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Access to the World After Myocardial Infarction: Experiences of the Recovery Process
Myocardial infarction (MI) is a traumatic health event and at the same time a transition of vital importance in human life. The purpose of this study was to elucidate recovery patterns after myocardial infarction with regard to the content of patients’ experiences. The study used a descriptive design and a qualitative method. Interviews with 16 men and women were performed, and data were subjected to a thematic content analysis. The recovery process had a pattern of ability, restraints, and reorientation. Through self-help and help from others, the mutual sharing of burdens, and clarifying restraints to recovery, the recovery process progressed toward reorientation. New values and motivation for change, as well as a new balance within the self and relationships were found. The MI had been integrated into life and, through the recovery process, patients’ attitudes were better focused, leading to an enhanced quality of life.
Myocardial infarction (MI) is a traumatic health event and at the same time a transition of vital importance in human life (Dixon, Lim, Powell, & Fisher, 2000; Roebuck, Furze, & Thompson, 2001). For some patients disease may lead to a qualitatively better life, but for others life takes a negative turn. Recovery depends on many factors such as the seriousness of the disease, emotions, interpersonal relations and the actual life situation (Bergman & Berterö, 2003; Brink, Karlson, & Hallberg, 2003; Dixon et al.; Gassner, Dunn, & Piller, 2002; Jaarsma, Kastermans, & Philipsen, 1995; Kärner, Göransson, & Bergdahl, 2003; Wiles & Kinmonth, 2001; Ostergaard Jensen & Petersson, 2003). Research shows that the emotional response is not always in proportion to the seriousness of the disease (Cherrington, 2001; Laerum, Johnsen, Smith, & Larsen, 1988). A minor MI may lead to severe anxiety and depression in some, while a massive MI seems to pass without any great problems in others. Interpersonal relationships and social support are of significant importance to wellbeing (Hildingh, Fridlund, & Segesten, 1995; Stewart, Davidson, Meade, Hirth, & Makrides, 2000) but can also play a negative role in the recovery after MI (Smith et al., 1997). Several studies have shown that traumatic events, conflicts, and misdirected attempts to help occur frequently (Roebuck et al., 2001; Stewart et al., 2000).
When a person tries to cope with MI, he or she appraises the situation and attributes meaning to it (Lazarus, 1999). This is a primary appraisal based on one’s values, goals, and beliefs about the self and the world, in addition to one’s situation and purpose in life. The secondary appraisal refers to a cognitive-evaluative process that is focused on what can be done to ease a stressful situation. Varied coping strategies, such as support seeking, optimism, confrontation and self-reliance, can be used to gain control and reduce uncertainties (Daly et al., 2000). In order to understand the recovery process after MI, it is important to listen to individuals with different goals, beliefs, and personal resources (McKibbin & Wilson, 2001). The purpose of this study was to elucidate the pattern of recovery after myocardial infarction with regard to the content of patients’ experiences.
Design and Setting
A qualitative research design was used to describe experiences of recovery. The study was implemented in a healthcare area in southern Sweden, with a catchment area of 50,000 inhabitants.
Informants were recruited from the nurse-led healthcare center for cardiac patients located at a district hospital. To ensure heterogeneity, a strategic selection was used based on age, gender, marital status, education, and participation in a rehabilitation program (Table 1). Sixteen men and women who visited the nurse-led healthcare center 8–9 months after their MI were asked to participate in the study. A nurse distributed information about the nature and purpose of the study. All patients who were asked participated.
The Research Ethics Committee, Lund University, Sweden, approved the study. The researchers contacted those persons who had shown interest in participating in the study and all 16 were still interested. Time and place for the interviews were decided and at the time of the interview a prior consent form was signed.
The interviews, performed by two of the researchers (CH, EL) with experiences of cardiac nursing, took place in the informants’ homes except for one interview, which was performed at a workplace. Experiences related to recovery were evoked by asking, “Please tell me about your experiences of recovery.” Follow-up questions were asked individually during the interview in order to clarify meanings. The interviews were tape-recorded and transcribed verbatim. Each person was interviewed once for an average of 1 hour, and afterward there was plenty of time to reflect on the interview with the aim not to leave the informant with feelings of insecurity.
The first part of the analysis was performed by two of the authors in parallel according to content analysis (Graneheim & Lundman, 2004). Familiarization with the material to obtain a sense of the whole was obtained by repeatedly reading through the transcripts. The text about the informant’s experience of recovery—the unit of analysis—was divided into meaning units that were condensed. The condensed meaning units were abstracted and labeled with a code. The codes were discussed and then differences and similarities were sought and the various codes were compared and sorted into 11 subcategories and 3 categories, constituting the manifest content. The third author who had read the transcripts checked the codes, subcategories, and categories. Through a process of reflection and discussion, the three authors agreed on the categorization. They formulated a theme out of the categories that constitutes the underlying meaning, or the latent content of the text.
The recovery process was described by the theme “access to the world” formulated from three categories: ability, restraints, and reorientation. The categories contained 12 subcategories: approachability, competence, confirmation, mutuality, practical attainments, fear, vigilance, physical pain, psychosocial pain, new values, motivation for change, and balance (see Table 2).
