o d i s c u s s t h e r e s u m p t i o n o f s e x u a l a c t i v i t y w i t h p a t i e n t s . T h e r e a s o n s f o r t h i s a r e u n k n o w n , b u t b o t h p a t i e n t s w h o w e r e s e x u a l l y a c t i v e p r e - o p e r a t i v e l y a n d t h o s e w h o w e r e n o t e x p r e s s e d a n e e d f o r t h i s t o p i c t o b e a d d r e s s e d . P e r s o n a l p r e f e r e n c e s w e r e e x p r e s s e d w i t h r e g a r d t o t h e t i m i n g , m e t h o d a n d a m o u n t o f i n f o r m a t i o n r e q u i r e d . v • C o n s e q u e n t l y , a t h o r o u g h e v a l u a t i o n o f t h e p a t i e n t ' s l e a r n i n g m e t h o d s a n d l e a r n i n g n e e d s i s r e q u i r e d , b e f o r e t h e e d u c a t i o n a l p r o c e s s i s i m p l e m e n t e d . F i n a l l y , i t i s r e l a t i v e l y r a r e t o f i n d a c a r d i a c s t u d y w h i c h i s r e p r e s e n t a t i v e o f b o t h t h e m a l e a n d f e m a l e p o p u l a t i o n . S o m e s p e c i f i c d i f f e r e n c e s w e r e d i s c o v e r e d i n t h e l e a r n i n g n e e d s b e t w e e n t h e s e x e s . . O v e r a l l i t i s b e l i e v e d t h a t t h e s e r e s u l t s j u s t l y r e p r e s e n t t h e p e r c e i v e d l e a r n i n g n e e d s o f b o t h f e m a l e a n d m a l e c a r d i a c p a t i e n t s d u r i n g t h e e a r l y w e e k s o f r e c o v e r y . I m p l i c a t i o n s T h e r e s u l t s o f " t h i s s t u d y h o l d i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n , p r a c t i c e , r e s e a r c h a s w e l l a s f o r o t h e r h e a l t h c a r e p r o f e s s i o n a l s . I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n M o s t p a r t i c i p a n t s s t a t e d t h a t n u r s e s p r o v i d e d t h e m w i t h s o m e i n f o r m a t i o n w h i l e i n h o s p i t a l . T h e r e f o r e , n u r s e s a s s t u d e n t s m u s t l e a r n t o a s s e s s t h e p a t i e n t ' s p e r s p e c t i v e a s p a r t o f t h e l e a r n i n g n e e d s a s s e s s m e n t . . I n d i v i d u a l l e a r n i n g n e e d s a r e d e r i v e d f r o m b o t h p a s t a n d p r e s e n t e x p e r i e n c e s . P a t i e n t s m a y o n l y w a n t t o l e a r n a b o u t c e r t a i n i s s u e s o r s u b j e c t s a n d n o t o t h e r s , o r t h e y m a y a l r e a d y b e k n o w l e d g e a b l e i n c e r t a i n a r e a s . C o n s e q u e n t l y n u r s i n g s t u d e n t s m u s t b e a w a r e t h a t t h e p a t i e n t ' s p e r s p e c t i v e c o n s t i t u t e s a n i n t e g r a l p a r t o f a t h o r o u g h l e a r n i n g n e e d s a s s e s s m e n t ; W i t h t h i s p e r s p e c t i v e r e i n f o r c e d a t t h e c l a s s r o o m l e v e l , i t i s h o p e d t h a t t h e - n u r s e w i l l , o n c e i n p r a c t i c e , b e m o r e a w a r e o f t h e p a t i e n t p e r s p e c t i v e , a n a l y z i n g i t m o r e f u l l y , a n d i n c o r p o r a t e i t i n p r a c t i c e . I t i s r e c o g n i z e d t h a t t h i s i s n o t n e w i n f o r m a t i o n ; h o w e v e r , t h e i s s u e < o f n u r s e s l e a r n i n g t o f u l l y a s s e s s p a t i e n t n e e d s r e q u i r e s r e i n f o r c e m e n t . I m p l i c a t i o n s f o r P r a c t i c e R e f e r e n c e m a t e r i a l s a r e n o t p r e s e n t l y p r o v i d e d t o e v e r y s u r g i c a l c a n d i d a t e , e v i d e n c e d b y t h e f a c t , t h a t h a l f o f t h e p a r t i c i p a n t s s e a r c h e d l i b r a r i e s a n d p h a r m a c i e s f o r a d d i t i o n a l i n f o r m a t i o n . T h e p r o v i s i o n o f e d u c a t i o n a l m a t e r i a l s s u c h a s a p a m p h l e t o r v i d e o o u t l i n i n g t h e " p r o s a n d c o n s " o f e a c h v a l v e a n d s o m e o f t h e p o t e n t i a l b u t n o r m a l s i d e e f f e c t s e n c b u n t e r e d a f t e r s u r g e r y ( s u c h a s h a l l u c i n a t i o n s , h y p o t e n s i o n , s t r o k e ) w o u l d s e r v e t o r e i n f o r c e t h e p a t i e n t e d u c a t i o n p r o v i d e d , a n d w o u l d p o t e n t i a l l y r e d u c e t h e n u m b e r o f q u e s t i o n s r e p e a t e d l y a s k e d o f s u r g e o n s , n u r s e s a n d o f f i c e a s s i s t a n t s . I t w o u l d r e p r e s e n t a p a r a d i g m s h i f t t o w a r d s w h a t S u l l i v a n ( 1 9 9 3 ) t e r m e d a " l e a r n e r c o n t r o l l e d s y s t e m " . P a r t i c i p a n t s w o u l d b e a b l e t o . a c c e s s i n f o r m a t i o n a t a t i m e w h e n t h e y w e r e r e a d y , w a n t i n g o r f e e l i n g t h e n e e d t o d o s o . . T h i s p r o c e s s m a y a l s o s e r v e t o r e d u c e f e a r s , t h u s a s s i s t i n g / w i t h p o s t - o p e r a t i v e a d j u s t m e n t . I f p r o p e r l y e d u c a t e d , p a t i e n t s m a y e v e n d e c i d e a g a i n s t s u r g e r y . H o w e v e r , t h i s i s s p e c u l a t i v e a n d r e q u i r e s e m p i r i c a l v a l i d a t i o n . T h e m e t h o d s u s e d t o p r o v i d e i n f o r m a t i o n a n d e d u c a t i o n r e p r e s e n t a c o n s t a n t c h a l l e n g e t o h e a l t h c a r e p r o f e s s i o n a l s - . T h i s s t u d y r e i n f o r c e d t h a t n o t a l l h e a l t h c a r e u s e r s a r e ', l i t e r a t e , a n d t h a t i n d i v i d u a l s e x p r e s s t h e i r l e a r n i n g n e e d s i n d i f f e r e n t w a y s b a s e d o n c u l t u r a l , e t h n i c a n d r e l i g i o u s b e l i e f s . A s a r e s u l t , n u r s e s a n d o t h e r h e a l t h c a r e p r o f e s s i o n a l s a l i k e m u s t f i n d n e w w a y s o f r e c o g n i z i n g a n d m e e t i n g t h e c o n s u m e r ' s l e a r n i n g n e e d s . : •-. ' P a t i e n t e d u c a t i o n , l e a d i n g t o i n f o r m e d c o n s e n t , i s e q u a l l y a n u r s i n g r e s p o n s i b i l i t y , o n e w h i c h s e e m s t o h a v e b e e n s o m e w h a t l a c k i n g w i t h t h i s g r o u p . T h e f a c t t h a t n o t a i l o f t h e p a r t i c i p a n t s w e r e p r o v i d e d w i t h p r e - a n d p o s t - o p e r a t i v e e d u c a t i o n r a i s e s t h e q u e s t i o n w h e t h e r p a t i e n t e d u c a t i o n i s a n u r s i n g p r i o r i t y , o r i f n u r s e s h a v e t h e t i m e n e c e s s a r y t o u n d e r t a k e t h i s a c t i v i t y . N u r s e s i n p r a c t i c e n e e d t o b e r e m i n d e d o f t h e i r p r o f e s s i o n a l o b l i g a t i o n t o e n s u r e t h a t p a t i e n t s u n d e r s t a n d t h e s u r g i c a l e v e n t , a n d a r e p r o v i d i n g i n f o r m e d c o n s e n t f o r t h e s u r g e r y . O n l y w h e n t h i s i s a c h i e v e d • < . . 