Lifestyle Changes Following Acute Myocardial Infarction: Patients Perspectives

Risk factors among people surviving out-of-hospital cardiac arrest and their thoughts about what lifestyle means to them: a mixed methods study

BACKGROUND

The known risk factors for coronary heart disease among people prior suffering an out-of-hospital cardiac arrest with validated myocardial infarction aetiology and their thoughts about what lifestyle means to them after surviving have rarely been described. Therefore the aim of the study was to describe risk factors and lifestyle among survivors.

METHODS

An explanatory mixed methods design was used. All people registered in the Northern Sweden MONICA myocardial registry between the year 1989 to 2007 who survived out-of-hospital cardiac arrest with validated myocardial infarction aetiology and were alive at the 28th day after the onset of symptoms (n = 71) were included in the quantitative analysis. Thirteen of them participated in interviews conducted in 2011 and analysed via a qualitative manifest content analysis.

RESULTS

About 60% of the people had no history of ischemic heart disease before the out-of-hospital cardiac arrest, but 20% had three cardiovascular risk factors (i.e., hypertension, diabetes mellitus, total cholesterol of more or equal 5 mmol/l or taking lipid lowering medication, and current smoker). Three categories (i.e., significance of lifestyle, modifying the lifestyle to the new life situation and a changed view on life) and seven sub-categories emerged from the qualitative analysis.

CONCLUSIONS

For many people out-of-hospital cardiac arrest was the first symptom of coronary heart disease. Interview participants were well informed about their cardiovascular risk factors and the benefits of risk factor treatment. In spite of that, some chose to ignore this knowledge to some extent and preferred to live a "good life", where risk factor treatment played a minor part. The importance of the support of family members in terms of feeling happy and having fun was highlighted by the interview participants and expressed as being the meaning of lifestyle. Perhaps the person with illness together with health care workers should focus more on the meaningful and joyful things in life and try to adopt healthy behaviours linked to these things.

Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.

The experience of younger adults following myocardial infarction

The aim of this study was to elucidate the meaning of the experience of younger people (< 55 years) during their first year following a myocardial infarction. We analyzed 17 interviews using a phenomenological-hermeneutic method. The core theme and central phenomenon was the everyday fight to redress the balance in life, which encompassed an existential, physical, and emotional battle to regain a foothold in daily life. The aftermath of a life-threatening event involved a process of transition while at the same time creating a new meaning in life. Lack of energy and its impact on the complex interplay of midlife combined with unreasonable demands from employers and health care professionals seemed to color the experience of the informants. The knowledge gained in this study can constitute a valuable contribution to overall quality assurance in nursing care and the development of nursing interventions for the cardiac rehabilitation of younger patients.

Patients' perceptions of depression and coronary heart disease: a qualitative UPBEAT-UK study

BACKGROUND

The prevalence of depression in people with coronary heart disease (CHD) is high but little is known about patients' own perceptions and experiences of this. This study aimed to explore (i) primary care (PC) patients' perceptions of links between their physical condition and mental health, (ii) their experiences of living with depression and CHD and (iii) their own self-help strategies and attitudes to current PC interventions for depression.

METHOD

Qualitative study using consecutive sampling, in-depth interviews and thematic analysis using a process of constant comparison. 30 participants from the UPBEAT-UK cohort study, with CHD and symptoms of depression. All participants were registered on the General Practitioner (GP) primary care, coronary register.

RESULTS

A personal and social story of loss underpinned participants' accounts of their lives, both before and after their experience of having CHD. This theme included two interrelated domains: interpersonal loss and loss centred upon health/control issues. Strong links were made between CHD and depression by men who felt emasculated by CHD. Weaker links were made by participants who had experienced distressing life events such as divorce and bereavement or were living with additional chronic health conditions (i.e. multimorbidity). Participants also felt 'depressed' by the 'medicalisation' of their lives, loneliness and the experience of ageing and ill health. Just under half the sample had consulted their GP about their low mood and participants were somewhat ambivalent about accessing primary care interventions for depression believing the GP would not be able to help them with complex health and social issues. Talking therapies and interventions providing the opportunity for social interaction, support and exercise, such as Cardiac Rehabilitation, were thought to be helpful whereas anti-depressants were not favoured.

