548508 research-article2014
CNRXXX10.1177/1054773814548508Clinical Nursing ResearchNoureddine et al.
Article
Deciding to Seek Emergency Care for Acute Myocardial Infarction
Clinical Nursing Research 2015, Vol. 24(5) 487–503 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814548508 cnr.sagepub.com
Samar Noureddine, PhD, RN, FAHA1, Nuhad Y. Dumit, PhD, RN1, and Mohammad Saab, RN, MSN1
Abstract The purpose of this qualitative descriptive study was to explore how patients who experience acute myocardial infarction (AMI) decide to seek emergency care. Fifty patients with AMI were interviewed at two hospitals in Lebanon. The perspective of 22 witnesses of the attack was also sought about the cardiac event. The themes that transpired from the data were as follows: making sense of the symptoms, waiting to see what happens, deciding to come to the hospital, and the family influenced the decision to seek care. The witnesses of the cardiac event, mostly family members, supported the decision to seek emergency care. Deciding to seek emergency care for AMI is complex. Nurses must solicit their patients’ perception of the cardiac event to provide them with tailored education and counseling about heart attack symptoms and how to respond to them in case they recur. Family members must be included in the education process. Keywords coronary artery disease, acute care settings, qualitative, patient education
1American
University of Beirut, Lebanon
Corresponding Author: Samar Noureddine, Professor, Hariri School of Nursing, American University of Beirut, Maamari Street, Beirut 1107 2020, Lebanon. Email: [email protected]
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Heart disease is the leading cause of morbidity and mortality worldwide (Norving, Puska, & Mendis, 2011), including Lebanon (Jabbour, Giacaman, Khawaja, & Nuwayhid, 2012). Prompt treatment of acute myocardial infarction (AMI) is essential for its effectiveness, because delayed treatment is significantly related to increased mortality (Nallamothu et al., 2007). The time from symptom onset till arrival to the hospital is called delay time and most of it is accounted for by how long it takes the patient to decide to seek emergency care. Western countries reported median delay times near 2 hr (Dracup et al., 2009; Turin et al., 2011) versus 3.5 to 5 hr in Asia (Abba et al., 2003; Khraim, Scherer, Dorn, & Carey, 2009; Yu et al., 2006), including 4.5 hr in Lebanon (Noureddine et al., 2006). The Ministry of Public Health (MOPH) regulates health care in Lebanon. Eighty percent of the MOPH budget is allocated to subsidize private hospitals for the treatment of patients who cannot afford to pay (Huijer, Noureddine, & Dumit, 2004). Other patients have private health insurance or are covered through their employers (Noureddine & Arevian, 2004); yet most insurance plans do not cover care provided in the emergency department (ED) unless the patient gets admitted to the hospital. There is no national emergency medical system. The Lebanese Red Cross offers emergency services at no cost, but without provision of advanced cardiac life support due to restrictive laws, making it crucial that AMI victims reach the hospital promptly.
Research on Delay Several factors associated with prolonged delay in seeking care during an AMI were identified in quantitative studies, such as female gender, old age, and comorbidity. Moreover, patients were found to delay longer when their symptoms developed slowly or were intermittent, did not match their expectation of an AMI, or were attributed to non-cardiac causes (Caldwell & Dracup, 2008; Khraim & Carey, 2009; Turin et al., 2011). Qualitative investigators studied the delay phenomenon mostly in women (Arslanian-Engoren, 2005; Harralson, 2007; Herning, Hansen, Bygbjerg, & Lindhatt, 2011; Higginson, 2008; Rosenfeld, Lindauer, & Darney, 2005; Sjöström-Strand, 2008; Turris & Finamore, 2008); few included men (Galdas, Cheater, & Marshal, 2007; Isaksson, Brulin, Eliason, Näslund, & Zingmark, 2011), while others included both genders (Kaur, Lopez, & Thompson, 2006; O’Donnell & Moser, 2012; Pattenden, Watt, Lwein, & Stanford, 2002). Patients were found to cluster in groups: Self-managers versus those who relinquish the decision to others (Rosenfeld et al., 2005), with the need to maintain control contributing to delay in seeking care (Higginson, 2008; Isaksson et al., 2011; Kaur et al., 2006; Turris & Finamore, 2008). Perception
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of one’s risk for AMI (Harralson et al., 2007; Herning et al., 2011), the role of witnesses of the attack (Herning et al., 2011; Sjöström-Strand & Fridlund, 2008), and cultural values (Galdas et al., 2007) also influenced delay. Many studies on delay used the Common Sense Model of Illness Behavior (Diefenbach & Leventhal, 1996), which stipulates that patients evaluate their symptoms, respond to them, and appraise the outcome of their action, until they finally decide to seek emergency care. Most intervention studies that used community educational campaigns did not achieve reduced delay time (Kainth et al., 2004). Similarly, a randomized controlled trial titled Patient Response to Myocardial Infarction Following a Teaching Intervention Offered by Nurses (PROMOTION) that tested an individualized one-on-one education and counseling intervention in patients with acute coronary syndrome failed to reduce delay (Dracup et al., 2009). In Lebanon, data on delay in seeking care for AMI is raising researchers’ interests because this problem adversely affects patients’ outcomes. To develop an effective intervention tailored to the context and beliefs of Lebanese patients, an in-depth understanding of the delay phenomenon is needed. The aim of this qualitative study was to explore the decision-making processes of patients as they experienced symptoms of an AMI and related factors.
