The recovery mosaic: older women's lived experiences after a myocardial infarction

Telephone-based peer support intervention to reduce depressive symptoms in women with coronary heart disease, a randomized controlled trial in Germany

Depressive symptoms in patients with coronary heart disease (CHD) predict adverse outcomes regarding e.g. cardiovascular complications. We trained women with CHD to support female peers through telephone-based counseling and tested whether depressive symptoms can be reduced, and perceived social support can be improved by the intervention over six months. 108 women with CHD and self-reported depressive or anxiety symptoms were included in a randomized controlled trial. The intervention group was offered immediate telephone-based peer support for six months, while the waiting list control group received the intervention with a 6-months delay. Primary outcomes were depressive symptoms and perceived social support immediately after the intervention period and at 6-months-follow-up. 40% of the women made use of the peer support. During the first six months, both groups showed a reduction in depressive symptoms (IIG: t(169) = -1.79, p = .08; WCG: t(169) = -2.76, p = .007) and a significant improvement in social support (IIG: t(175) = 3.54, p < .001; WCG: t(175) = 3.36, p < .001). We found no significant group × time interactions. There was no influence of telephone-based peer support on depressive symptoms and social support. We discuss potential causes for both lack of specific treatment effects and the general improvement over time in both groups.

Perceived needs for attaining a 'new normality' after surviving myocardial infarction: A qualitative study of patients' experience

Background: A comprehensive understanding of the various aspects of patients’ myocardial infarction (MI) experiences may help to guide these patients and their relatives through the many uncertainties they face and help them to stabilize their lives after the disruption they experienced.

Objectives: To explore MI patients’ experiences of life with MI, the challenges they face during the process of accepting their condition, and the setting and resetting of their personal goals.

Methods: Thirty semi-structured, individual interviews were conducted. The grounded theory method was used, and Atlas.ti qualitative data analysis software was used to facilitate the analysis.

Results: Three main themes and explanatory models emerged from the data analysis: a good adaptation – the ‘new normality;’ maladjustment – a continuous search for a ‘new normality;’ and perceived needs in the search for a new normality. Patients perceived several areas of need that they felt must be met before they could reach the state of a new normality. These needs included overcoming the anxiety of a possible MI recurrence; acquiring knowledge about MI in general and about ‘my MI’ in particular; the need for a timeline; for patience and steadiness; for both objective and subjective health status improvement; for taking control over the disease; and living within a supportive context.

Conclusion: When faced with a dramatic life event, most patients succeed in achieving a new normality in which they live changed but still satisfying lives. The needs experienced by patients when searching for a new normality may guide practitioners in leading patient-centred consultations.

KEY MESSAGES

Most MI patients achieve a new normality.

My physical identity is new: my body is different but still functional.

My personal identity is new: I am not the same as before, the disease is part of me, but I retain parts of my previous self.

Intrusion and Confusion—The Impact of Medication and Health Professionals after Acute Myocardial Infarction

Background: Secondary prevention is important in preventing new cardiovascular events after acute myocardial infarction (AMI).

Aim: To explore patients' experiences of secondary prevention after a first AMI.

Methods: A qualitative approach with hermeneutical analysis of in depth interviews was used.

Results: Twenty patients (12 men and 8 women, aged 34–79 years) were interviewed. None of the patients was previously treated for cardiovascular disease except one that had a history of angina pectoris. Two main themes emerged from the analysis. 1) Impact of medication: patients interpreted bodily sensations as a consequence of being medicated rather than as a result of their heart attack. The medication led to feelings of being intruded upon but also to positive feelings of security. 2) Impact of health professionals: communication with health professionals resulted in confusion about both treatment and the severity of the coronary disease. Patients expressed a need of being reassured by their physician regarding their physical status.

Conclusions: Health professionals need to consider the impact of pharmacological treatment on patients' life, at least in patients who suffer from a first AMI. The point of departure in secondary preventive work must be patients' beliefs about their condition and the treatment they receive. Nurses and physicians must be aware of the information each patient has been given, and from this starting point, they have to be in concordance with one another. From the patients' perspective it is deemed necessary for the physicians to discuss the disease and the consequences it may have, both in the near future and in the long run, as soon as possible.