CONCLUSIONS

The experiences and needs of patients with CHD and depression are diverse and include psycho-social issues involving interpersonal and health/control losses. In view of the varying social and health needs of patients with CHD and depression the adoption of a holistic, case management approach to care is recommended together with personalised support providing the opportunity for patients to develop and achieve life and health goals, where appropriate.

Coping Experiences: A Pathway towards Different Coping Orientations Four and Twelve Months after Myocardial Infarction-A Grounded Theory Approach

Background. Patients recovering from a myocardial infarction (MI) are faced with a number of serious challenges. Aim. To create a substantive theory on myocardial infarction patients' coping as a continuum. Methods. Grounded theory method was used. Data were collected by using individual interviews. The informants were 28 MI patients. Results. The core category “coping experiences—a pathway towards different coping orientations” includes 2 main categories: “positive and negative coping experiences” (4 months after MI) and “different coping orientations” (12 months after MI). Conclusion. Coping with a myocardial infarction is a long-term dynamic process of dealing with varied emotions and adjustment needs. Coping is threatened, if the patient denies the seriousness of the situation, suffers from depression and emotional exhaustion, or if there are serious problems in the interaction with family members. This study stresses the importance of recognizing the patient's depressive state of mind and the psychological aspects which affect family dynamics. A more family-centered approach involving a posthospital counseling intervention is recommended. Relevance to Clinical Practice. The results of this study can be used in nursing care practice when organizing support interventions for myocardial infarction patients.

Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data

BACKGROUND

Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.

METHODS

Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.

RESULTS

From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.

CONCLUSIONS

There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

Matters of the heart: patients' adjustment to life following a cardiac crisis

In a sample of patients who experienced a myocardial infarction, coronary artery bypass graft surgery or both within the past year, we examined the extent to which patients' attempts to intrapersonally inhibit their emotions about their cardiac event and their attempts to disclose their feelings about the event to their partner predicted their psychological health (depression, anxiety, post-traumatic stress) and relational functioning (closeness, satisfaction). The more patients inhibited their feelings about their cardiac event, the poorer their psychological and relational functioning. Greater disclosure was associated with greater closeness to their partner. However, frequency of disclosure was also an indicator of level of distress, such that the more frequently patients talked about their feelings regarding the cardiac event with their partner, the more they had anxiety and post-traumatic stress symptoms. Important interactions of inhibition by disclosure on outcomes as well as moderation by time since the cardiac event were found and are discussed in greater detail.

The effects of Hartcoach, a life style intervention provided by telephone on the reduction of coronary risk factors: a randomised trial

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide. Secondary prevention is essential, but participation rates for cardiac rehabilitation are low. Furthermore, current programmes do not accomplish that patients with CVD change their lifestyle in a way that their individual risk factors for recurrent events decrease, therefore more effective interventions are needed. In this study, the effectiveness of the Hartcoach-programme, a telephonic secondary prevention program focussing on self management, is studied.

Methods/design

A multicenter, randomised parallel-group study is being conducted. Participants are 400 patients with acute myocardial infarction (STEMI, NSTEMI,) and patients with chronic or unstable angina pectoris (IAP). Patients are recruited through the participating hospitals and randomly assigned to the experimental group (Hartcoach-programme plus usual care) or the control group (usual care).

The Hartcoach-programme consists of a period of six months during which the coach contacts the patient every four to six weeks by telephone. Coaches train patients to take responsibility for the achievement and maintenance of the defined target levels for their particular individual modifiable risk factors. Target levels and treatment goals are agreed by the nurse and patient together. Data collection is blinded and occurs at baseline and after 26 weeks (post-intervention). Primary outcome is change in cardiovascular risk factors (cholesterol, body mass index, waist circumference, blood pressure, physical activity and diet). Secondary outcomes include chances in glucose, HbA1c, medication adherence, self-management and quality of life.