Method A qualitative descriptive design was used that is best suited for studying decision-making processes, so patients’ experiences are understood holistically from their perspective. Qualitative description was sought to capture the meanings patients attribute to these experiences (Sandelowski, 2000), which could be missed in quantitative studies of Lebanese cardiac patients.
Sample A convenience sample of 50 patients admitted to coronary care with a diagnosis of AMI was recruited from two hospitals in Beirut, Lebanon, a 350-bed tertiary center, and a 200-bed community hospital. Inclusion criteria were age 21 years or older, diagnosis of AMI, and admission through the ED. Patients who were transferred from other institutions, had cognitive deficits, psychiatric illness, or hemodynamic instability were excluded. In the tertiary hospital, 35 eligible participants were approached; 8 refused participation as they were tired or anxious and 2 were lost to follow up. In the community hospital, 3 out of 30 eligible patients refused participation and 2 were lost to follow up. The final sample included 50 patients. In addition, a witness of the AMI was interviewed to explore his or her perspective of the
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event. Person triangulation was attempted through interviewing witnesses in both recruitment hospitals, to obtain a comprehensive description of the cardiac event and validate the patients’ data, assuming that they may have forgotten some aspects of their experience due to its acute nature. Out of a total of 33 witnesses (3 coworkers, 1 neighbor, and 29 family members), 22 were available for interview: 9 from the tertiary center and 13 from the community hospital; of those, 16 were the patients’ spouses, 5 were their children, and 1 was the patient’s brother. Only in three instances, the symptoms occurred at work and the witness was a coworker; nevertheless, the coworkers were not available to be interviewed.
Data Collection The Institutional Review Boards of the university and both hospitals approved the study. Data were collected between August and December 2010. Eligible patients were recruited in their rooms. Those who agreed to participate were provided with a written informed consent form and interviewed within 72 hr of admission. Data were collected by graduate nursing students trained by the primary investigator who did not work in coronary care, so did not know the participants in advance. Each interview was tape recorded and lasted 20 to 30 min. The opening question was, “Tell me about what happened from the time you first felt your symptoms till the time you arrived to the ED.” Patients told their stories at their own pace. Next, probes were used to elicit information about the time and context of symptom onset, characteristics of the symptoms; whether or not the patient suspected a heart attack; his or her thoughts, feelings, and responses to the symptoms; and how he or she decided to come to the hospital. Demographic and clinical data, and the time of arrival to the ED were obtained from the medical records. Witnesses who accompanied the patient during the attack were informed about the study and invited to participate. Following consent, witnesses were interviewed in the hospital. They were asked about their experience, thoughts, feelings, and their role during the attack. One month after discharge, patients were interviewed at home to validate summaries of the interviews conducted in the hospital. The second interview served mostly as a member check to ensure that the analysis captured the patient’s perspective of the cardiac event.
Data Analysis The interviews were transcribed verbatim and analyzed using thematic analysis (Braun & Clarke, 2006). Each transcript was read and re-read and codes were identified. Next, codes were examined systematically across the data set
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and sorted into categories. The most frequently occurring categories with similar content were further sorted into themes that were reviewed and named and color-coded within the transcripts. Transcripts were also re-read to develop a chronological process connecting the emerging themes, and a summary was prepared for each transcript. Two of the authors analyzed all transcripts independently and discussed the derived themes; there was no disagreement regarding the analyzed data. Interviews were conducted and transcribed in Arabic and the transcripts were analyzed in Arabic. The extracted themes, categories, and excerpts were then translated to English independently by the authors who are bilingual. The English versions were discussed and there was full agreement on the translation.