The effectiveness and experience of self-management following acute coronary syndrome: A review of the literature

OBJECTIVES

To evaluate the effectiveness of interventions used to support self-management, and to explore patients' experiences after acute coronary syndrome in relation to self-management.

DESIGN

Scoping review.

DATA SOURCES

Keyword search of CINAHL Plus, Medline, the Cochrane Library, and PsycINFO databases for studies conducted with adult population and published in English between 1993 and 2014.

REVIEW METHODS

From title and abstract review, duplicated articles and obviously irrelevant studies were removed. The full texts of the remaining articles were assessed against the selection criteria. Studies were included if they were original research on: (1) effectiveness of self-management interventions among individuals following acute coronary syndrome; or (2) patients' experience of self-managing recovery from acute coronary syndrome.

RESULTS

44 articles (19 quantitative and 25 qualitative) were included. Most studies were conducted in western countries and quantitative studies were UK centric. Self-management interventions tended to be complex and include several components, including education and counselling, goal setting and problem solving skills which were mainly professional-led rather than patient-led. The review demonstrated variation in the effectiveness of self-management interventions in main outcomes assessed - anxiety and depression, quality of life and health behavioural outcomes. For most participants in the qualitative studies, acute coronary syndrome was unexpected and the recovery trajectory was a complex process. Experiences of making adjustment and adopting lifestyle changes following acute coronary syndrome were influenced by subjective life experiences and individual, sociocultural and environmental contexts. Participants' misunderstandings, misconceptions and confusion about disease processes and management were another influential factor. They emphasised a need for ongoing input and continued support from health professionals in their self-management of rehabilitation and recovery, particularly during the initial recovery period following hospital discharge.

CONCLUSIONS

Evidence of the effectiveness of self-management interventions among people with acute coronary syndrome remains inconclusive. Findings from the patients' experiences in relation to self-management following acute coronary syndrome provided important insights into what problems patients might have encountered during self-managing recovery and what support they might need, which can be used to inform the development of self-management interventions. Theoretical or conceptual frameworks have been minimally employed in these studies and should be incorporated in future development and evaluation of self-management interventions as a way of ensuring clarity and consistency related to how interventions are conceptualised, operationalised and empirically studied. Further research is needed to evaluate self-management interventions among people following acute coronary syndrome for sustained effect and within different health care contexts.

Women's experiences of how their recovery process is promoted after a first myocardial infarction: Implications for cardiac rehabilitation care

BACKGROUND

A rapid improvement in the care of myocardial infarction (MI) in the emergency services has been witnessed in recent years. There is, however, a lack of understanding of the factors involved in a successful recovery process, after the initial stages of emergency care among patients, and in particular those who are women. Both preventive and promotive perspectives should be taken into consideration for facilitating the recovery process of women after a MI.

AIM

To explore how women's recovery processes are promoted after a first MI.

METHODS

A qualitative content analysis was used.

FINDINGS

The women's recovery process is a multidirectional process with a desire to develop and approach a new perspective on life. The women's possibility to approach new perspectives on life incorporates how they handle the three dimensions: behaviour, that is, women's acting and engaging in various activities; social, that is, how women receive and give support in their social environment; and psychological, that is, their way of thinking, reflecting, and appreciating life.

CONCLUSIONS

The personal recovery of women is a multidirectional process with a desire to develop and approach a new perspective on life. It is important for cardiac rehabilitation nurses to not only focus on lifestyle changes and social support but also on working actively with the women's inner strength in order to promote the recovery of the women.

Can Anyone Hear Me? Does Anyone See Me? A Qualitative Meta-Analysis of Women's Experiences of Heart Disease

Female heart patients are underdiagnosed and undertreated. The purpose of this qualitative meta-data-analysis was to explain how societal expectations related to gender and the treatment environment influence women's experiences and can inform optimal care. The authors used grounded theory methodology and a social constructionist gender lens to analyze 43 studies (1993-2012) of women's experiences of heart disease. The analysis illustrates how social expectations within both medical and relational contexts led to women experiencing barriers to diagnosis and treatment and inadvertent minimization of their experience and knowledge. Women's descriptions of their experiences suggest three kinds of health care strategies that have the potential to increase women's engagement with heart disease treatment and rehabilitation: (a) support give and take in relational connections, (b) identify and acknowledge unique health-promoting behavior, and (c) focus on empowerment. These findings have interdisciplinary implications for practice with women with heart disease.