1 5 0 a r e n u r s e s r e s p o n d i n g t o p a t i e n t f o c u s e d l e a r n i n g n e e d s a n d a c t i n g a s t r u e p a t i e n t a d v o c a t e s . S o m e o f t h e r e c e n t s u r g i c a l d e l a y s h a v e b e e n b l a m e d o n n u r s i n g s h o r t a g e s . N u r s i n g a s a p r o f e s s i o n h a s a r e s p o n s i b i l i t y t o r e c o g n i z e t h i s p r o b l e m a n d t o w o r k t o a v o i d p r a c t i c e r e l a t e d d e l a y s w h e r e p o s s i b l e . A s p r e v i o u s l y n o t e d , ' s u r g i c a l d e l a y s a d d ' a d d i t i o n a l s t r e s s t o t h e a l r e a d y c h r o n i c a l l y i l l p a t i e n t . T h e f a c t t h a t m a n y p a r t i c i p a n t s w e r e n o t " r a t i o n a l " i n . t e r m s o f t h e i r p r e - o p e r a t i v e e x p e c t a t i o n s l e n d s c r e d e n c e t o t h e n e e d f o r r o u t i n e . , n u r s i n g a d m i n i s t e r e d , p r e - a d m i s s i o n c l i n i c s . T h i s s e r v i c e , w h i c h i n c l u d e s a n e x p l a n a t i o n , o f t h e v a r i o u s r o u t i n e s a n d a t o u r o f t h e v a r i o u s u n i t s , m a y h e l p t o a l l a y a n x i e t y , a n d a s s i s t w i t h t h e t r a n s i t i o n t o " i n h o s p i t a l " s t a t u s . Women w h o a r e l a r g e b r e a s t e d c o u l d b e i n f o r m e d a t t h i s t i m e t h a t b r e a s t s u p p o r t o f s o m e t y p e w i l l b e r e q u i r e d w h i l e i n h o s p i t a l . ' : T h e h e a l t h c a r e t e a m n e e d s t o m a k e e v e r y e f f o r t t o e n s u r e . t h a t d i s c h a r g e p l a n n i n g i s • i n s t i t u t e d f r o m t h e m o m e n t t h e p a t i e n t a r r i v e s i n h o s p i t a l . T h e p a r t i c i p a n t s i n t h i s s t u d y h a v e c l e a r l y s t a t e d t h a t t h e y p r e f e r t o h a v e t h e i r l e a r n i n g n e e d s a d d r e s s e d w e l l b e f o r e l e a v i n g t h e h o s p i t a l . S p e c i f i c a l l y , t h e y s t a t e d t h a t d i s c h a r g e p l a n n i n g s h o u l d b e . c e n t r e d a r o u n d s y m p t o m m a n a g e m e n t a n d a c t i v i t i e s o f d a i l y l i v i n g . T h i s i n c l u d e s f a t i g u e , , l o s s o f m o b i l i t y , ' p a i n a n d 1 5 1 medication management, loss of appetite, post-operative complications and i n c i s i o n care, valve related Issues, emotional adjustment, the resumption of sexual a c t i v i t y and the need for support at home. Advance notice of the hospital discharge i s required by both patients and family members i n order to make the requisite arrangements for going home. Informing patients of average length of hospital stay (6-8 days), the usual c r i t e r i a for discharge (such as walking 2 f l i g h t s of s t a i r s , normal heart rhythm, resolving shortness of breath), and the general discharge process (unescorted walk with paperwork and valuables completed at the point of exit) would provide patients with a general guideline for estimating their own discharge date. It would also a s s i s t i n creating r e a l i s t i c expectations for the discharge day i t s e l f . Those nurses who undertake patient education must be made consciously aware that their perspective pertaining to the learning needs of patients with heart valve replacements d i f f e r from those of the patient. Nurses must complete thorough patient assessments i n order to i d e n t i f y what patients perceive as important knowledge, as well as the individual's preference for the timing and method of teaching. However, i t must also be acknowledged that the unin i t i a t e d patient w i l l not be aware of a l l that they need to know. It i s the educator's r e s p o n s i b i l i t y to recognize this and as s i s t the patient where • 1 5 2 n e e d e d . T h i s w i l l u l t i m a t e l y b e n e f i t p a t i e n t s a n d a s s i s t t h e m i n r e g a i n i n g t h e i r i n d e p e n d e n c e . T h e r e s u l t s o f t h e s t u d y s u g g e s t t h a t p a t i e n t s c o n t i n u e t o h a v e l e a r n i n g n e e d s , b u t t h a t t h e y a r e n o t a w a r e o f t h e n u r s e s ' r o l e i n m e e t i n g t h e s e v a r i o u s n e e d s . L e s s t h a n h a l f o f t h e s u b j e c t s w e r e c o n f i d e n t i n a c c o r d i n g t h e b e d s i d e n u r s e t h e r o l e o f e d u c a t o r . C o n s e q u e n t l y n u r s e s i n p r a c t i c e n e e d t o m a k e p a t i e n t s a w a r e o f t h e i r r o l e a s e d u c a t o r s . T h e y a l s o n e e d t o d e v e l o p m o r e a u t o n o m y . D e f e r e n c e t o m e d i c a l o p i n i o n s h o u l d n o t b e a u t o m a t i c . I m p l i c a t i o n s f o r F u r t h e r R e s e a r c h ' T h i s . s t u d y e x a m i n e d t h e l e a r n i n g n e e d s f o r f i r s t t i m e h e a r t v a l v e r e c i p i e n t s a n d t h e s e h a v e b e e n i d e n t i f i e d . I t w o u l d b e s i g n i f i c a n t t o d i s c o v e r i f p a t i e n t s w h o u n d e r g o r e p e a t h e a r t v a l v e s u r g e r y e n c o u n t e r e d t h e s a m e i s s u e s p o s t -o p e r a t i v e l y , o r i f t h e y w e r e b e t t e r a b l e t o m a n a g e b e c a u s e o f t h e i r p r e v i o u s e x p e r i e n c e s . I n o r d e r t o v a l i d a t e t h e r e s u l t s o f t h e s t u d y , r e p l i c a t i o n , t h e " c o r n e r s t o n e " o f r e s e a r c h , i s a l s o r e c o m m e n d e d . T h i s s t u d y d i d n o t i n c o r p o r a t e a s p e c i f i c c u l t u r a l , e t h n i c o r g e n d e r f o c u s . I t w a s e v i d e n t t h a t p e o p l e f r o m v a r i o u s c u l t u r e s a n d o f v a r y i n g e t h n i c i n f l u e n c e r e a c t e d d i f f e r e n t l y t o t h e p r o c e s s , a n d t h a t s o m e p r e f e r r e d t h e d i s c h a r g e t e a c h i n g t o b e d o n e i n d i f f e r e n t w a y s . . T h e r e f o r e , i t w o u l d b e i n t e r e s t i n g 1 5 3 t o s t u d y l e a r n i n g n e e d s a n d h o w t h e y a r e m e t u s i n g a c u l t u r a l f r a m e w o r k . D o i n g s o m a y p r o v i d e i n f o r m a t i o n r e l a t e d t o s p e c i f i c c u l t u r a l l e a r n i n g n e e d s . F o r i n s t a n c e , o n c e c o u l d i n v e s t i g a t e t h e c u l t u r a l a n d e t h n i c i n f l u e n c e s s u r r o u n d i n g t h e e x p r e s s i o n o