Results The sample included 50 patients, 25 from each hospital. Demographic and clinical characteristics of patients are shown in Table 1. The majority of the participants were middle-aged (median = 56.5 years; range = 36-81 years) married men, employed, earning less than US $1,000 per month, with up to middle school education and insured. A substantial proportion of the sample was smokers or overweight; had hypertension, hyperlipidemia, diabetes mellitus, history of coronary artery disease, or family history of heart disease. Most patients (72%) had angioplasty and/or stenting; few (12%) had open heart surgery or were treated by medications only (16%). The median delay time from symptom onset to arrival to the hospital was 2 hr 40 min (range = 15 min to 6 days); 36% delayed longer than 6 hr. The majority of patients (64%) decided by themselves to seek emergency care; the rest kept deferring the decision till their symptoms became unbearable or their witnesses forced them to come to the hospital. In some cases, the patient and family collectively made the decision to come to the hospital. Patients were transported to the hospital mostly by their family, except for few patients who drove themselves and one who was transported by an ambulance. The themes that transpired from the data were as follows: (a) making sense of the symptoms, (b) waiting to see what happens, (c) deciding to come to the hospital, and (d) the family influenced the decision to seek care. The data collected from witnesses mostly validated the patients’ stories without adding much new information. Moreover, the last theme on family influence captured the witnesses’ narratives. Table 2 shows the themes and their corresponding categories.
Making Sense of the Symptoms The patients tried to make sense of their symptoms using a number of strategies. As a result of this assessment, most participants concluded a cause of
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Table 1. Sample Characteristics (N = 50). Variable Gender (male) Marital status Married Single Education Up to middle school Secondary University Monthly income $3,000 Age (M ± SD) Body mass index (M ± SD) Current smoking Hypertension Family history of coronary artery disease Hyperlipidemia Diabetes mellitus Previous history of coronary artery disease
Frequency
%
41
82.0
44 4
88.0 8.0
26 13 11
52.0 26.0 22.0
24 10 8
57.1 23.8 19.0 57.68 ± 12.03 27.33 ± 4.49
33 22 20 18 12 11
67.8 44.0 40.0 36.0 24.0 22.0
their symptoms, which was often determined by their location or context. Many patients who had chest pain compared their symptoms with those they experienced before. For example, one patient stated, I had chest pain last month, but it was mild, brief, and went on its own . . . When I used to make an effort, I would feel something over my chest but not longer than 50 seconds . . . This time I did not walk 50 meters when I felt like something over my chest and it lasted 15 to 20 minutes.
Other patients compared their symptoms with those experienced by their acquaintances. One lady who had severe chest pain and numbness in her hands said, I did not think it was the heart but the lungs because I smoke. The pain was in the center of my chest like knives but the heart is to the left. Our relative underwent open heart surgery; he had shoulder pain; I did not have any shoulder pain.
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Noureddine et al. Table 2. Themes and Categories of the Decision-Making Process for Seeking Emergency Care in Patients With AMI. Theme
Categories
Making sense of the symptoms
Waiting to see what happens
Deciding to come to the hospital
The family influenced the decision to seek emergency care
Compared their symptoms with those experienced before Compared their symptoms with those experienced by others Compared their symptoms with those they expected to occur during AMI Considered the location of symptoms Considered the context in which the symptoms occurred Being able to tolerate the pain Monitoring the symptoms after self-help measures Consulting others Not willing to trouble others Not trusting some health professionals Not willing to bother one’s family Triggers to seeking emergency care: Having severe symptoms Experiencing new symptoms Suspecting a heart attack Recommendation of a physician Thinking that one’s family needs him or her Family witnesses supported the patient’s decision to seek care Family witnesses forced the resisting patient to come to the hospital
Note. AMI = acute myocardial infarction.
Other participants compared their symptoms with what they expect an AMI would feel like. One participant who had severe left arm pain said, I know people during a heart attack have chest pain but did not expect there will be arm pain like this . . . Initially, when I had arm pain, I let it pass thinking arthritis and did not do anything; I did not think of the heart until the pain moved to my chest.