Managing lifestyle change to reduce coronary risk: a synthesis of qualitative research on peoples' experiences

BACKGROUND

Coronary heart disease is an incurable condition. The only approach known to slow its progression is healthy lifestyle change and concordance with cardio-protective medicines. Few people fully succeed in these daily activities so potential health improvements are not fully realised. Little is known about peoples' experiences of managing lifestyle change. The aim of this study was to synthesise qualitative research to explain how participants make lifestyle change after a cardiac event and explore this within the wider illness experience.

METHODS

A qualitative synthesis was conducted drawing upon the principles of meta-ethnography. Qualitative studies were identified through a systematic search of 7 databases using explicit criteria. Key concepts were identified and translated across studies. Findings were discussed and diagrammed during a series of audiotaped meetings.

RESULTS

The final synthesis is grounded in findings from 27 studies, with over 500 participants (56% male) across 8 countries. All participants experienced a change in their self-identity from what was 'familiar' to 'unfamiliar'. The transition process involved 'finding new limits and a life worth living' , 'finding support for self' and 'finding a new normal'. Analyses of these concepts led to the generation of a third order construct, namely an ongoing process of 'reassessing past, present and future lives' as participants considered their changed identity. Participants experienced a strong urge to get back to 'normal'. Support from family and friends could enable or constrain life change and lifestyle changes. Lifestyle change was but one small part of a wider 'life' change that occurred.

CONCLUSIONS

The final synthesis presents an interpretation, not evident in the primary studies, of a person-centred model to explain how lifestyle change is situated within 'wider' life changes. The magnitude of individual responses to a changed health status varied. Participants experienced distress as their notion of self identity shifted and emotions that reflected the various stages of the grief process were evident in participants' accounts. The process of self-managing lifestyle took place through experiential learning; the level of engagement with lifestyle change reflected an individual's unique view of the balance needed to manage 'realistic change' whilst leading to a life that was perceived as 'worth living'. Findings highlight the importance of providing person centred care that aligns with both psychological and physical dimensions of recovery which are inextricably linked.

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Women's experience of a myocardial infarction: 5 years later

BACKGROUND

Myocardial infarction (MI) has long been seen as a male disease despite the fact that it is also a health problem for women. Factors that may influence their recovery, such as co-morbidity and requirements for support, have received less scientific attention.

AIM

To explore and describe how women conceived their health and daily life 5 years after an MI.

METHOD

An explorative and descriptive approach inspired by phenomenography was chosen as the design. The present study includes 12 women who have been described in earlier short-term studies.

FINDINGS

The women described how the MI caused limitations in their lives even 5 years after the MI. They experienced physical restrictions, fatigue and also other health complaints. Furthermore, the older women suffered from various co-morbidities such as diabetes, kidney disease, high blood pressure, and stroke. Some women did not perceive their heart disease to interfere in daily life. Many of the women had thoughts about having a new MI. Furthermore, some women were grateful and described it as having a second opportunity.

CONCLUSION

  The present study indicates how women in the recovery process 5 years after an MI still need support to continue with lifestyle changes. The women continue to struggle with different kinds of issues, such as financial stress, co-morbidity and side effects of medication. Support from the health care only in the first year after the MI is not enough. The women should benefit from the possibility to visit or consult professionals in primary care with knowledge of CHD.