f p a i n A s t u d y r e l a t i n g t o t h e l e a r n i n g n e e d s t h a t w o m e n h a v e s e e m s i n v a l u a b l e b e c a u s e t h i s s t u d y r e v e a l e d t h a t w o m e n d o h a v e d i f f e r e n t l e a r n i n g n e e d s d u r i n g e a r l y r e c o v e r y . H i s t o r i c a l l y , w o m e n a n d c a r d i a c i l l n e s s h a v e b e e n p o o r l y i n v e s t i g a t e d d e s p i t e t h e i n c r e a s i n g i n c i d e n c e o f c a r d i a c d i s e a s e i n w o m e n ( S t a t i s t i c s ' C a n a d a , 1 9 9 2 ) . B e c a u s e e i g h t p a r t i c i p a n t s d i s c u s s e d t h e a n g i o g r a m , i t w a s e v i d e n t t h a t t h i s w a s a n i m p o r t a n t p a r t o f t h e i l l n e s s d i a g n o s t i c p r o c e s s . E t h i c a l r e s e a r c h p e r t a i n i n g t o t h e p r o c e s s o f p r o v i d i n g i n f o r m e d c o n s e n t f o r t h e a n g i o g r a m a n d t h e s u r g e r y i t s e l f i s r e q u i r e d . T h e r e s u l t s f r o m t h e s t u d y s u g g e s t t h a t p a t i e n t s d i d n o t f e e l a d e q u a t e l y i n f o r m e d a b o u t t h e i r c h o i c e s d u r i n g t h e s e p r o c e s s e s , n o r w e r e t h e y w e l l i n f o r m e d a b o u t t h e v a l v e t y p e s a n d t h e p o t e n t i a l c o m p l i c a t i o n s i n h e r e n t . P r a c t i s i n g n u r s e s . s h o u l d b e s u r v e y e d t o d i s c o v e r w h o t h e y b e l i e v e s h o u l d b e u n d e r t a k i n g d i s c h a r g e t e a c h i n g . S o m e p a t i e n t s r e p o r t e d t h a t t h e i r n u r s e s d e f e r r e d t o t h e p h y s i c i a n s , w h i l e o t h e r s c l e a r l y s t a t e d t h a t t h e n u r s e s p r o v i d e d t h e m w i t h m o s t o f t h e r e q u i s i t e i n f o r m a t i o n . T h i s d i s c r e p a n c y s u g g e s t s t h a t n u r s e s h o l d v a r y i n g p e r c e p t i o n s p e r t a i n i n g t o w h o s h o u l d 1 5 4 b e t h e p a t i e n t ' s p r i m a r y e d u c a t o r . T h i s r p l e r e q u i r e s c l a r i f i c a t i o n f o r a l l p a r t i e s c o n c e r n e d , t h e p a t i e n t , t h e n u r s e a n d t h e p h y s i c i a n . T h e t i m i n g o f p a t i e n t e d u c a t i o n r e q u i r e s f u r t h e r c l a r i f i c a t i o n . I t i s c l e a r l y d o c u m e n t e d i n t h i s s t u d y t h a t f o l l o w u p o n c e h o m e w a s n o t d e e m e d n e c e s s a r y a n d t h a t t h e r e i s t i m e i n h o s p i t a l w h e n i t c a n b e d o n e p r i o r t o t h e d a y o f d i s c h a r g e . I t w o u l d b e o f i n t e r e s t t o m a n y h e a l t h c a r e p r o f e s s i o n a l s i f p a t i e n t s w e r e s p e c i f i c a l l y a s k e d w h e r e t h e y w o u l d p r e f e r t o b e t a u g h t , i n h o s p i t a l o r a t h o m e , a n d i f s o ' w h e n . I m p l i c a t i o n s f o r H e a l t h C a r e P r o f e s s i o n a l s M a n y p r o f e s s i o n s a r e i n v o l v e d i n t h e p r o c e s s o f c a r d i a c s u r g e r y . C o n s e q u e n t l y s o m e i m p l i c a t i o n s f o r o t h e r h e a l t h c a r e p r o f e s s i o n a l s w e r e g a t h e r e d f r o m t h e r e s e a r c h . K n o w i n g t h a t s u r g i c a l d e l a y s c a u s e a n x i e t y f o r p a t i e n t s , t h e s u r g e o n s h a v e a r e s p o n s i b i l i t y t o p r o v i d e t h e p a t i e n t w i t h a r e a s o n a b l e e s t i m a t e f o r t h e d a t e o f s u r g e r y . . A s p r e v i o u s l y n o t e d , t h i s m a y h e l p a l l e v i a t e w a i t i n g t i m e s t r e s s a n d a n x i e t y . T h e f a m i l y p h y s i c i a n ' s r o l e i n p a t i e n t e d u c a t i o n r e q u i r e s f o l l o w u p . T h e y h a v e a u n i q u e o p p o r t u n i t y t o d i s c u s s a v a r i e t y o f i s s u e s w i t h t h e c o n v a l e s c i n g p a t i e n t . I t i s n o t k n o w n i f n u r s i n g c o u l d p l a y a r o l e i n t h e p r o c e s s o f p a t i e n t e d u c a t i o n d u r i n g t h i s t i m e , b u t i t w a r r a n t s f u r t h e r i n v e s t i g a t i o n . M a n y p a r t i c i p a n t s d i s c u s s e d t h e l a c k o f d i r e c t b e n e f i t d e r i v e d f r o m t h e i n - h o s p i t a l p h y s i o t h e r a p y c l a s s e s . C o n s e q u e n t l y , t h e p h y s i o t h e r a p i s t s n e e d t o r e a s s e s s t h e c o n t e n t , o b j e c t i v e s a n d m e t h o d s o f t i m i n g a n d d e l i v e r y o f t h e i r c l a s s e s . T h i s s t u d y h a s s h o w n t h a t h e a r t v a l v e r e p l a c e m e n t p a t i e n t s h a v e u n i q u e l e a r n i n g n e e d s , a n d n o t a l l p a r t i c i p a n t s b e l i e v e d t h e s e w e r e a d e q u a t e l y a d d r e s s e d . d u r i n g p h y s i o t h e r a p y . S u m m a r y T h i s c h a p t e r h a s p r e s e n t e d t h e c o n c l u s i o n s t o b e d e r i v e d f r o m t h e r e s u l t s p r e s e n t e d . I t a l s o a d d r e s s e d t h e i m p l i c a t i o n s t h e s e h a v e 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 , r e s e a r c h a n d o t h e r h e a l t h c a r e p r o f e s s i o n s . T o c o n c l u d e , t h i s s t u d y ' s f i n d i n g s s u g g e s t t h a t h e a r t v a l v e r e p l a c e m e n t p a t i e n t s h a v e u n i q u e l e a r n i n g n e e d s . T h e s e l e a r n i n g n e e d s m u s t b e a s s e s s e d , a l o n g w i t h w h e n a n d h o w t h e p a t i e n t l e a r n s b e s t p r i o r t o " t e a c h i n g " t h e p a t i e n t . D o i n g s o w i l l a s s i s t i n a d d r e s s i n g n e e d s , p r o v i d e r e a s s u r a n c e , a n d p r o m o t e h e a l t h y l i v i n g w i t h a c h r o n i c i l l n e s s . References Allen, J. (1990). Physical and psychosocial outcomes after coronary artery bypass surgery: Review of the l i t e r a t u r e . Heart, and Luna. 19(1), 49-54. Allen, J., Becker, D., & Swank, R. (1990). Factors related to functional status after coronary artery bypass surgery. Heart and Luna. 19(4), 337-43. Baker, C. (1989). Recovery: A phenomenon extending beyond discharge. Scholarly Inquiry for Nursing Practice, 3 (3) , 181-193. Beckie, T. (1989). A supportive-educative telephone program: Impact on knowledge and anxiety after coronary artery bypass graft surgery: Heart and Lung. 18.