Most of the patients whose symptom was epigastric pain thought that the cause was their stomach. One patient reported, “I felt nauseated and the tip of my stomach hurt me, so I thought it was my stomach, an ulcer or something . . . I took a medication for the stomach.” The context of symptoms also
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influenced what participants thought to cause their symptoms. One patient with pressure like chest pain stated, “We had our relatives visit us a few days ago and all of them had the flu, so when I had the symptoms I thought I got the flu . . . I took two paracetamol tablets.” Once the patients came up with a self-diagnosis, they tried self-help measures to relieve their symptoms, and then monitored their effect. The assumed cause of symptoms often persisted even when their symptoms changed or were not relieved by self-help measures. The patient above who thought his symptoms were due to the flu started having severe chest pain at 11:00 p.m., with dyspnea and numbness of the hands. Although his pain radiated to his shoulder and arms and was not relieved by paracetamol and herbal tea, his flu diagnosis remained; so he just rested and waited till morning before calling his son to take him to the hospital. Otherwise, when patients could not guess what caused their symptoms, they told someone to take them to the hospital. For instance, the patient whose chest pain was much more prolonged than before could not guess the cause but felt “something was not right,” so he decided to come to the hospital.
Waiting to See What Happens Another common theme was waiting to see what happens, which patients attempted initially when the symptoms started, and after trying some action to relieve them. For example, one participant who experienced chest pain, cold sweating, and some nausea at work, stated, I came home because I felt there is something abnormal . . . I sat on the bed and waited to see what is going to happen; will the symptoms resolve or become stronger? If they go it means, this was due to an air draft from the AC and so I would rest and skip work tomorrow . . . I took my baby aspirin as a precaution . . . the sweating stayed for about 2 hours then stopped, but the pain remained over the center of my chest. My wife started calling the neighbors by phone to ask them what to do, then went to a nearby pharmacist and described my symptoms to him . . . he said it may be a heart condition . . . It was then that I considered coming to the hospital.
In describing their waiting, patients often referred to being able to tolerate the symptoms, not willing to trouble others especially when symptoms occurred at night, and sometimes lack of trust in health care providers. One participant was having dyspnea and intermittent chest pain for a number of days. The day prior to admission around midnight the pain recurred with burning and radiation to the left arm. He said “The pain was burning over my
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chest but bearable. I kept fighting till 4:00 a.m. in the morning. Then, I got tired . . . So I slept the whole day.” Another patient who had prior open heart surgery started having chest pain after a late dinner. He reported having had this pain on and off for 4 months: the pain was mild compared to my symptoms 10 years ago before the surgery . . . it was bearable . . . I was stubborn and did not want to go to the hospital until my family called my doctor who came and examined me and insisted that I go to the ED.
Thinking about one’s family acted as a barrier to the decision to seek emergency care. One patient was having shortness of breath and heartburn for some time. Then, the chest pain started and was increasing in severity; he said, “The pain started at midnight, then at 1:00 a.m., it became very strong; the family was asleep I did not want to wake them up so I waited.” Women, who often depended on others for transportation to the hospital, were concerned about bothering their children, so they waited before calling them about their symptoms. One widow who lives with an 8-year-old daughter and has two married daughters who lived with their families nearby said, “It was nighttime and I did not want to worry my daughters so I waited till morning.” Lack of trust in some health care providers made some patients wait before seeking care. One patient had the symptoms at 2:00 a.m., and initially thought it was from his reflux disease; then when the symptoms radiated laterally to both sides, he went with his wife over brochures they had about heart attack and became convinced that this was happening. Nevertheless, they waited till 9:00 a.m. next morning to see his physician in the clinic, because the patient did not want to be treated by medical students in the ED, but rather by his own cardiologist. Other participants did not trust general practitioners; so they double checked with a cardiologist before coming to the hospital. One patient who developed severe chest pain went to his family physician who suggested that he have chest X ray and ECG. Rather than doing the test immediately, the patient waited a few days before coming to the emergency room. He said, “The family doctor stated this may be a heart attack but I wanted to be sure, so I saw another doctor who is a cardiologist. He asked that I must come to the hospital.” This pattern was noted mostly in the community hospital group; participants from that hospital often consulted their general practitioner about their symptoms. The practitioner recommended having ECG and cardiac biomarker tests and asked them to report the results back to him. One participant, for instance, took 2 days to do the tests, then another day to report to the physician, who then referred
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him to a cardiologist who ordered immediate hospitalization. These instances contributed to delay in seeking emergency care.