Discussion

This study evaluates the effects of the Hartcoach-programme on the reduction of individual risk factors of patients with CVDs. Patients who are not invited to follow a hospital based rehabilitation programme or patients who are unable to adhere to such a programme, may be reached by this home based Hartcoach-programme. If positive results are found, the implementation of the Hartcoach-programme will be extended, having implications for the management of many people with CVD.

Trial registration

NTR2388

Beyond resolutions? A randomized controlled trial of a self-regulation lifestyle programme for post-cardiac rehabilitation patients

BACKGROUND

As lifestyle adherence and risk factor management following completion of cardiac rehabilitation (CR) have been shown to be problematic, we developed a brief self-regulation lifestyle programme for post-CR patients.

DESIGN

Randomized-controlled trial.

METHODS

Following completion of CR 210 patients were randomized to receive either a lifestyle maintenance programme (n = 112) or standard care (n = 98). The programme was based on self-regulation principles and consisted of a motivational interview, seven group sessions, and home assignments. Risk factors and health behaviours were assessed at baseline (end of CR) and 6 months thereafter.

RESULTS

ANCOVAs showed a significant effect of the lifestyle programme after 6 months on blood pressure, waist circumference, and exercise behaviour.

CONCLUSION

This trial indicates that a relatively brief intervention based on self-regulation theory is capable of instigating and maintaining beneficial changes in lifestyle and risk factors after CR.

A questionnaire on treatment satisfaction and disease specific knowledge among patients with acute coronary syndrome. II: Insights for patient education and quality improvement

OBJECTIVE

Secondary prevention for coronary heart disease is achieved by pharmaceutical control of risk factors and patients' own self management behaviour. To comply with longterm treatment patients need sufficient knowledge of their condition and should be satisfied with acute care. Therefore a questionnaire measuring both issues was constructed.

METHODS AND RESULTS

Latent class analysis applied in a sample of over 2000 patients suffering from acute coronary syndrome revealed 4 configurative patterns of knowledge and 5 distinct patterns of (dis-)satisfaction. Nearly 50% of all patients displayed insufficient knowledge upon discharge. Deficits clustered around misinformation on necessary lifestyle changes versus dysfunctional strategies for future emergency situations. Satisfaction and disease specific knowledge were interrelated in complex patterns.

CONCLUSIONS

Disease specific knowledge and satisfaction with treatment proved to be psychometrically valid indicators of the quality of the treatment process that might also have an impact on outcome.

PRACTICE IMPLICATIONS

A validated questionnaire is ready for routine administration after discharge of patients with acute coronary syndrome from acute hospital care. Patient education efforts and quality improvement in treatment centres might be effectively monitored using this questionnaire.

Primary healthcare nurses' experiences with motivational interviewing in health promotion practice

AIM

The aim of the study was to describe primary healthcare nurses' experiences with motivational interviewing as a method for health promotion practice.

BACKGROUND

A person's lifestyle has a major effect on his or her health. Motivational interviewing is one way of working with lifestyle changes in health promotion practice. The basic plan of motivational interviewing is to help people understand their lifestyle problems and make positive lifestyle changes. Motivational interviewing has been proven to be more effective than conventional methods in increasing patient motivation.

DESIGN

This study has a descriptive design and uses a qualitative method.

METHODS

Twenty nurses who worked in primary health care and actively used motivational interviewing in their work were interviewed. Qualitative content analysis was used to process the data.

RESULTS

The primary healthcare nurses' experiences with motivational interviewing as a method of health promotion practice demonstrate that motivational interviewing is a demanding, enriching and useful method that promotes awareness and guidance in the care relationship. The results also show that motivational interviewing is a valuable tool for primary healthcare nurses' health promotion practice.

CONCLUSION

This study shows that motivational interviewing places several different demands on nurses who use this method. Those who work with motivational interviewing must make an effort to incorporate this new method to avoid falling back into the former practice of simply giving advice. Maintaining an open mind while implementing motivational interviewing in real healthcare settings is crucial for nurses to increase this method's effectiveness.