(1) , ,46-55. Bengtsson, K. (1983). Rehabilitation after myocardial i n f a r c t i o n : A controlled study. Scandinavian Journal of Rehabilitation Medicine, 15(1), 1-9. Blachly, P., & Starr, A. (1964). Post-cardiotomy delirium. American Journal of Psychiatry, 121, 371-375. Boogaard, M.A .K. (1984). Rehabilitation of the female patient after myocardial i n f a r c t i o n . Nursing C l i n i c s of North America, 19(3), 433-440. Boyd, C. (1987). Patient education promotes transition.from - hospital to home. Patient- Education and Counselling, 9.(3), 295-8. , ' -Brink, P.J., & Wood, M.J. (1983). Basic steps i n planning nursing research: From question to proposal. (2nd ed.) . Monterey CA: Wadsworth: ' Bubela, N., Galloway, S., McCay, E., McKibbon, A., Nagle, L., Pringle, D. , Ross, E. , & Shamian, J". (1990). Factors influencing patients' informational needs at time of .'. hospital discharge. Patient Education and Counselling, 16(1) , 21-28. Canadian Council of Cardiovascular Nurses. (1993). Standards for cardiovascular health education. Ottawa: Heart and Stroke. Foundation of Canada. Certo, C M . (1985). History of cardiac r e h a b i l i t a t i o n . Physical Therapy, 65(12), 1793-1795. 1 5 7 Clancy, C.A., Wey, J.M., & Guinn, G.A. (1984). The effect of . patients' perceptions on return to work after CABG surgery. Heart and Lung, 13(2), 173-6. Comoss, P., Burke, E., & Swails, S. (1979). Cardiac r e h a b i l i t a t i o n : A comprehensive nursing approach. Toronto: J.B. Lippincott. Cooke, P., & Alley, J. (1992).. Discharge planning: Who's re s p o n s i b i l i t y i s i t ? Caring, 11(1), 28-32. ' Costello, J. (1992). Heart valve surgery: Nursing issues. Canadian Journal of Cardiovascular Nursing, 3(2-3), 32-3. Cronin, S. (1990). Psychosocial adjustment to coronary artery disease: Current knowledge and future directions. Journal of Cardiovascular Nursing. 5(1), 13-24. Diehl, L-N. (1989) . Client and family learning i n the re h a b i l i t a t i o n setting. Nursing C l i n i c s of North America. 24(1), 257-264. Dion, W.F., Grevenow, P., Pollock, M. , Squires, R.W., Foster, C , Johnson, W.D., & Schmidt, D.H. (1982). Medical problems and physiologic responses during supervised in-patient cardiac r e h a b i l i t a t i o n : The patient aft e r coronary artery bypass grafting. Heart and Lung, 11.(3), 248-255. Dodge, J. (1969). Factors related to patients perceptions' of their cognitive needs. Nursing Research, 18.(6), 502-513. Downe-Wamboldt, B. (1992). Content analysis: Method, applications and issues. Health Care for Women International. 13(3), 313-321. Dubois, M., Cassidy, H., & Wilson, T. (1994). The team approach. The Canadian Nurse, 90(10), 28-30. Duryee, R. (1992). The eff i c a c y of in-patient education after myocardial i n f a r c t i o n . Heart and Lung, 21(3), 217-224. Fahrenfort, M. (1987). Patient emancipation by health education: An impossible goal? Patient education and counselling, 10(1), 25-37. F i e l d , P., & M o r s e , J. (1985). N u r s i n g r e s e a r c h : T h e a p p l i c a t i o n o f q u a l i t a t i v e a p p r o a c h e s . R o c k v i l l e M D : A s p e n . 158 Finkelmeier, B., Hartz, R., Fisher, E., & Michaelis, L. (1989). Implications of prosthetic valve implantation: An 8-year follow-up of patients with porcine bioprostheses. Heart and Luna. 18 (6), 565-74. Fitzpatrick, M.A., & McCone, F. (1991) . An audit of anticoagulation and endocarditis prophylaxis after heart valve surgery. The New Zealand Medical Journal, 104(907) , 85-88. Fleming, V. (1992). Client education: A f u t u r i s t i c outlook. Journal of Advanced Nursing, 17 (2), 158-163. Fletcher, B.J., Lloyd, A.L., & Fletcher, G.F. (1988)., Outpatient r e h a b i l i t a t i v e training i n patients with cardiovascular disease: Emphasis on training method. Heart and Lung, 17(2), 199-205. Ford, J.A. (1989). Uncertainty over time and i t s relationship to l i f e s a t i s f a c t i o n for b i o l o g i c a l valve patients. Unpublished Masters Thesis. Vancouver: University of B r i t i s h Columbia. Gassert, A., & Burrows, S.G. (1993). Moving right along after open heart surgery. Atlanta: Pritchett & Hull Associates.. Gerard, P., & Peterson, L. (1984) . Learning needs of cardiac patients. The Journal of Cardiovascular Nursing. 20(2), 7-11. G i l l i s s , C. (1984). Reducing family stress during and after coronary artery bypass surgery. Nursing C l i n i c s of North America, 19(1), 103-111. Grady, K.L. , Buckley, D.J., Cisar, N.S., Fink, M. , & Ryan, S.D. (1988). Patient perceptions of cardiovascular surgical patient education. Heart and Lung, 17(4), 349-54. Greenland, P. (1988). Efficacy of cardiac r e h a b i l i t a t i o n services: With emphasis on patients after myocardial i n f a r c t . Annals of Internal Medicine. .109(8), 650-663. Hagenhoff, B., Feutz, C , Conn; V. , Sagehorn,"K., & Moranville-Hunziker, M. (1994). Patient education needs as reported by congestive heart f a i l u r e patients and their nurses. Journal of Advanced Nursing; 19(4), 685-690. Hammermeister, K., Sethi, G., Henderson, W. , Oprian, C , Kim, 159 T., & Rahimtoola, S. (1993). A comparison of outcomes i n men 11 years after heart valve replacement with a mechanical valve or bioprosthesis. The New England Journal of Medicine, 328(18), 1289-1296. Hart, L., & Frantz, R. (1977). Characteristics of post-operative patient-education programs for open heart surgery patients i n the United States. Heart and Lung, 6.(1), 137-141. s Henderson, V. (1961). ICN Basic p r i n c i p l e s of nursing care. Torquay: Devonshire Press. Henderson, V. (1964). The nature of nursing. American Journal of Nursing. 64(8), 62-68. Henderson, V. (1991). The nature of nursing: Reflections a f t e r 25 years. New York: National League for Nursing. Hertanu, J., Davis, L., Focseneanu, M., & Lahman, L. (1986). Cardiac r e h a b i l i t a t i o n exercise program: Outcome assessment. Archives of Physical Medicine and Rehabilitation. 67(7). 431-435. H i l l , M. (1989). Teaching after CABG surgery: A family a f f a i r . C r i t i c a l Care Nurse. 9(8), 58-72. Holm, K., Fink, N., Christman, N., & Reitz, N. (1985). The -cardiac patient and exercise: A sociobehavioral analysis. Heart and Lung. 14(6). 586-593. Holmback', A., Sawe, U., & Fagher, B. (1994). Training after myocardial i n f a r c t i o n : Lack of long-term effects on physical capacity and psychological variables. Archives of Physical Medicine and Rehabilitation, 75(5), 551-554. Jasnoski, M., & Holmes, D. (1981). Influence of i n i t i a l , aerobic fitness, aerobic training and changes i n aerobic fitness on personality functioning. Journal of Psychosomatic Research. 25, 553-556. Jenkins, CD. , Stanton, B., Savageau, J., Ockene S.; Denlinger, P., & Klein, M. (1983). Physical, psychologic, s o c i a l and economic outcomes afte r cardiac valve surgery. Archives of Internal Medicine. 