[Psychosocial stress and utilization of medical services after coronary bypass operation]

This study examines the relationship between psychosocial stress and social support before coronary surgery and the amount of health care utilization in a sample of 136 patients during postoperative hospitalization. The aim of the study is to test the hypothesis that there is a correlation between a high psychosocial stress profile and the utilization of medical care (so called high utilizers). The sample consists of 80.7% men and 19.3% women aged between 31 and 78 years (mean 64; sd 9.1). In this first data analysis psychosocial impact is assessed by anxiety, depression and social support (HADS-D, F-SOZU). Detailed somatic factors concerning severity of the illness, inpatient course and the utilization of health care (medication, technical examinations, consultations) are assessed by means of a documentation system. With regard to anxiety, depression and social support the sample is located within the normal range. In contrast to our expectations the results show that high scores of anxiety and depression as well as a low level of emotional support do not correlate significantly with an increased use of medication, the number of consultations and technical examinations. Furthermore no correlation has been found between the length of hospitalization and preoperative comorbidity as compared to the mentioned psychosocial stress variables. On the other hand the data analysis showed that about 30% of the patients during the postoperative period utilize about half of the total amount of the different medical treatments. In the postoperative period these high utilizers cannot be distinguished from the other patients, neither by sociodemographic variables nor by means of an increased psychosocial stress or severity of illness.

Coronary artery bypass graft surgery patients and their family member caregivers: outcomes of a family-focused staged psychoeducational intervention

This experimental study examined the effectiveness of a psychoeducational intervention delivered over 12 weeks. The sample was comprised of 38 coronary artery bypass graft (CABG) surgery patient-family member caregiver dyads who completed all six data collection points. Experimental and control groups did not differ in emotional health, functional health status, or satisfaction. Differences in the number of self-reported complications/symptoms were not in the predicted direction. Improvement occurred in clinical, functional, and emotional outcomes; however, several symptoms, such as fatigue and pain, persisted. Family caregivers reported more depressive symptoms than patients preoperatively and at later stages of recovery. Implications include the need for instruction about the recovery trajectory and adequate preparation and support of home health nurses and family caregivers.

Cardiovascular outcomes initiative: case studies in performance improvement

Multidisciplinary health care teams are trying to change practice in ways that will improve patient outcomes. Three case studies are presented that demonstrate such practice changes. The practice changes involved a multidisciplinary team working toward commonly defined goals over an 18-month period. Several goals were attained, and lessons learned are presented. Nursing staff played a significant role in identifying and implementing the recommended changes.

Mood state as a predictor of neuropsychological deficits following cardiac surgery

OBJECTIVES

mood disorders and neuropsychological deficits are both commonly reported occurrences after cardiac surgery. We examined the relationship between mood state and postoperative cognitive deficits in this population.

METHODS

assessments of neuropsychological functions and mood state (depression, anxiety, stress scales; DASS) were performed preoperatively and postoperatively on 147 patients undergoing cardiac surgery.

RESULTS

the incidence of preoperative depression, anxiety, and stress symptomatology was 16%, 27%, and 16%, respectively. The incidence of postoperative anxiety symptomatology significantly increased to 45% (p<0.001), while the incidence of depression and stress symptomatology remained stable (19% and 15%, respectively; ns). Changes in mood state did not influence changes in neuropsychological performance. Preoperative mood was a strong predictor of postoperative mood, and was related to postoperative deficits on measures of attention and memory.

CONCLUSIONS

an assessment of preoperative mood is critical in identifying patients at risk of postoperative mood disorders and neuropsychological deficits. Measures assessing somatic manifestations of anxiety may not be suitable for a surgical population.

Guided imagery: replication study using coronary artery bypass graft patients

Replication of a guided imagery study, based on the work of D. Tusek and colleagues, was initiated for coronary artery bypass graft patients, using the Center for Advanced Nursing Practice's Evidence-Based Practice Model. Through the leadership of clinical nurse specialists and the support of perioperative and postoperative bedside clinicians, this initiative offered benefits to patients and served as a template for program expansion to other patient populations.