This category describes the ability of the self and others to aid recovery. It varied a great deal and concerned approachability of people or organizations, competence and confirmation by others, and the ability to take advantage of mutuality when meeting similar patients. Approachability was described in terms of contact and information. The nurse at the healthcare center had ample time for the patients and it was easy to call or visit her for guidance and support. However, it was more difficult to get in contact with the doctors, because they had less time for each patient and the informants expressed how they had to fight to get another appointment. Approachability also dealt with health information given at the hospital, which was experienced as easy to grasp and sufficient time was allowed for it. Competence was related to healthcare professionals and their skill to support the recovery. It was important to meet someone who had the competence and authority to help them recover.
Confirmation from colleagues and family was important. Workmates could be accepting and considerate. When a spouse or partner allowed the patient to relax, the informants felt better. Lack of confirmation was experienced when the family didn’t understand fragility and loss of strength. Mutuality between equals led to experiences of shared burdens. When meeting people in the rehabilitation group there were possibilities to compare oneself with others and it was a relief to find that one was not alone. Practical attainments contained both skills and insights. Informants had learned about a well-balanced diet and got the ability to choose differently. Informants also expressed how they paid attention to exercise in their daily life, which wasn’t noticed before. New insights had been incorporated and the informants were clear about how to behave to feel good.
This category describes experiences of restraints in connection with recovery dealing with fear and vigilance as well as physical and psychosocial pain. Fear was a hindrance in daily life and informants described how frightening it was to sleep, because of a fear that something terrible might happen during sleep. Some informants found it frightening to go outdoors, because they experienced accelerated heart rate as soon as they went out. Vigilance was described as a daily strain, because there was always fear of recurrence. Some bodily sensations gave rise to vigilance. Participants expressed worry of being alone and the inconvenience of asking others for help. Pain influenced different aspects of life. For some, pain influenced all activities of daily living and caused a lack of confidence in the future, while others described how they had got a totally new life without pain after treatment with percutaneous coronary intervention.
This category describes experiences of reorientation after MI. The experiences dealt with new values, motivation for change and balance in self as well as in relationships. The distribution between work and leisure time was valued in a new way as well as the image of self and others. Most informants had developed another way of looking at life and were clear about the value of leisure time. Self-image was influenced and some men expressed that they no longer found it necessary to prove their masculinity. The image of others also had changed. It was no longer meaningful to waste energy on negative relationships. The MI motivated them to set limitations and to be receptive to lifestyle changes. The disease could make it easier to say no to people with unreasonable demands. Others talked about lifestyle changes regarding food and exercise. They obtained balance in self and others. Family members were mostly understanding in the beginning and helpful with everything, but as they saw improvements they gradually retreated. The balance was important to all family members. Leisure activities helped them find balance in life again. Imbalance emerged when there was a lack of communication within relationships and some informants described how they retired into themselves.
This article examines how persons with MI experienced the recovery process and how data were analyzed according to qualitative content analysis (Graneheim & Lundman, 2004). This method for analysis is relevant as it stays close to the empirical data, which is important to be able to understand the recovery process from the informant’s perspective. The strategic selection ensures heterogeneity and thereby contributed to a good representation because the informants were able to describe recovery from various perspectives. The confirmability in this study is related to the researchers’ awareness and bracketing of their preunderstanding of the cardiac field. Furthermore, confirmability was strengthened by the description of the process and quotations supporting the analysis. The data analysis was performed in parallel by the researchers (CH, EL). After that a comparison and discussion took place until agreement was reached. The dependibility of the study was tested by comparing the subcategories and the categories to the empirical data and through discussion of this process among the researchers. Qualitative generalizability (i.e., the results may be transferred to other individuals who are in a similar situation; Polit & Hungler, 1999) is possible regarding the findings in this study because the result is in line with other studies in this field.
In this study recovery was described as a process whereby the MI was integrated into life while at the same time health improved. The evolving pattern of ability, restraints, and reorientation enabled a new life focus: integration of insights and movement toward new values, motivation for change and balance in self and relationships. Ability in self and others contributed to gaining access to the surrounding world after the MI. The cardiac nurse had the ability to make the information accessible to the individual creating satisfaction in the patients. The importance of satisfaction with information and care provided by healthcare professionals has been shown in other studies as association with lower levels of anxiety and perceived benefits of a healthy lifestyle (Davies, 2000; Zrinyi & Horvath, 2003). Ability was also demonstrated through other strategies such as approachability to the cardiac nurse, welcoming attitudes, and sufficient time for patients and spouses. This is a way to show respect to patient’s dignity. However, inability of the healthcare system to provide patients with appointments to see a doctor was also revealed. This can be seen as a lack of approachability. Even if this was a question of organization, it was nevertheless detrimental to both patients and staff.
The informants’ positive experience of the follow-up after the MI in the present study was in contrast to the result described by Henriksen and Rosenquist (2003). Here, findings showed that healthcare professionals had difficulty understanding the patients’ situation and collaborating between levels of care and that follow-up processes were lacking.