143(11), 2107-2113. J i l l i n g s , CR. (1977) . Phases of recovery from open heart surgery. Masters thesis. Vancouver: University of B r i t i s h Columbia. ' .... 160 J i l l i n g s , CR. (1988). Cardiac r e h a b i l i t a t i o n nursing. Rockville MD: Aspen. Karlik, B.A., & Yarcheski, A. (1987). Learning needs of cardiac patients: A p a r t i a l r e p l i c a t i o n study. Heart and Lung, 16(5), 544-551. King, K.M. (1994) . Valve disorders-: Theoretical and p r a c t i c a l nursing perspectives. Canadian Journal of Cardiovascular Nursing, 5(1), 13-17. Kloosterman,' N.D.. (1991). Cultural care: The missing l i n k i n severe sensory alteration. Nursing Science Quarterly, 4(3), . - 119-122. Knowles, M . (1985). Applications i n continuing education :for health professionals... Chapter f i v e of androgogy i n action. Journal of Continuing Education for Health Science Professional, 5(2), 80-100. Leino K i l p i , H., l i r e , L., Suominen, T., Vuorenhimo, J., & Valimaki, M. (1993). Client and information: A l i t e r a t u r e review. Journal of C l i n i c a l Nursing, 2(6), 331-340. Linde, B., & Janz, N. (1979). Effects of a teaching program on knowledge and compliance of cardiac patients. Nursing Research. 28(5) , 282-287 . Lindsay, C , Jenrich, J.A., & Biemolt, M. (1991). Programmed instruction booklet for cardiac r e h a b i l i t a t i o n teaching. Heart and Lung, 20(6), 648-53. Lipetz, M., Bussigel, M., Bahnerman, J., & Risley, B. (1990). What i s wrong with patient education programs? Nursing Outlook, 38(4), 184-189. Luker, K. , & Caress', A.L. (1989). Rethinking patient education. Journal of Advanced Nursing, 14.(9), 711-718. Lumpp, F. (1968) '. Manifestations of heeds of patients undergoing surgery for aortic valve replacement and the nursing actions involved i n their care. United States Public Health Service: Grant No: 00186-01. LoBiondo-Wood, G., & Haber, J. (1990). Nursing research: Methods, c r i t i c a l appraisal, and u t i l i z a t i o n (2nd ed.). Toronto:' C.V. Mosby. 161 MacKenzie, G. (1993). Role patterns and emotional responses of women with ischemic heart disease 4 to 6 weeks afte r discharge from hospital. Canadian Journal of Cardiovascular Nursing. 4(2), 9-15. Marshall, J.A. (1985). Rehabilitation of the coronary bypass patient. Cardiovascular Nursing. 21(4), 19-23. Marshall, J., Penckofer, S., & Llewellyn, J. (1986). Structured post-operative teaching and knowledge and compliance of patients who had coronary artery bypass surgery. Heart and Lung, 15 (1), 76-81. McKnight-Nicklin, W. (1986). Post-discharge concerns of cardiac patients as presented v i a a telephone callback system. Heart and Lung. 15(3), 268-272. Meyer, B., Blacher, R., & Brown, F. (1961). A c l i n i c a l study of psychiatric and psychological aspects of mitral surgery. Psychosomatic Medicine. 23(3), 194-217. M i l l e r , P., Johnson, N., Garrett, M., Wickoff, R., & McMahon, M. (1982). Health b e l i e f s of and adherence to the medical regimen by patients with ischemic heart disease. Heart and Lung. 11(4), 332-339. M i l l s , G., Barnes, D.E., Rodell, D., & Terry, L. (1985). An evaluation of an in-patient cardiac patient/family education program. Heart and Lung," 14(4). 400-406. Mirka, T., & Rukholm, E. (1993). Understanding post operative psychosis and sleep deprivation: A case approach. Canadian Journal of Cardiovascular Nursing. 3.(4) , 3-6. Morse, J.M. (1992). Qualitative health research. Newbury Park: Sage Publications. Moser, D., Dracup, K., & Marsden, D. (1993). Needs of' recovering cardiac patients and th e i r spouses: Compared views. International Journal of Nursing Studies. 30.(2), 105-114. Moynihan, M. (1984). Assessing the educational needs of post-myocardial i n f a r c t i o n patients. Nursing C l i n i c s of North America. 19(3), 441- 447. Newton, K.M., & K i l l i e n , M.G. (1988). Patient and spouse learning needs during recovery from coronary artery bypass. Progress i n Cardiovascular Nursing. 3.(2), 62-69. 162 Nolan, S.P. (1992). Defining valve performance: Importance and d i f f i c u l t i e s i n testing heart valve replacement devices. Journal of Medical Engineering and Technology, 16.(1), 1-3. O'Connor, B. (1987). Promoting heart health i n Canada: Report of the working group on the prevention and control of cardiovascular disease. Ministry of Health Government • Document: Ottawa. Raleigh, E.H., & Odtohan, B.C. (1987).. The effect of a cardiac teaching program oh patient r e h a b i l i t a t i o n . Heart and Lung, 16 (3) , 311-317 .. Rankin, S., & G i l l i s s , C. (1987). Intervening with middle-aged-families recovering from cardiac surgery. In L. Wright, & M. Leahey (Eds.), Families and Chronic Illness (pp 3 67-380). Pennsylvania: Springhouse. Rankin, S. (1990). Differences i n recovery from cardiac surgery: A p r o f i l e of male and female patients. Heart and Lung, 19(5), 481-5. Rosen, A., Klein, M., Rosen, H., Laczkovics, A., Rokitansky, A., & Beck, A. (1992) . Influence of valve surgery on female f e r t i l i t y . Gynecologic and Obstetric Investigation, 34.(3), 184-187. Roviaro, S., Holmes, D.,. & Holmsten, R. (1984). Influence of a cardiac r e h a b i l i t a t i o n program on the cardiovascular, psychological and so c i a l functioning of cardiac, patients. Journal of Behavioral Medicine, 7(1),. 61-81. Scalz i , C , Burke, L. , & Greenland, S. (1980). Evaluation of an in-patient educational program for coronary patients and families. Heart and Lung, 9.(5), 846-853. . Schakenback, L. (1987.). Physiologic dynamics of acquired valvular heart disease. The Journal of Cardiovascular Nursing, 1(3), 1-17. Sczekalla-Meyer, R., & Latz, P.A. (1979). What open heart surgery patients want to know. American Journal of Nursing, •' 79(5) ,' 1558-1561. Shaffer, J.A., Schulkers, N., & Wexler, L. (1991). Ambulatory post-operative care of patients following coronary artery bypass and valve replacement surgery: Discussion and algorithms. Progress i n Cardiovascular Nursing, 6.(1), 3-11. 163 Stanton, B., Jenkins, D., Savageau, J., Harken. D., & Aucoin, R. (1984). Perceived adequacy of patient education and fears and adjustments after cardiac surgery. Heart and Luna. H(5) , 525-531. S t a t i s t i c s Canada. (1992). Surgical procedures and treatment 1991-1992. Ottawa: Canadian Centre for Health Information. Steele, J., & Ruzicki, D. (1987). An evaluation of the effectiveness of cardiac teaching during h o s p i t a l i z a t i o n . Heart and Luna. 16(3), 306-310. Stern, M.J., & Cleary, P. (1982). The national exercise and heart disease project: Long term psychosocial outcomes. Archives of Internal Medicine. 