Sense of coherence: quality of life before and after coronary artery bypass surgery--a longitudinal study

The attention to patient outcome has nowadays extended from morbidity and mortality to an aspect of patients' benefits in terms of quality of life. One factor crucial for quality of life is coping capacity, in this study represented by the sense of coherence concept. Physical status and emotional state (often measured by comprehensive instruments not always suitable for clinical use) are also additionally used to reflect quality of life. The purpose was therefore to study sense of coherence and emotional state as indirect measures of quality of life in relation to coronary artery bypass grafting surgery. One hundred and eleven patients were studied by a developed questionnaire on five occasions in relation to the surgery: the week before the angiography, the day before surgery and then at 3, 6, and 12 months post-operatively. The main findings were: (1) The sense of coherence was changed (more than +/-10%) from before to 1 year after surgery in 41% of the patients, which is contrary to the theory of sense of coherence as a stable personality characteristic in adults. (2) Experience of depressed mood, stress, and anxiety decreased significantly from before to after surgery. (3) Beneficial outcome with regard to sense of coherence was significantly related to less experience of loneliness, depressed mood, stress and anxiety, and to less experience of chest pain 1 year after surgery. In conclusion, sense of coherence and emotional state variables, are suggested to be valuable as measurements of quality of life in relation to coronary artery bypass grafting surgery.

Similar-other support for men undergoing coronary artery bypass surgery

This field experiment examined effects of a support intervention on the physical and mental health of coronary artery bypass graft (CABG) surgery patients. Control participants (N = 90) received usual hospital care; experimental participants (N = 100) also received visits from a "similar other" while in the hospital. Similar others were Veterans Administration veterans who had CABG surgery previously and were trained in simple supportive techniques. Outcomes were assessed prior to surgery and at 1, 6, and 12 months afterwards. Unexpectedly, the intervention generally had no effects on participants' well-being. Further analysis showed that participants who talked often with fellow cardiac patients in the hospital ("de facto similar others") experienced improvements in their physical and emotional well-being over time.

Concerns and risk factor modification in women during the year after coronary artery surgery

BACKGROUND

Future plans or return to a usual lifestyle has been shown to be of concern to persons recovering from coronary artery surgery. However it is not clear whether early concerns remain stable or evolve over time.

OBJECTIVE

To examine women's concerns about having coronary artery surgery and living with coronary artery disease after surgery over time.

METHODS

Concerns and risk factor modification strategies were measured in 55 women at 1, 6, and 12 months after coronary artery surgery. The Carr and Powers Stressor Scale and an investigator-developed interview were used.

RESULTS

Women's primary concerns shifted over the year from surgical recovery to living with coronary heart disease. At 1 month after surgery, issues related to future plans, such as progress in recovery and resuming lifestyle, were rated as causing the most concern. Concern about diet was the highest rated concern 1 year after surgery. More than half of the women reported exercising more, and approximately three fourths reported eating a better diet 1 year after surgery.

CONCLUSIONS

The findings demonstrate that women are concerned about diet and exercise, and many women attempt to change their behavior. Capitalizing on women's concerns about living with coronary artery disease may help address risk factors. However, specialized interventions may be needed that focus on women who are not concerned about and/or not engaged in risk reduction behaviors.

Uncertainty and expectations: taking care of a cardiac surgery patient at home

Family members of postsurgical patients are, by necessity, taking on the caregiving role sooner without any specified resources to help them. The input of these caregivers is essential so nurses can understand their concerns, needs, and struggles and develop strategies to support the caregivers in their caregiving role. This study was designed to increase nursing knowledge regarding the experiences of being a caregiver of a cardiac surgery patient during the immediate postdischarge period. The qualitative research method of Interpretative Description, first described by Thorne, Kirkham, and MacDonald-Emes in 1997 guided the study. In-depth interviews were held with eight spousal caregivers. Findings revealed that the experience was molded by caregivers' past participation as a caregiver, as well as caregivers' and care recipients' outlook on life, their interpersonal relationship, and their expectations. Caregivers engaged in the process of caregiving that involved being vigilant and monitoring the care recipient's recovery, implementing strategies to assist the recovery process, and taking on a role to provide care and seek help as required. The encounter with caregiving affected all realms of caregivers' lives, and they experienced feelings of stress, vulnerability, and having to put their lives on hold; these feelings were often compounded by uncertainty.