RELEVANCE TO CLINICAL PRACTICE

The nurses in the study had a positive experience with motivational interviewing, which can contribute to the increased use, adaption and development of motivational interviewing among primary healthcare professionals. Increased motivational interviewing knowledge and skills would also contribute to promotion of health lifestyle practices.

[The significance of dietary and behavioral changes in patients with chronic metabolic disorders: a review]

Eating behavior and the psycho-cultural significance of food for patients with chronic metabolic disorders have been a focus of interest due to the difficulty in ensuring the compliance of these patients in terms of changing their habits and in fostering self-care. A review of the literature was condusted using the LILACS and MEDLINE databases and the PUBMED search engine to identify qualitative studies in which the opinion of patients with respect to diet and lifestyle was analyzed. Key words used were: metabolic syndrome; eating behavior; diet; obesity; psychological factors; qualitative study; and dietary habits. Inclusion criteria consisted of: articles in English, Spanish or Portuguese, published between 2000 and 2008; studies carried out in adult populations; containing one or more of the key words in the title. Based on the 15 papers analyzed, it was concluded that compliance with a change of habit is a dynamic process that depends on various individual factors and requires greater interaction between professionals and patients in clinical practice. Promoting self-care depends on respecting the decisions and feelings resulting from personal experience.

Patients' participation as it appears in the nursing documentation, when care is ruled by standardized care plans

This study aimed to describe inpatients with myocardial infarction and their participation in care as documented in the nursing records when standardized care plans are used in care. The use of standardized care plans not only has increased the quality of medical treatment but has also overlooked patients' opportunities to participate in their own care. There is a lack of knowledge about how standardized care plans influence patients' participation in nursing care. Data were collected from thirteen patients' records with diagnoses of myocardial infarction. Participation in the decision-making process and participation associated with “sharing with others” were searched for in the analysis. The analytical process was guided by content analysis. The findings were grouped into two categories: patients' intermediary participation and patients' active participation. The main results indicated that patients' intermediary participation depended on healthcare professionals' power to rule the nursing care situation.

Testing a Model of Physical and Psychological Recovery After a Cardiac Event

Little is known about the specific sources and types of support that assist patients in alleviating stress and achieving positive recovery outcomes after a cardiac event. The purpose of this study is to examine the effects of illness-related stress, emotional and tangible support from a significant other, and informational support from a health care provider on physical and psychological recovery outcomes in cardiac patients 8 weeks after their cardiac event. The sample consists of 220 cardiac patients. Data analysis uses structural equation modeling. Final fit indices were as follows: χ2 ( df = 110) = 156.169, comparative fit index = .963, Tucker—Lewis index = .949, and root mean square error of approximation = .044 suggesting an acceptable model. Illness-related stress has direct effects on depression, physical recovery, and activity levels. Partner emotional support has a direct effect on depression. The findings provide direction for developing social support interventions aimed at improving recovery outcomes.

Nurse-led telephone interventions for people with cardiac disease: a review of the research literature

BACKGROUND

Nurse-led telephone follow-up offers a relatively inexpensive method of delivering education and support for assisting recovery in the early discharge period; however, its efficacy is yet to be determined.

AIM

To perform a critical integrative review of the research literature addressing the effectiveness of nurse-led telephone interventions for people with coronary heart disease (CHD).

METHODS

A literature search of five health care databases; Sciencedirect, Cumulative Index to Nursing and Allied Health Literature, Pubmed, Proquest and Medline to identify journal articles between 1980 and 2009. People with cardiac disease were considered for inclusion in this review. The search yielded 128 papers, of which 24 met the inclusion criteria.

RESULTS

A total of 8330 participants from 24 studies were included in the final review. Seven studies demonstrated statistically significant differences in all outcomes measured, used two group experimental research design and valid and reliable instruments. Some positive effects were detected in eight studies in regards to nurse-led telephone interventions for people with cardiac disease and no differences were detected in nine studies.

DISCUSSION

Studies with some positive effects generally had stronger research designs, large samples, used valid and reliable instruments and extensive nurse-led educative interventions.