142(6), 1093-7. Stovsky, B., & Dehner, S. (1994). Patient education a f t e r valve surgery. C r i t i c a l Care Nurse. 14.(2), 117-23. Sullivan, P. (1993). F e l t learning needs of pregnant women. The Canadian Nurse. 89(1)# 42-45. Tack, B., & G i l l i s s , C. (1990). Nurse-monitored cardiac recovery: A description of the f i r s t eight weeks. Heart and Luna. 19(5) , 491-499. Thome, S., & Robinson, C. (1988). Health care relationships: The chronic i l l n e s s perspective. Research i n Nursing and Health, 11(5), 293-300. Utz, S.W., & Grass, S. (1987). M i t r a l valve prolapse: Se l f -care needs, nursing diagnoses and interventions. Heart and Lung. 16(1) , 77-83. Varvaro, F.F. (1965). Teaching the patient about open heart surgery. American Journal of Nursing, 65.(10), 111-115. Waitkoff, B.., & Imburgia, D. (1990). Patient education and continuous improvement i n a phase one cardiac r e h a b i l i t a t i o n program. Journal of Nursing Quality Assurance, 5(1), 38-48. Webber, G. (1990). Patient Education: A review of the issues. The Journal of Medical Care. 28(11), 1089-1101. Wenger, N.K. (1986). Rehabilitation of the coronary Patient: Status 1986. Progress i n Cardiovascular Diseases, 29(3) . 181-204. 164 Wiggins, N.C. (1989). Education and support for the newly-diagnosed cardiac family: A v i t a l l i n k i n r e h a b i l i t a t i o n . Journal of Advanced Nursing. 14(1), 63—67. Wilson, H.S. (1989). Research i n nursing. (2nd ed.). Rockville MD: Addison Wesley. Wilson-Barnett, D., & Carrigy, T. (1978).A comparison of i n -hospital.education approaches for coronary bypass patients. . Nursing Research. 27(5), 242-247. Wingate, S. (1987). Rehabilitation of the patient with valvular heart disease. The Journal of Cardiovascular ' Nursing. 1(3), 52-64. , Wingate, S. (Ed.). (1991). Cardiac nursing: A c l i n i c a l management and patient care resource. Rockville MD: Aspen. World Health Organization. (1964) . Rehabilitation of patients with cardiovascular diseases. World Health Organization Technical Report no. 270, Geneva. Zyzanski, S., Stanton, B., Jenkins, CD., & Klein, M. (1981). Medical and psychosocial outcomes i n survivors of major heart surgery. Journal of Psychosomatic Research. 23(3), 213-221. 1 6 5 i Appendix A Information L e t t e r to P o t e n t i a l P a r t i c i p a n t s . . (UBC L e t t e r h e a d w a s u s e d f o r a l l a p p e n d i c e s ) 166 Heart Valve Replacement P a t i e n t s ' Perceptions of T h e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge D e a r S i r / M a d a m , M y n a m e i s A n d r e w L e s p e r a n c e . I am a R e g i s t e r e d N u r s e a n d s t u d e n t i n t h e M a s t e r o f N u r s i n g S c i e n c e p r o g r a m a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . I am c u r r e n t l y c o n d u c t i n g a r e s e a r c h s t u d y f o r my t h e s i s . P a t i e n t s s u c h a s y o u r s e l f w h o h a v e r e c e n t l y u n d e r g o n e h e a r t , v a l v e s u r g e r y a r e b e i n g a s k e d t o p a r t i c i p a t e . W o u l d y o u b e i n t e r e s t e d i n h e l p i n g me f i n d o u t w h a t p a t i e n t s f e e l t h e y n e e d t o l e a r n a b o u t a f t e r h a v i n g h a d a h e a r t v a l v e r e p l a c e d ? I w i s h t o i n t e r v i e w p e o p l e f o u r t o t e n w e e k s a f t e r t h e y h a v e b e e n d i s c h a r g e d f r o m h o s p i t a l . I f y o u a r e i n t e r e s t e d a n d w i l l i n g t o p a r t i c i p a t e , t h i s i s w h a t y o u c a n e x p e c t : - - A t e l e p h o n e c a l l f r o m m y s e l f , A n d r e w L e s p e r a n c e , i n .•" o r d e r t o a r r a n g e a c o n v e n i e n t t i m e f o r t h e i n t e r v i e w . A n - ' i n t e r v i e w c o n d u c t e d i n y o u r h o m e a t a t i m e o f y o u r c o n v e n i e n c e , l a s t i n g a p p r o x i m a t e l y o n e h o u r . T h i s . i n t e r v i e w w i l l b e t a p e r e c o r d e d . T h e i n t e r v i e w w i l l c o n s i s t o f a s e r i e s o f q u e s t i o n s • d e s i g n e d t o a s k y o u a b o u t w h a t t h i n g s y o u f e e l y o u n e e d e d t o l e a r n a b o u t t o h e l p y o u r e c o v e r f r o m y o u r h e a r t v a l v e s u r g e r y . - A t t h e e n d o f t h e i n t e r v i e w , a f e w q u e s t i o n s r e g a r d i n g b a c k g r o u n d i n f o r m a t i o n w i l l b e a s k e d , s u c h a s d a t e o f s u r g e r y a n d t y p e o f v a l v e i m p l a n t e d . A t a n y p o i n t i n t h e i n t e r v i e w y o u m a y d e c i d e t o h a v e t h e t a p e t u r n e d o f f o r p o r t i o n s o f i t e r a s e d . Y o u r : n a m e w i l l n o t b e u s e d , a n d y o u w i l l n o t b e i d e n t i f i e d i n a n y w a y i n t h e r e s u l t s . T h e r e i s t h e p o s s i b i l i t y o f t h e n e e d f o r a s e c o n d i n t e r v i e w l a s t i n g a p p r o x i m a t e l y 1 5 o r 2 0 m i n u t e s . T h i s w o u l d o n l y h a p p e n i f t h e r e w a s a n e e d t o c l a r i f y s o m e o f t h e i n f o r m a t i o n p r e v i o u s l y p r o v i d e d . I f t h i s i s r e q u i r e d , y o u w i l l b e c o n t a c t e d b y t e l e p h o n e . A l l t h e i n f o r m a t i o n c o l l e c t e d w i l l b e d e s t r o y e d a f t e r i t h a s b e e n a n a l y z e d . 167 You w i l l also have the opportunity to ask me questions regarding your recovery and I w i l l endeavour to a s s i s t you where possible. You have the right to refuse to participate i n this study and your refusal w i l l i n no way affect your present or future medical or nursing care. If you aire w i l l i n g to participate, please provide your name and phone number on the sheet provided, and give this to the physician or o f f i c e assistant ( i f you are at your doctor's office) or the assistant head nurse ( i f you are i n ho s p i t a l ) . I w i l l contact you by telephone over the next few days to arrange a suitable time for an interview. Thank you for your time, Andrew Lesperance RN, BSN, Phone: 224-3214 Carol J i l l i n g s PhD, Phone: 822-7479 Research Supervisor Associate Professor UBC School of Nursing Heart Valve Replacement P a t i e n t s ' , Perceptions of T h e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge 168 B y p r o v i d i n g my n a m e a n d p h o n e n u m b e r , I am g i v i n g p e r m i s s i o n t o A n d r e w L e s p e r a n c e t o c o n t a c t me b y t e l e p h o n e t o d i s c u s s p a r t i c i p a t i o n i n t h i s r e s e a r c h s t u d y . N a m e : T e l e p h o n e N u m b e r : Appendix B Consent Form f o r the Research • • 1 7 0 Heart Valve