Carers' opinions and emotional responses following cardiac surgery: cardiac rehabilitation implications for critical care nurses

The recent joint position statement made by the RCN Critical Care and Rehabilitation Nursing Forums highlights the need for rehabilitation to commence early. This paper reports the findings of a descriptive survey of 59 carers of cardiac surgery patients and presents implications for cardiac rehabilitation. Data were obtained by postal questionnaire during early recovery (one week following discharge) and six weeks later. The questionnaire explored carers' perceptions about the timing of discharge from hospital; opinions of the information provided by hospital staff; and anxiety and depression measured on the Hospital Anxiety and Depression Scale. The results indicated that carers assumed a heavy burden once the patient had left the specialist cardiac centre. Carers responding at one week were less satisfied with the timing of discharge than those questioned at six weeks. Information provided by nurses was rated more highly than that provided by doctors or physiotherapists. However, there was scope for increasing input. The findings suggest that cardiac rehabilitation needs to be aimed at carers as well as patients. Investment in targeted carer support could facilitate patient recovery and rehabilitation. Strategies aimed at the carer need to begin early and commence during the acute stage of the patients' recovery.

The effects of self-hypnosis on quality of life following coronary artery bypass surgery: preliminary results of a prospective, randomized trial

The effects of complementary techniques and alternative medicine on allopathic therapies is generating much interest and research. To properly evaluate these techniques, well controlled studies are needed to corroborate the findings espoused by individuals practicing complementary medicine therapies. To this end, we evaluated the role of one of these therapies, self-hypnosis relaxation techniques, in a prospective, randomized trial to study its effects on quality of life after coronary artery bypass surgery. Subjects were randomized to a control group or a study group. Study group patients were taught self-hypnosis relaxation techniques the night prior to surgery. The control group received no such treatment. Patients then underwent routine cardiac management and care. The main endpoint of our study was quality of life, assessed by the Profile of Moods Scale. Results demonstrated that patients undergoing self-hypnosis the night prior to coronary artery bypass surgery were significantly more relaxed than the control group (p = 0.0317). Trends toward improvement were also noted in depression, anger, and fatigue. This study demonstrates the beneficial effects of self-hypnosis relaxation techniques on coronary surgery. This study also identifies endpoints and a study design that can be used to assess complementary medicine therapies. Results of this preliminary investigation are encouraging and demonstrate a need for further well-controlled studies.

Reliability and validity of the Food Pyramid Self Efficacy Scale: use in coronary artery bypass patients

Inappropriate dietary intake is associated with 5 of the 10 leading causes of U.S. death; coronary artery disease (CAD) ranks highest regardless of gender in people over the age of 65. Of the modifiable risk factors for CAD, two of four pertain to food choices. Although lifestyle habits can enhance or impair health, people's beliefs that they can motivate and regulate their own behavior (self efficacy) plays a crucial role in whether they even consider changing detrimental health habits. The Food Pyramid Self Efficacy Scale (FPSES) is an instrument to measure an elder's confidence in his/her ability to choose healthy food items in a variety of situations. The purpose of this study was to determine the reliability and validity of the FPSES. Thirty postoperative CABG patients participated (mean age 70.4). FPSES test-retest (r = 0.78, p = 0.008); coefficient alpha = 0.92. Six content experts judged the FPSES (content validity index [CVI] = 0.85). Construct validity of the instrument was achieved through hypothesis testing, supporting the statement that the higher the nutritional risk, the greater the functional decline (r = 0.37, p = 0.05). As many of the health problems associated with the elderly are preventable or controllable through health promotion, it is vital that measures exist to determine a person's confidence that one believes in the capability to change to healthy eating behaviors.

Anxiety, depression and sleep in male patients undergoing coronary artery bypass surgery

The aim of this study was to examine the prevalence of depression and anxiety following coronary artery bypass surgery (CABG) and to see how those patients with depression and anxiety differ in sleeping pattern. The individual reaction to sleep loss was tested as a predictor of certain emotional symptoms in the follow-up period. Thirty-eight males, between 45 and 68 years, were interviewed prior to, and 1 month after, surgery, and received a questionnaire at the 6-month follow-up. Eighty per cent scored moderate anxiety prior to surgery and six patients were depressed. An anxiety-prone individual reactivity persisted in the same patients in 38.9% (n = 14) following CABG, with significantly more sleep disturbances, firedness, energy deficits, immobility, and lower degree of quality of life (QoL). Sad/depressed mood or cognitive/behavioural fatigue symptoms as reactions to sleep loss were predictors of sleep problems and daytime sequelae, whereas a higher postoperative NYHA class was predicted by cognitive/behavioural fatigue and dysphoria reactions. Being less refreshed by sleep on final awakening prior to surgery related to 44.5% of the variance in QoL outcome 6 months following surgery. In conclusion, an anxiety-prone individual reactivity is significantly associated with sleep disturbances. Reactions to sleep loss prior to surgery are associated with emotional distress after surgery.