The importance of these qualities may be better understood in light of stress theory (Lazarus, 1999) where it is stated that the interaction between the individual and the environment is crucial for the experience and appraisal of the situation. Complexity in the relationships after the MI is illustrated by one informants’ expression of well-being (i.e., when his wife helped him to relax). The MI had made the informants temporarily vulnerable and to some extent dependent, a circumstance that can be difficult to understand and manage in relationships.
In other studies the complexity of relationships is described in terms of disturbances, conflicts, and misguided attempts (Roebuck et al., 2001; Stewart et al., 2000). However, sharing experiences with a layperson or in a peer support group has been found to be an important part of recovery (Bergman & Berterö, 2003; Hildingh et al., 1995).
Practical attainments included self-reliance, illustrated by the opinion that participation in rehabilitation programs would only generate more stress instead of support. Furthermore, other and more interesting activities than those offered by hospital-based cardiac rehabilitation were chosen. Discussions with informants concerning their own opinions and activities led to more flexible cardiac rehabilitation. Henriksen and Rosenquist (2003) found contrasting attitudes in healthcare professionals and emphasized that healthcare professionals’ attitudes and actions mirror their view of the patients as either collaborators or passive receivers. Yamada and Holmes (1998) recommend the consumers’ perspective as an aid to understanding recovery after MI, in addition to which, patients’ self-reliance needs to be considered in cardiac rehabilitation.
After the MI emotions led to restraints, access to the surrounding world was not the same as before. Fear of doing things and the threat of a re-infarction, death, or the loss of what was deemed to be important values forced the respondents to remain permanently vigilant (Ostergaard Jensen & Petersson, 2003). Such threats create stress reactions that require a lot of energy (Lazarus, 1999). On the other hand, to take into account that something may happen indicates that the disease has been integrated into life. Percutaneous coronary intervention was often performed before discharge from the hospital. This rapid treatment was an important part of recovery. The negative effects of the interaction between anxiety and chest-pain were eliminated, thus enabling a qualitatively better access to the surrounding world along the recovery process.
The importance of feeling well emotionally is supported by Ostir, Goodwin, Markides, Ottenbacher, Balfour, and Guralnik (2002) who found that emotional health is associated with the recovery of functional ability a year after a major health event. There are difficulties in understanding patients’ emotional response to MI, because the response is not always in proportion to the seriousness of the disease. A minor MI can lead to severe anxiety and depression in some people, but a massive MI seems to cause no great problems in others (Dixon et al., 2000). How patients interpret the situation and how this interpretation affects emotions and physical factors needs to be understood by healthcare professionals (Cherrington, 2001; Lazarus, 1999).
In the present study, reorientation was one out of the three categories describing the recovery process. Reorientation after MI changed the access to the surrounding world. New values and new motivation for lifestyle changes were found and a new balance was sought. The previous balance was no longer appropriate. In order to avoid stress and make recovery possible, former habits had to be changed and relationships had to be revalued in order to find a new life balance. This phenomenon can be explained by a system theory (i.e., once a system is disturbed it normally strives for a new balance; Whitchurch & Constantine, 1993). The content of the reorientation showed that the MI was a turning point in life. This implies, contrary to the findings of Kärner, Göransson, and Bergdahl (2003), that the MI was not perceived as a disease of a temporary nature but rather as a chronic condition. Wiles and Kinmonth (2001) emphasize that patients may be motivated to undertake lifestyle changes if they understand the MI as an acute symptom of an underlying chronic disease. Reorientation as a category was also found in Bergman and Berterö (2003) and in Brink et al., (2003), both pointing out the active self as central to the recovery process.
The recovery process had a pattern of ability, restraints, and reorientation. Through the ability of the self and others, the mutual sharing of burdens, and insights in restraints, the recovery process made progress toward reorientation. New values, motivation for change, and a new balance in self and relationships were found. The MI had been integrated into life and through the recovery process the patients’ attitudes were better focused, leading to an enhanced quality of life. Flexible thinking among nurses is a prerequisite for a positive collaboration with patients in the recovery process. A patient’s competence has to be respected and used in creative ways by nurses. This does not mean withdrawing but rather having respect for the patient’s self-image. Nurses need to be acutely aware of their responsibility because of the patients’ vulnerability and need for both dependence and independence.
We wish to express our gratitude to Elisabeth Persson, RN, for her assistance with this study.
About the Authors
Cathrine Hildingh, RNT PhD, is a senior lecturer at the School of Social and Health Sciences, Halmstad University, Halmstad, Sweden. Direct correspondence to her at firstname.lastname@example.org.
Bengt Fridlund, RNT PhD, is a professor at the School of Social and the Health Sciences, Halmstad University, Halmstad, Sweden, and the Centre for Ambulance and Acute Care, School of Health Sciences and Social Work, Växjö University, Växjö, Sweden.
Evy Lidell, RNT PhD, is a senior lecturer at the School of Social and Health Sciences, Halmstad University, Halmstad, Sweden.
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