Replacement P a t i e n t s 1 Perceptions of T h e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge Consent form B y p r o v i d i n g my s i g n a t u r e I am c o n s e n t i n g t o p a r t i c i p a t e i n a-s t u d y w h o s e p u r p o s e i s t o i d e n t i f y w h a t h e a r t v a l v e r e p l a c e m e n t p a t i e n t s f e e l t h e y n e e d t o k n o w a f t e r h e a r t s u r g e r y i n o r d e r t o b e t t e r m a n a g e r e c o v e r y a t h o m e . T h e s t u d y , i t s p u r p o s e a n d w h a t i s e x p e c t e d o f me h a v e b e e n f u l l y e x p l a i n e d t o m e . I u n d e r s t a n d t h a t I m a y a s k a n y q u e s t i o n s I c h o s e . w h i c h a r e r e l e v a n t t o t h e s t u d y . I r e a l i z e t h a t I am f r e e t o w i t h d r a w f r o m t h e s t u d y a t a n y t i m e a n d am u n d e r n o o b l i g a t i o n t o c o m p l e t e t h i s f o r m . I h a v e b e e n t o l d t h a t f a i l u r e . t o p a r t i c i p a t e i n t h i s s t u d y w o u l d i n n o w a y j e o p a r d i z e m y p r e s e n t o r f u t u r e n u r s i n g o r m e d i c a l c a r e . I f u r t h e r a g r e e t h a t A n d r e w L e s p e r a n c e i s a l l o w e d t o v i s i t w i t h me i n m y h o m e a t a m u t u a l l y , c o n v e n i e n t t i m e , i n o r d e r t o c o n d u c t t h e r e q u i r e d o n e h o u r i n t e r v i e w . I u n d e r s t a n d t h a t t h e i n t e r v i e w w i l l b e t a p e r e c o r d e d a n d t h a t t h e t a p e s w i l l b e . • e r a s e d w h e n t h e . s t u d y i s c o n c l u d e d . I a l s o u n d e r s t a n d t h a t I m a y r e q u e s t t o h a v e t h e t a p e t u r n e d o f f o r a n y p a r t o f i t e r a s e d a t a n y p o i n t d u r i n g t h e i n t e r v i e w . I u n d e r s t a n d t h a t t h e r e i s s o m e d e m o g r a p h i c i n f o r m a t i o n r e q u i r e d s u c h a s t h e t y p e o f v a l v e I h a d i m p l a n t e d , t h e d a t e , o f my s u r g e r y , my a g e a n d l e v e l o f e d u c a t i o n . I a l s o u n d e r s t a n d t h a t a- s e c o n d i n t e r v i e w l a s t i n g n o m o r e t h a n 1 5 t o 2 0 m i n u t e s m a y b e r e q u e s t e d i n o r d e r t o c l a r i f y t h e r e s p o n s e s p r o v i d e d . I h a v e b e e n i n f o r m e d t h a t m y i d e n t i t y w i l l b e k e p t c o n f i d e n t i a l , a l t h o u g h p o r t i o n s o f t h e t r a n s c r i b e d i n t e r v i e w -m a y b e s h a r e d w i t h t h e r e s e a r c h e r ' s s u p e r v i s o r s . A n y i d e n t i f y i n g d a t a s u c h a s my n a m e w i l l b e o m i t t e d p r i o r t o t h e s h a r i n g o f s u c h i n f o r m a t i o n ; 1 7 1 A l l m y q u e s t i o n s p e r t a i n i n g t o t h e s t u d y h a v e b e e n a n s w e r e d b y A n d r e w L e s p e r a n c e . I h a v e r e c e i v e d a c o p y o f t h e l e t t e r o f i n f o r m a t i o n a n d t h e c o n s e n t f o r m . I h a v e b e e n i n f o r m e d t h a t i f I c h o o s e , I m a y o b t a i n a s u m m a r y o f t h e r e s u l t s a t t h e c o n c l u s i o n o f t h e s t u d y , a n d g i v e p e r m i s s i o n t o A n d r e w L e s p e r a n c e t o m a i l t h i s t o m e . N a m e : D a t e : W i t n e s s : D a t e : R e s e a r c h e r : A n d r e w L e s p e r a n c e R N , B S N U B C S c h o o l o f N u r s i n g P h o n e : 2 2 4 - 3 2 1 4 S u p e r v i s o r : C a r o l J i l l i n g s P H D A s s o c i a t e P r o f e s s o r U B C S c h o o l o f N u r s i n g P h o n e : 8 2 2 - 7 4 7 9 172 Appendix C Learning Needs Interview Guide 173 Heart Valve Replacement P a t i e n t s ' Perceptions of T h e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge L e a r n i n g N e e d s I n t e r v i e w G u i d e O p e n i n g S t a t e m e n t : P e o p l e w h o h a v e h a d h e a r t s u r g e r y s i m i l a r t o y o u r s e x p e r i e n c e m a n y d i f f e r e n t i s s u e s a f t e r s u r g e r y . W h i l e c a r i n g f o r p a t i e n t s n u r s e s h a v e t r i e d t o d e t e r m i n e w h a t s o r t o f h e l p o r k n o w l e d g e p a t i e n t s w i t h h e a r t v a l v e r e p l a c e m e n t s w i l l n e e d o n c e t h e y a r e d i s c h a r g e d h o m e . M o r e a n d m o r e w e r e a l i z e t h a t t h e p a t i e n t i s t h e o n e w h o c a n b e s t p r o v i d e t h i s i n f o r m a t i o n a n d t h a t i s w h a t my s t u d y i s a b o u t . I am i n t e r e s t e d i n y o u r p e r s p e c t i v e r e g a r d i n g w h a t y o u f e e l y o u ' v e n e e d e d t o k n o w a b o u t s i n c e t h e t i m e o f y o u r h o s p i t a l d i s c h a r g e i n o r d e r t o a s s i s t i n y o u r r e c o v e r y . N o w t h a t y o u h a v e b e e n h o m e f o r s e v e r a l w e e k s : l a ) D e s c r i b e f o r me w h a t s u b j e c t s o r i s s u e s y o u f e e l y o u ' v e n e e d e d t o l e a r n a b o u t i n o r d e r t o h e l p w i t h y o u r d a i l y a c t i v i t i e s a n d r e c o v e r y ? b ) W h e n d i d y o u f i r s t n o t i c e t h a t y o u n e e d e d t o f i n d o u t a b o u t ( X X X X ) ? c ) I ' d l i k e t o k n o w h o w y o u w e n t a b o u t f i n d i n g o u t w h a t y o u n e e d e d t o k n o w a b o u t ( X X X ) ? ( W h o , w h a t s o u r c e s , w h e r e ? ) d ) I ' m i n t e r e s t e d i n k n o w i n g i f i n f o r m a t i o n r e g a r d i n g ( X X X X ) w a s p r o v i d e d t o y o u b e f o r e b e i n g d i s c h a r g e d f r o m t h e h o s p i t a l a n d i f i t w a s a d e q u a t e ? 2) I ' d l i k e t o h e a r a b o u t w h a t other s u b j e c t s o r i s s u e s y o u f e e l y o u ' v e n e e d e d t o l e a r n o r g e t i n f o r m a t i o n a b o u t i n o r d e r t o h e l p w i t h t o d a y ' s a c t i v i t i e s a n d r e c o v e r y ? ( Q u e s t i o n s 1. (b) t o (d ) w i l l t h e n b e r e p e a t e d . Interview Guide T e l l me w h a t y o u ' v e n e e d e d t o k n o w a b o u t / o r O t h e r p e o p l e h a v e d i s c u s s e d t h e n e e d f o r i n f o r m a t i o n a n d e d u c a t i o n p e r t a i n i n g t o : 1. B r e a t h i n g / R e s p i r a t i o n ( S p l i n t i n g , c o u g h i n g , p a i n ) T o p i c d i s c u s s e d W h e n n o t e d t h a t i n f o w a s n e e d e d • 2 . D i e t / N u t r i t i o n ( c h a n g e s , a p p e t i t e , w e i g h t l o s s / g a i n ) T o p i c d i s c u s s e d W h e n n o t e d t h a t i n f o w a s n e e d e d 3 . E l i m i n a t i o n / B o w e l f u n c t i o n -T o p i c d i s c u s s e d W h e n n o t e d t h a t i n f o w a s n e e d e d . 