Social support and physical and psychological recovery one year after myocardial infarction or coronary artery bypass surgery

The aim of this study was to evaluate the role of different support factors supposed to explain physical and psychological recovery after myocardial infarction (MI) or coronary artery bypass surgery (CABS). The subjects comprised 147 MI patients and 159 CABS patients. Support factors included formal services, semi-formal assistance, and informal social support. The outcome measures used for analysis were functional activities level (Duke Activity Status Index, DASI), physical working capacity, anxiety, and depression one year after MI or CABS. In general, support factors had a limited role in this study. The patient's functional and psychological status at three months was the main determinant to recovery at one year. The outcome factors measured at three months explained 36-56% of their variance at one year, and the support factors increased the explanatory power by 0-10%. The support model employed in this study revealed that some single factors may have a positive or negative role in the recovery after MI or CABS.

[The medical rehabilitation of servicemen following aortocoronary bypass]

The results of aortocoronary shunting (ACSh) were studied in 243 patients after myocardial infarction at different stages of rehabilitation--in rehabilitative hospital and military sanatorium. Result assessment at the final stage of therapy in sanatorium confirmed ACSh efficiency in overwhelming majority of patients. At the same time principal peculiarities were revealed showing the necessity of differential approach to determination of volume and place for conduction of restorative therapy. Process of successful adaptation in most patients is achieved during the periods up to 8 weeks that corresponds to two-staged rehabilitative system. More long periods of therapy are required for patients having complications not arrested at hospital stage, low exercise tolerance, poor psychological readaptation. Optimization of rehabilitative system in order to determine the volume and place of rehabilitation will contribute to further improvement of staged therapy in such patient group.

The determinants of CABG patients' outcomes

This study examined the self-reported health status of 90 patients who had undergone Coronary Artery Bypass Grafting (CABG). Data were collected by the Short Form-36 (SF-36) instrument, administered twice at preoperative and postoperative periods. The reliability of the SF-36 ranged from 0.68 to 0.93 in the analysis of preoperative and postoperative measures of health status. The CABG patients reported markedly lower health status on all eight SF-36 dimensions at the preoperative period and considerable improvements on all dimensions at the postoperative period. The assessment of CABG patients' outcomes showed that perceived usefulness of the procedure contributed positively to their perceived health status when the effect of preoperative health status was controlled. Patients who perceived the CABG procedure as useful appeared to have more improved postoperative health status after the procedure.

Predictors of chest pain after coronary artery bypass grafting

To identify preoperative biopsychosocial factors characterizing patients who will experience chest pain (self-reported) one year after coronary artery bypass grafting (CABG), 111 patients under 61 years of age were evaluated by questionnaire before CABG and 12 months postoperatively. A "Coronary Health Profile" was evolved to study quality-of-life indicators, e.g. "Sense of Coherence" (SOC), emotional state (loneliness, depressed mood, stress, anxiety) and social support as well as experience of chest pain, and the results were correlated to biomedical data. Chest pain was experienced in the first postoperative year by 34% of the patients. These patients, who were younger than those without chest pain, generally had a body mass index >25, as well as lower preoperative values for SOC, poorer emotional state and social support. Independent predictors in a multivariate stepwise logistic regression analysis were moderate/weak SOC, ejection fraction <50%, and moderate/severe mood depression. We conclude that biomedical as well as psychosocial factors have a significant impact as predictors of chest pain (of any origin) after CABG, and must be considered in preoperative evaluation. The findings indicate the need for biopsychosocial support/intervention before as well as after CABG.

[Good quality of life after heart surgery. Comparable ratings by patients and their relatives]

In a series of 83 patients undergoing coronary artery bypass grafting for angina, perceived QOL (quality of life) was rated by the patients and their spouses, preoperatively and at two and 12 months postoperatively, using the SWED-QUAL instrument. One year after surgery, QOL had improved to a level which might be expected of a normal population comparable in age and gender distribution. Good correlation existed between patient and spouse ratings, especially on physical measures.