CONCLUSION

The results suggest that people with cardiac disease showed some benefits from nurse-led/delivered telephone interventions. More rigorous research into this area is needed.

Patients' Perspectives on Cardiac Rehabilitation, Lifestyle Change and Taking Medicines: Implications for Service Development

Objectives

Cardiac rehabilitation programmes offer eligible coronary heart disease patients information on lifestyle modification and medicines. Our aim was to understand patients' perspectives on these topics.

Methods

In-depth qualitative interviews were conducted and audiotaped with 15 patients approximately three months after hospital discharge, after they had completed a hospital-based cardiac rehabilitation programme. Repeat interviews with ten patients explored whether their perspectives had changed when interviewed again approximately nine months later.

Results

Patients tended to talk about the exercise component of cardiac rehabilitation and only talk about the information provision component when prompted, which suggested they viewed the programme as being primarily about exercise. They seemed to have little subsequent contact with health services, except routine six-monthly check-ups for their coronary heart disease. Unmet information needs were common, especially about medicines. Nevertheless, all patients reported continuing to take cardiac medicines, but tended to only maintain changes to aspects of lifestyle perceived as causes of coronary heart disease, rather than viewing lifestyle recommendations as standards to achieve.

Conclusion

Ensuring that individual patients' information needs about medicines and lifestyle are adequately met remains a key focus for cardiac rehabilitation development. Key aspects include individualizing information and actively seeking and responding to patients' needs during and after cardiac rehabilitation.

Patient perspectives on fluid management in chronic hemodialysis

OBJECTIVE

We sought to describe the perspectives and experiences of chronic hemodialysis (CHD) patients regarding self-care and adherence to fluid restrictions.

DESIGN

Semistructured focus groups.

SETTING

Two outpatient hemodialysis centers.

PARTICIPANTS

Nineteen patients on chronic hemodialysis.

INTERVENTION

Patients were asked a series of open-ended questions to encourage discussion about the management of fluid restriction within the broad categories of general knowledge, knowledge sources or barriers, beliefs and attitudes, self-efficacy, emotion, and self-care skills.

MAIN OUTCOME MEASURE

We analyzed session transcripts using the theoretical framework of content analysis to identify themes generated by the patients.

RESULTS

Patients discussed both facilitators and barriers to fluid restriction, which we categorized into six themes: knowledge, self-assessment, psychological factors, social, physical, and environmental. Psychological factors were the most common barriers to fluid restriction adherence, predominantly involving lack of motivation. Knowledge was the most discussed facilitator with accurate self-assessment, positive psychological factors, and supportive social contacts also playing a role. Dialysis providers were most commonly described as the source of dialysis information (54%), but learning through personal experience was also frequently noted (28%).

CONCLUSION

Interventions to improve fluid restriction adherence of chronic hemodialysis patients should target motivational issues, assess and improve patient knowledge, augment social support, and facilitate accurate self-assessment of fluid status.

Superparamagnetic microsphere-assisted fluoroimmunoassay for rapid assessment of acute myocardial infarction

Rapid assessment of acute myocardial infarction (AMI) was successfully demonstrated using an improved superparamagnetic polymer microsphere-assisted sandwich fluoroimmunoassay to detect two early cardiac markers-myoglobin and human heart-type fatty acid binding protein (H-FABP). This assay used a preparation of superparamagnetic poly(styrene-divinylbenzene-acrylamide) microspheres, glutaraldehyde-coupled capture antibodies (monoclonal anti-myoglobin 7C3 and anti-H-FABP 10E1) grafted onto the polymer microspheres, and a sequential sandwich fluoroimmunoassay using detection antibodies (FITC-labeled anti-myoglobin 4E2 and FITC-labeled anti-H-FABP 9F3). Characterization of the polymer microspheres by TEM, SEM and Fourier transform infrared spectroscopy (FT-IR) showed that the microspheres were uniformly round with an average diameter of 1.12 microm, and had a Fe(3)O(4)-polymer core-shell structure (shell thickness was about 84 nm) with 0.22 mmol/g amino groups on their surfaces. The magnetic behavior of the Fe(3)O(4)-polymer microspheres was superparamagnetic (M(s)=13 emu/g, H(c)=13.1 Oe). Fluorescence images of the post-immunoassay microspheres recorded using a confocal laser-scanning microscope showed that the average fluorescence intensity was correlated with the concentration of cardiac markers, in agreement with the results obtained by an F-4500 FL spectrophotometer; this indicated that the fluoroimmunoassay could be used to semi-quantitatively detect both myoglobin and H-FABP. The detection limit was 25 ng/mL for myoglobin and 1 ng/mL for H-FABP.

