"It's like an explosion in your life...": lay perspectives on stress and myocardial infarction

Critical Realism in Symptom Science - A Scoping Review

There has been an increasing interest in research positioned within critical realism (CR). This analysis aimed to determine how CR has been applied in symptom science through a scoping review of the literature. Fifty-two articles were identified through searches in seven databases and search engines, and grey literature. Quantitative and qualitative analyses were performed using Excel and ATLAS.ti 8.0. Review findings indicate that CR has been used to examine two key aspects of symptoms - symptom experiences and symptom interventions. The details of how CR was operationalized are presented. This first scoping review highlights how a critical realist lens would help examine individual and contextual factors that influence symptom experiences, response to interventions, and outcomes.

Psychometric properties and factorial invariance of the Farsi version of the Stress Mindset Measure

The Stress Mindset Measure consists of eight items to assess whether individuals hold a stress-is-enhancing or a stress-is-debilitating mindset. The current research is a cross-sectional study and aimed to investigate the factor structure, internal consistency reliability, and construct and convergent validity of the Farsi version of the Stress Mindset Measure (SMM). Prior to conducting the study, forward and backward translations of the SMM were performed. Using the convenience sampling method, we recruited 400 none-clinical sample (161 men and 239 women; aged 18 to 69). We utilized SPSS version 24, Amos, and Mplus 7.1 software to analyze the data. Results revealed satisfactory reliability and validity indexes for the Farsi version of the Stress Mindset Measure. The internal consistency of the Farsi version of the Stress Mindset Measure was in the excellent range (α = 0.87). The results of the confirmatory factorial analysis revealed two factors of the Stress Mindset Measure instead of the single factor suggested by the previous studies (fitness indices for the two-factor model were RMSEA = 0.78, CFI = 0.96, and TLI = 0.94). Moreover, we found that the stress-is-debilitating mindset is positively associated with stress (r = 0.233), depression (r = 0.163), and anxiety (r = 0.197). However, this mindset has been found to have no significant relationship with cognitive strategies of emotion regulation and life satisfaction. Also, findings showed no significant correlation between the stress-is-enhancing mindsets and the other variables. The results of this study suggest that the Farsi SMM has proper psychometric properties to assess stress mindsets.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.

Empowered to gain a new foothold in life--A study of the meaning of participating in cardiac rehabilitation to patients afflicted by a minor heart attack

This study aimed to investigate what it means to patients afflicted by a minor heart attack to participate in cardiac rehabilitation (CR). CR is well-established internationally to support patients towards moving forward in satisfying, healthy, and well-functioning lives. Studies indicate that patients achieve improvement in quality of life when participating in CR. However, knowledge of how patients are supported during CR is sparse. Moreover, knowledge of what participating in CR means to patients afflicted by a minor heart attack is lacking. In-depth knowledge in this area is crucial in order to understand these patients' particular gains and needs. In a phenomenological-hermeneutic frame field observations, focus group interviews, and individual interviews were conducted among 11 patients during and after their participation in CR. Field notes and transcribed interviews underwent three-phased interpretation. It was found that patients were supported to gain renewed balance in their lives during CR. Three themes were identified: (1) receiving a helpful but limited caring hand, (2) being supported to find new values in life, and (3) developing responsibility for the remaining time. The patients were carefully guided through a difficult time and supported to continue in healthy everyday lives. They were given hope which enabled them to find themselves a new foothold in life with respect to their own sense of well-being. This guidance and a sense of hopefulness were provided by heart specialists and more seasoned heart patients. In conclusion, patients were empowered to achieve a healthier lifestyle and improve their personal well-being during CR. However, structural barriers in the programme prevented adequate support regarding the patients' total needs. Knowledge of the benefits of CR emphasizes the significance of the programme and highlights the importance of high inclusion. Efforts should be made to develop more flexible and longer lasting programmes and further involvement of relatives must be considered.

The Cultural Meaning of Cardiac Illness and Self-Care Among Lebanese Patients With Coronary Artery Disease

BACKGROUND

Cardiac disease is the leading cause of death in Lebanon, accounting for 22% to 26% of total deaths in the country. A thorough understanding of perceptions of cardiac illness and related self-care management is critical to the development of secondary prevention programs that are specific to the Lebanese culture.

PURPOSE

To explore the cultural perceptions of cardiac illness and the associated meaning of self-care among Lebanese patients.

DESIGN

Using a qualitative descriptive method, semistructured interviews were conducted with a purposive sample of 15 Lebanese cardiac patients recruited from a medical center in Beirut, Lebanon.

FINDINGS

The qualitative descriptive analysis yielded one overarching and two other themes describing perceptions of cardiac illness and self-care within the Lebanese cultural context. The overarching cultural theme was, "Lebanese cardiac patients were unfamiliar with the term concept and meaning of self-care." Lebanese cardiac patients thanked God and accepted their fate (Theme I). The participants considered their cardiac incident a life or death warning (Theme II).

IMPLICATIONS FOR PRACTICE

Health care providers need to consider patients' cultural perception of illness while planning and evaluating cardiac self-care programs.