Being in the world of the suffering patient: a challenge to nursing ethics

Ethics in caring is what we actually make explicit through our approach and how we invite the suffering patient into a caring relationship. This phenomenological study investigates suffering and health and how this presupposes a deeper reflection on ethics in caring. The aim was to try to discover, describe and understand how patients experience their life situation three years after undergoing surgery. The theoretical approach is based on central aspects of Eriksson's caritative theory (i.e. the view of the person as body, soul and spirit). The informants were four women and four men aged between 55 and 77 years. The empirical material revealed suffering that was connected with both illness and life. Suffering involves experiences of grief, loneliness and struggling. Health implies a yearning for something beyond the current life situation, a yearning to experience some meaning in life. This leads to an awareness of unplumbed possibilities. Understanding the experiences of individual patients demands of us, as both researchers and nurses, to act, seeking after the scientific truth (i.e. a deeper reflection of the ontological, epistemological and methodological questions). The idea of responsibility helps us to interpret and meet the innermost desires of suffering patients in their true presence. Caritative caring ethics means 'being there', confirming patients' absolute dignity; it is a manifestation of the love that 'just exists'. Compassion requires an inner disposition to go with others to the places where they are weak, vulnerable, lonely and broken. An ontology of caring provides both a starting point and a context for reflection about ethics and the ethical life.

Life course of people with coronary artery disease

The purpose of this study was to describe the life course of coronary artery disease patients from their own perspective at the onset of coronary artery disease and during both the in-patient period and the one-year period of aftercare. Nineteen people selected from a population of 200 patients who had undergone either coronary artery bypass surgery or percutaneous transluminal coronary angioplasty were available for thematic interviews. Interviews were conducted one year after the treatment in the subject's homes. Analyses revealed two distinct types of life course; accepting and progressive, as opposed to non-accepting and regressive. Participants who represented an accepting and progressive life course achieved a better level of rehabilitation than those with a non-accepting and regressive life course. If health care personnel are able to identify the problems related to a non-accepting, regressive life course, they will be better able to support patients' individual life course planning. According to the present findings, a rehabilitation programme is particularly needed for patients with acute onset of coronary artery disease at a relatively early age, disruption of an active working career, financial problems, dissatisfaction with outcome of treatment, family problems and a dismal view of the future. The findings challenge health care personnel to listen to coronary patients' own experiences.

Quality of life comparisons after coronary angioplasty and coronary artery bypass graft surgery

OBJECTIVE

To examine the differences in realization of expected benefits, complications, and quality of life (QOL) 3 months after percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery.

DESIGN

Nonexperimental, prospective, and comparative. Before discharge, participants listed benefits expected from the procedure, as well as comorbid health problems (Charlson Comorbidity Index) and complications. At 3 months, they quantified their realization of expected benefits, reported postdischarge complications, and completed Ferrans and Powers' Quality of Life Index-Cardiac Version III.

SAMPLE

36 patients who had PTCA; 38 patients who had CABG.

RESULTS

There were no differences between groups in realization of expected benefits or QOL. Patients who had CABG reported a greater number of complications after discharge, and a greater proportion of patients who had PTCA reported angina. Patients who had PTCA and then recurrent angina had significantly lower health QOL and psychologic and spiritual QOL.

CONCLUSIONS

Patients who undergo CABG need guidance regarding what complications to expect, and patients who undergo PTCA need to know that recurrent angina is possible and how to manage it.

Plasma catecholamines, pharmacotherapy and mood of subjects with cardiovascular disorder

This study investigated whether drug therapy explains why the concentration of arterial plasma catecholamines in patients who have received an orthotopic heart transplant (OHT) or coronary bypass and graft (CABG) is greater than in those with heart failure (HF). The results suggest that the differences in plasma catecholamine concentrations in these groups of patients could not be attributed to administration of any of the drugs studied here. An additional finding is that the use of aspirin is associated with a higher concentration of plasma noradrenaline, but not adrenaline. Patients who were taking aspirin also had a more positive mood, as rated by the Profile of Mood States; this was mainly because they had a lower fatigue score than did patients who were not taking this drug. In contrast, several agents (warfarin, Ca2+-channel blockers and 'mixed cardiac' drugs), which had no effects on catecholamine overspill, were linked with negative mood; this was expressed consistently as a higher tension score. These findings suggest that drugs which are administered for their effects in the periphery could also influence patients' psychological status. With the possible exception of aspirin, this does not involve changes in spillover of catecholamines in the periphery.