Illness experiences of patients with ischemic heart disease during their transitional phase from hospitalization to discharge in Japan

The purpose of this study was to explore the experience of patients with ischemic heart disease (IHD) during the transitional phase from hospitalization to discharge. Twenty-four patients who experienced IHD for the first time comprised the sample of the study. Semi-structured interviews were conducted during the transitional phase. The results of the qualitative inductive analysis showed two categories of illness experience: (i) the connection of heart attack experience with the self, and (ii) the instability of the self as a patient with heart disease. The participants were found to vacillate between the self as patient with a heart disease and the typical self before the disease onset. The transitional phase is the time when patients experience changes in their symptoms and physical conditions rather than a condition of stability signifying recovery. Patients are expected to manage the symptoms of their heart disease by themselves; however the participants showed signs and symptoms of confusion and anxiety about facilitating their own care. These findings suggest the importance of outpatient nursing practice focusing on the support and emphasis on nursing interventions for patient anxiety and alleviation of confusion through the management of symptoms of heart disease after discharge.

A Behavior Change Intervention for Women in Cardiac Rehabilitation

There is undeniable evidence for physical and psychosocial benefits of cardiac rehabilitation programs for individuals suffering from coronary heart disease. Yet, fewer women than men are referred to, begin, or complete cardiac rehabilitation programs. The numerous logistical, economic, and motivational barriers to healthy behavior change place women at risk for subsequent CHD events. To close this gender gap and improve outcomes, novel, efficacious, and individualized rehabilitative approaches for women with coronary heart disease are needed. The purpose of this article is to describe a theory-driven behavioral intervention designed exclusively for women with coronary heart disease. The 12-week intervention is being tested in a randomized controlled trial involving women referred to a cardiac rehabilitation program. The tenets of the Transtheoretical Model of behavior change and motivational interviewing guided the development and implementation of the stage-matched, individualized intervention to promote healthy behavior change for women with coronary heart disease. The ongoing trial will examine the efficacy of the intervention on physiological and psychosocial outcomes.

Women, men and coronary heart disease: a review of the qualitative literature

AIM

This paper presents a review of the qualitative literature which examines the experiences of patients with coronary heart disease. The paper also assesses whether the experiences of both female and male patients are reflected in the literature and summarizes key themes.

BACKGROUND

Understanding patients' experiences of their illness is important for coronary heart disease prevention and education. Qualitative methods are particularly suited to eliciting patients' detailed understandings and perceptions of illness. As much previous research has been 'gender neutral', this review pays particular attention to gender.

METHODS

Published papers from 60 qualitative studies were identified for the review through searches in MEDLINE, EMBASE, CINAHL, PREMEDLINE, PsychINFO, Social Sciences Citation Index and Web of Science using keywords related to coronary heart disease.

FINDINGS

Early qualitative studies of patients with coronary heart disease were conducted almost exclusively with men, and tended to generalize from 'male' experience to 'human' experience. By the late 1990s this pattern had changed, with the majority of studies including women and many being conducted with solely female samples. However, many studies that include both male and female coronary heart disease patients still do not have a specific gender focus. Key themes in the literature include interpreting symptoms and seeking help, belief about coronary 'candidates' and relationships with health professionals. The influence of social roles is important: many female patients have difficulties reconciling family responsibilities and medical advice, while male patients worry about being absent from work.

CONCLUSIONS

There is a need for studies that compare the experiences of men and women. There is also an urgent need for work that takes masculinity and gender roles into account when exploring the experiences of men with coronary heart disease.

Getting to the heart of social support: a qualitative analysis of the types of instrumental support that are most helpful in motivating cardiac risk factor modification

PURPOSE

This study evaluates the types of instrumental social support that are perceived by patients with coronary artery disease as being most helpful to health behavior modification.

METHODS

A purposive sample of 63 patients with coronary artery disease were enrolled in this qualitative study. Patients described lifestyle changes that they made in an effort to stay healthy and the types of instrumental supports provided by their social networks that helped them make these changes.

RESULTS

The most frequently cited lifestyle changes reported were making dietary changes, reducing responsibilities, keeping doctors' appointments, taking medications, and exercising more. The types of instrumental support that were perceived as being most helpful in making these changes were those that (1) made it easier and practical to engage in healthy behaviors, (2) alleviated stressful situations, and (3) facilitated the process of receiving medical care.

CONCLUSIONS

These findings identify practical ways in which social networks can promote risk factor modification and ultimately contribute to improving coronary artery disease outcomes.