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.

A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral

BACKGROUND

Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood.

METHODS

A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995.

RESULTS

Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile.

CONCLUSIONS

Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms.

Primary health care resources for rehabilitation and secondary prevention after myocardial infarction - a questionnaire survey

BACKGROUND

During the first year after a cardiac event, many patients are offered participation in a cardiac rehabilitation programme, after which the patients are often not given the opportunity to continue to attend rehabilitation and secondary prevention programmes.

AIM

This study describes the primary health care centres' (PHCC) resources regarding cardiac rehabilitation/secondary prevention programmes for coronary heart disease (CHD) patients in a southern Swedish region.

METHOD

A questionnaire containing 26 dichotomous or multiple choice questions was sent to the responsible manager of all 137 public and private PHCCs in Region Skåne. Questionnaires from 91 (66%) of the PHCCs were completed and returned.

RESULT

Few nurses at the PHCCs had special training regarding CHD (10%), cardiac rehabilitation (8%) or heart failure (32%). Twenty-one per cent of the physicians had special training regarding CHD. One third of the PHCCs did not offer long-term secondary prevention programmes, and few (6%) had any routines for offering socio-economic support to CHD patients. Comparison of private and public PHCCs showed that the private centres could not offer a physiotherapist (61 vs. 84%) or dietician (32 vs. 73%; p = 0.03) to the same extension as the public ones. Furthermore, the majority (91%) of PHCCs had no cooperation with patient organizations.

CONCLUSIONS

The PHCCs need to improve the strategies and long-term rehabilitation programmes. Furthermore, they need to focus on education programme for the staff. The result revealed that the PHCCs lack resources, strategies and long-term care programmes for CHD patients.

A qualitative study exploring why people do not participate in cardiac rehabilitation and coronary heart disease self-help groups, and their rehabilitation experience without these resources

BACKGROUND

Secondary prevention and self-management of coronary heart disease (CHD) are of major importance to people who survive myocardial infarction (MI). This can be facilitated by cardiac rehabilitation (CR; the formal health service programme) and informal CHD self-help groups. Non-participation is an important issue, yet it is poorly understood. Rehabilitation difficulties and prevention challenges have been identified among people following MI, but the particular experience and perspective of CR and CHD group non-participants are largely unknown.

AIM

The study aimed to understand non-participation in CR and CHD self-help groups from the perspectives of the non-participants and to provide insight into their experience and that of their 'significant others' in rehabilitating in the absence of these resources.

METHODS

In-depth interviews were conducted with 27 people who had not participated in either hospital-based CR or a CHD group, 6-14 months post-MI, and 17 'significant others' in Lothian, Scotland.

FINDINGS

Factors influencing non-participation fell into three broad themes 'No need/no point', 'Not worth it', and 'Not possible'. In the latter two categories, non-participation in these resources was often considered a 'missed opportunity' and needs had remained unmet. Shifts between categories could occur over time. Non-participation was linked to rehabilitation difficulties for some people and family members. Recommendations to enhance post-MI support are made.

Impact of Morbidity and Life Events on Successful Aging

The purpose of this study was to examine the risks of the incidence of chronic conditions and life events on successful aging. Longitudinal data from a 10-year follow-up health survey were used. Successful aging indicators included basic and advanced physical function, depressive symptoms, cognitive function, emotional support, participation in productive activities, and life satisfaction. The stressors included life events and morbidity years of 10 chronic conditions. Loss of offspring increased the risk to physical health, psychological health, and life satisfaction. Being newly widowed was related to depressive symptoms, whereas being newly divorced increased the risk of poor social support. Morbidity years increased the risk of failure in successful aging, especially for stroke, respiratory system disease, diabetes, and cancer. Emotional health of the elderly should be carefully monitored after onset of life events and incidences of chronic conditions.

‘It Got Right to the Spot’ The Patient Experience of Primary Angioplasty: A Qualitative Study

Background: Primary angioplasty is becoming an established treatment for myocardial infarction. Yet we have a limited understanding of patients' attitudes toward this treatment and their experiences of receiving it in practice.

Aims: Exploration of patients' experiences and perceptions of primary angioplasty as treatment for their heart attack.

Methods: Qualitative study of a purposive sample of patients admitted to a tertiary cardiology unit in east London, UK. Participants were interviewed either in their own homes or in hospital. Recruitment continued until no new substantial themes emerged. Eleven men and four women aged 35 to 74 years who had sustained a myocardial infarction were interviewed 13 to 90 days after primary angioplasty. We used the framework method of analysis to identify and explore emerging themes.

Results: Informants were expecting open-heart surgery as treatment for their heart attack. They were impressed by the service they actually received. They were generally not engaged in decisions about their treatment in the acute setting and this passivity sometimes persisted after discharge. Expectations of follow up in primary care were not often met.

Conclusions: Patients are satisfied with the primary angioplasty as treatment for acute myocardial infarction but have poor understanding of the management of this condition.