Sense of coherence as well as social support and network as perceived by patients with a suspected or manifest myocardial infarction: a short-term follow-up study

OBJECTIVE

To compare sense of coherence as well as social support and network as perceived by ischaemic heart disease patients at baseline and two weeks post-discharge in terms of age, sex, educational and marital status.

DESIGN

Multicentre study with a prospective short-term follow-up design.

SETTING

A university hospital, a central hospital and a district hospital in southern Sweden.

SUBJECTS

Consecutive sample of 246 patients with a suspect or manifest myocardial infarction.

MAIN MEASURES

The Lubben Social Network Scale (LSNS-R), the Medical Outcome Study (MOS) Social Support Survey and the Sense of Coherence Scale were included in a self-administered questionnaire and answered twice, together with sociodemographic variables.

RESULTS

Bivariate analyses indicated changes in social support (practical support increased in men and decreased in women; both P= 0.003) and social network (family network increased among >65 year olds; P= 0.001, men; P= 0.013, and women; P= 0.033, those with a low; P=0.017, and intermediate; P= 0.033, educational level, as well as those cohabiting; P= 0.0001), but did not reveal any difference in sense of coherence.

CONCLUSIONS

Sociodemographic variables have no influence on sense of coherence but do affect social support (i.e. practical support and social network, family). Ischaemic heart disease patients' short stay in hospital implies that the network outside the hospital has to assume responsibility, but at the same time it is important for health care professionals to have sufficient knowledge to be able to support the specific needs of patients and their family members.

RT-ABCDE strategy for management and prevention of human diseases

In this article, the authors summarized the RT-ABCDE strategy for the management and prevention of human diseases, which includes ReTro-ABCDE (Examination regularity, Disease and risk factor control, Changing lifestyle and reducing pathways of infection and spread, Biochemical and Antagonistic index control and therapeutic treatment as well as RT--Routine and Right Treatment). The RT-ABCDE strategy, a novel concept and an essential method, should be a routine strategy for disease control and prevention. It should be proposed and applied in both clinical and preventive medicine.

Promotion of family integrity in the acute care setting: a review of the literature

The acute illness of 1 family member can then negatively affect all family members and lead to the disruption of family functioning and integrity. During the patient's hospitalization, nurses are in a key position to support family members, maintain family integrity, and ready them for assuming the role of caretaker during the patient's recovery and management of health at home. This article reviews current research findings that provide empirical support for activities that promote family integrity. Strategies for nurses to support family members during the hospitalization of an adult family member and suggestions for future research are provided.

On the dynamics of health capital accumulation

This paper presents a key model from the economics literature that has been adjusted and reinterpreted as a simple, formal, quantitative tool for formalising the inputs and outputs involved in personal health regimes undertaken to accumulate Grossman's health capital. Implications of the model fit with commonsensical clinical results. We find that higher variance of previous health capital increases leads to higher "good health" needed before health regimes are undertaken permanently. Conversely, the higher the target amount of health capital the lower the health capital "trigger" level for instigating the regime. Indeed, we find that the higher an individuals motivation is, as measured by a personal discount rate, the lower this personal "trigger" health capital level is. It is theorised that such a model can be used as a clinical application, whereby a patient's personal health history can generate the "motivation" and instigate health capital levels in a quantitative, as opposed to qualitative manner. Further implications are discussed.