4 . A c t i v i t y / P o s t u r e T o p i c d i s c u s s e d _____ W h e n n o t e d t h a t i n f o w a s n e e d e d 5. R e s t a n d S l e e p ( p a i n a n d i t s ' e f f e c t s ) T o p i c d i s c u s s e d _____ W h e n n o t e d t h a t i n f o w a s n e e d e d 6 . C l o t h i n g / D r e s s i n g / U n d r e s s i n g T o p i c d i s c u s s e d • ' W h e n n o t e d t h a t i n f o w a s n e e d e d 7 . B o d y T e m p e r a t u r e T o p i c d i s c u s s e d . . W h e n n o t e d t h a t i n f o w a s n e e d e d . 175 8. Integument (Care pf in c i s i o n , wound) Topic discussed When noted that info was needed 9. Adapting to the environment (safety, cleaning, laundry, s t a i r s , tub, valve clicking) Topic discussed When noted that info was needed 10. Emotions/Communications (mood swings, depression, anxiety sexual a c t i v i t y ) Topic discussed When noted that info was needed ; ; 11. Religious and s p i r i t u a l needs Topic discussed . When noted that info was needed. 12. Work/Productive Occupation Topic discussed When noted that info was needed 13. Recreational A c t i v i t i e s (driving, f l y i n g , travel) Topic discussed When noted that info was needed 14. Learning about disease/illness, medications, rehab (prophylactic a n t i b i o t i c s , valve c l i c k i n g , pregnancy and meds) Topic discussed When noted that info was needed . '. •• • •• , -.• . ', •.. 17 3) These days patient education can happen i n many ways. What ••.. . '/, '". • do you think i s the best way for you and other.patients l i k e yourself to be provided with education.and information related to recovering from open heart surgery? 4) Describe for me when i t would have been most b e n e f i c i a l for you to receive patient education and information.pertaining to your recovery? 5) Whom do you. believe should be providing this information? This can be more than one person. 6) Please f e e l free to provide any other information you f e e l ' ... ;'• - • V • ' would be helpful. ,. Demographic information to be asked at the end of the i n t e r v i e w . 1. Age:_ 2. What type of valve did you have implanted during your > surgery: Mechanical • "• ... Porcine (Pig) - ". 3'. 1 Can you t e l l me what grade you completed i n school? 4. Date of Surgery: ~. .. - • 5. Date of Discharge: '• '• — 6. Please f e e l free to provide any other information you fe e l would be helpful Appendix D Information L e t t e r to the Surgeons 1 7 8 Heart Valve Replacement P a t i e n t s ' Perceptions of Th e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge Dear Dr. My name i s Andrew Lesperance and I am a Registered Nurse i n the Master of Science i n Nursing program at the University of B r i t i s h Columbia. I am conducting a research study for my thesis, that seeks to determine the learning needs of heart valve replacement patients four to ten weeks after hospital discharge. With the present trend toward early discharge of patients form hospital, the need for post operative patient education i s essential. , I would l i k e to access and interview twenty heart valve replacement patients from the Vancouver Hospital and Health Sciences Centre for this study. Because some of the potential participants w i l l be your patients, your permission to approach the patient i s presently being sought. Potential candidates w i l l have undergone their f i r s t heart valve replacement without bypass. They must speak English and reside i n the Greater Vancouver Area. They must also provide their consent to participate i n the study. In addition, I would l i k e to rec r u i t potential participants from your o f f i c e at the time of their follow up v i s i t . This would require having your o f f i c e assistant (or yourself) asking patients i f they are w i l l i n g to participate, as well as providing them with a l e t t e r of information (provided by myself) which de t a i l s the purpose and conditions of the study.. When patients agree to participate, they w i l l place their name and number on a sheet provided and remit this to your o f f i c e . I w i l l c o l l e c t these p e r i o d i c a l l y . There i s no additional commitment on your part. If you have any questions regarding this study, I may be . reached at home at 224-3214. 179-Consent: I, the undersigned, consent to my patients who have had valve replacement surgery being approached while i n hospital to request th e i r p a r t i c i p a t i o n i n this study. Signature: Date: I further consent to patients/being recruited from my o f f i c e at the time of their six week follow up v i s i t . Signature: ; Date: Thanking you i n advance for your assistance Andrew Lesperance RN, BSN Phone: 224-3214 Carol J i l l i n g s PHD Phone: 822-7479 Research Supervisor Associate Professor UBC School of Nursing 1 8 0 Appendix E Intermediary Information Sheet 1 8 1 Heart Valve Replacement P a t i e n t s 1 Perceptions of T h e i r Learning Needs Four to Ten Weeks a f t e r H o s p i t a l Discharge I n f o r m a t i o n t o b e r e a d t o p o t e n t i a l p a r t i c i p a n t s v i a t h e i n t e r m e d i a r y : H e l l o We h a v e a M a s t e r s S t u d e n t w i t h t h e U B C S c h o o l o f N u r s i n g w h o i s l o o k i n g t o i n t e r v i e w p e o p l e f o r h i s m a s t e r s t h e s i s . H e i s w a n t i n g t o f i n d o u t w h a t t h i n g s h e a r t v a l v e r e p l a c e m e n t p a t i e n t s f e e l t h e y n e e d t o l e a r n a b o u t i n o r d e r t o r e c o v e r f r o m s u r g e r y . I f y o u a r e o v e r 2 5 , f l u e n t i n E n g l i s h , l i v i n g i n t h e L o w e r M a i n l a n d , h a v e h a d a h e a r t v a l v e i m p l a n t e d f o r t h e f i r s t t i m e a n d w i l l i n g t o p a r t i c i p a t e i n t h i s s t u d y , I w i l l p r o v i d e y o u w i t h a n i n f o r m a t i o n l e t t e r f r o m A n d r e w L e s p e r a n c e w h i c h p r o v i d e s g r e a t e r d e t a i l a b o u t t h e s t u d y . I f y o u l i k e , we c a n r e v i e w t h i s l e t t e r t o g e t h e r , o r I w i l l l e a v e i t w i t h y o u t o r e a d . 1 8 2 A p p e n d i x F D e m o g r a p h i c s T a b l e s Table I Aae Ranges Age Females Males T o t a l 25-35 1 1 2 36-45 1 1 2 46-55 0 2 2 56-65 3 1 4 66-75 3 3 6 76+ 1 1 2 Table II S u r g i c a l Replacement Valve Females Males T o t a l A o r t i c 3 7 10 M i t r a l 4 2 6 Combination 2 0 2 Table I I I Education L e v e l Females Males T o t a l To Grade 8 2 3 5 Grade 9-12 3 3 6 College/ 4 3 7 U n i v e r s i t y 

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