Managing consequences and finding hope--experiences of Swedish women and men 4-6 months after myocardial infarction

Research has focused more on symptoms, risk factors and treatment, than on individuals' experiences of illness and recovery after myocardial infarction (MI). Therefore, the aim of the study was to describe the experiences of present everyday life of women and men 4-6 months after MI and their expectations for the future. Semi-structured interviews were conducted with 20 women and 19 men from January 2000 to November 2001. Data were analysed with content analysis. Two themes, 'Managing consequences of MI' and 'Finding a meaning in what had happened', were generated. The first theme reveals that many of the patients had not established a stable health condition, even if symptoms and emotional distress had diminished over time. They had to manage health problems, lifestyle modifications, emotional reactions and changes in social life. The support from their social network encouraged them to move on. The second theme shows that patients also found positive consequences of what they had gone through, new life values and hopes in the future. The conclusions were that most of the patients moved on and began to regain a balance in everyday life, but some patients still struggled hard to find this balance. Those patients experienced large difficulties with managing their everyday life and felt a lack of support from their social network. Health professionals can be an important resource in helping patients in their adaptation to changes if they are more sensitive to patients' needs of support both in a short- and long-term perspective.

A critical realist approach to understanding and evaluating heart health programmes

Secondary prevention programmes for Coronary Heart Disease (CHD) aim to reduce cardiovascular risks and promote health in people with heart disease. Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach, this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient contextual factors, and thereby fails to account for programme variations. Alternative constructivist approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual, programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how a critical realist approach can guide research into secondary prevention programmes is provided.

Stress in women's daily life before and after a myocardial infarction: a qualitative analysis

BACKGROUND

Little is known about women's perceptions of their daily life before and after a myocardial infarction (MI), especially with regard to stress, which is a risk factor for coronary heart disease (CHD).

AIM

To describe and explore women's perceptions of stress before and after an MI.

METHOD

Two interviews with women who suffered an MI, the first at the hospital (n = 20) and the second 4-10 months after the MI (n = 14), were analysed using a phenomenographic approach.

FINDINGS

The stress emanated either from within themselves (personal traits) or as an effect of their immediate surroundings. The period before the MI was stressful due to the different roles they had to maintain in their private and professional lives. They lost control over their daily life. After hospital discharge they both wanted and needed support, as they were terrified when they returned home. They did not know how much they could do and neither did their relatives, while little or no support was provided by the healthcare professionals.

CONCLUSIONS

To prevent CHD in daily life and avoid reinforcing stress, it is important to place greater emphasis on stress as an important risk factor. An understanding of this phenomenon can assist primary healthcare, coronary care unit (CCU) and rehabilitation nurses in supporting these women as well as their partners to adapt their daily lives both before and after an MI. It is essential to formulate and implement individualised treatment plans and to provide support groups for women.

Striving for balance in daily life: experiences of Swedish women and men shortly after a myocardial infarction

AIM

The aim is to describe experiences of daily life of women and men during the first four to six months after a myocardial infarction. The focus is on problems, managing problems and support from their network.

BACKGROUND

A cardiac event is traumatic and may influence well-being during a significant period of time. Few qualitative studies have investigated experiences of both women and men after a myocardial infarction and remarkably little research has been conducted on men's experiences.

DESIGN

The study design was descriptive, retrospective and qualitative.

METHODS

Semi-structured interviews were conducted with 20 women and 19 men from January 2000 to November 2001. Data were analysed using qualitative content analysis.

RESULTS

Three themes were generated from the analysis: 'Threatening ordinary life', 'Struggling for control' and 'The ambiguous network'. Physical symptoms and emotional distress were the most commonly described problems during the first months after a myocardial infarction. The informants manage the problems by negotiating with themselves, relying on their own capabilities, changing attitudes and behaviours and taking their own decisions and actions. The network was generally supportive but rather often the informants also experienced communication problems when they interacted with their network.

CONCLUSIONS

Women and men strive for balance between problems and resources in daily life after a myocardial infarction. How well they succeeded depends on how secure they feel how well they communicate their needs to their network and how sensitive their network is to their spoken and unspoken needs.

RELEVANCE TO CLINICAL PRACTICE

The findings provide an insight into what kind of problems women and men may experience after myocardial infarction and how caregivers can aid them to increase security in their daily life. Some risk characteristics that may have increased their problems in daily life are suggested, for women and men respectively.

Living with a stoma: a review of the literature

AIMS AND OBJECTIVES

This systematic review looks at the psychological and social impact of stoma surgery on peoples' lives.

BACKGROUND

The formation of a stoma can have a negative effect on a person's quality of life and affect lifestyle in a number of ways.

METHODS

The review examines nursing literature from 1990 to date and focuses on how stoma patients' lives are affected by the presence of a stoma. It informs nursing practice so nurses are better able to help individuals improve, maintain or recover their health following ostomy surgery.

RESULTS

The findings of the review indicate that stoma surgery can impact on individuals' lives in many different ways.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of the problems stoma patients can experience can help nurses plan care in an individualized way. Recommendations for nursing practice and future research are made.