Deciding to Come to the Hospital Patients eventually realized the seriousness of their symptoms and decided to come to the hospital. Factors that triggered the decision to seek emergency care included the severity and novelty of symptoms, suspecting a heart attack, the recommendation of a physician, and thinking that one’s family needs him or her. One participant had his symptoms at night, so he drank water and thought he would wait till morning and if they did not subside then he would get checked. However, the symptoms became more severe; he stated, “I could not tolerate the symptoms anymore”; this was when he decided to go to the ED. Another participant had severe epigastric pain and heartburn while lying down. He called his brother to come take him to the hospital. Upon probing, he stated, This is not the first time I get this pain. However, before I used to have it only when I walk uphill but then it would quickly go when I rest . . . this time the pain was very severe so I decided to come to the hospital . . . I wanted to get rid of this pain.
In other cases, the novelty of symptoms took the patient by surprise, triggering the decision to seek care. One patient reported, I started sweating much more than usual. I felt as if someone is pressing hard over my chest and pain over my stomach and back. I felt breathless . . . I have never experienced such symptoms before. I felt there was something abnormal so I left my wife and went down and asked my brother in law to take me to the hospital.
Suspecting a heart attack triggered many of the participants’ decision to come to the hospital. One participant said, “I knew there was something wrong with my heart, so I decided to come to the hospital.” Participants who consulted a physician, especially a cardiologist, decided to come to the hospital upon the physician’s recommendation, as exemplified by the following quote: “The cardiologist said you should go to emergency immediately.” One participant who had his symptoms at work stated, I consulted a work colleague who had a similar experience and he suggested that I go to the ED but I was not convinced, so we called the physician of the bank and described my situation to him. The physician recommended that I go to emergency.
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Consulting physicians over the phone was often a precursor to the decision of seeking emergency care. Another trigger to deciding to come to the hospital was thinking about one’s family. One participant shared his concern about his family: You know I was afraid for I thought this was a heart attack and I have heard about many people dying from it. I was mostly afraid for my son and my wife who is also pregnant. Who will take care of them if something happens to me?
The Family Influenced the Decision to Seek Care Most patients experienced the AMI at home and in the presence of many family members. The narratives of the witnesses corroborated the participants’ interviews. The family witnesses overall supported the patients’ decision to come to the hospital by consulting with others and taking them to the hospital. Witnesses were supportive even when they were hesitant about going to the hospital. For example, one patient had severe epigastric pain; when he said he wanted to go to the hospital, the wife suggested asking a cardiologist first about what to do. She said, “I am afraid of hospitals. You know as they say you go to the hospital for one complaint, they create 100 problems for you.” However, when the patient called his brother to take him to the hospital, the wife agreed to his decision. In other cases, the family forced the resisting patient to come to the hospital by calling a physician acquaintance to come and convince him. One patient had severe chest pain following dinner at his daughter’s house. She said, He was not looking well and asked that we massage him between the shoulders. He was still in pain after that and I told him let me take your blood pressure; you may be having a heart attack . . . His blood pressure was very high yet he still refused going to the hospital. I went to my brother who lived in the top floor to come maybe he can convince him but he could not so I called our family physician who talked to him on the phone but he refused. So the physician came and examined him. He told him you must go to emergency, so my brother took him there.
Discussion This qualitative study explored how patients experiencing AMI in Lebanon decide to come to the hospital and factors that influence the decision. The findings showed that the decision-making process is complex, does not progress in a linear fashion, and is shaped by many considerations. In brief, the most common process involved the patients evaluating their symptoms and
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trying to identify their cause, taking some action to get relief, assessing its results then acting further till they come to the hospital. A lot of waiting and monitoring characterized the experience, and consultations were made with relatives and/or physicians to validate the need to go to the hospital. Thinking about and presence of the family influenced the decision process. The qualitative approach allowed an in-depth evaluation of the decisionmaking process. Confirmability was supported by the agreement between investigators, as their independent interpretations of data were congruent in terms of the themes and categories extracted. The member check conducted with all patients following discharge and the witnesses’ accounts supported the credibility of the results by validating the researchers’ interpretation of data and ensuring a rich data through person (witness) triangulation (Polit & Beck, 2011). The results are overall in line with the Common Sense Model of Illness Behavior (Diefenbach & Leventhal, 1996) in terms of the cognitive appraisal of the threatening symptoms, cognitive and behavioral responses, appraisal of the outcomes, and influential factors involved. However, the emotional reaction to the symptoms was not articulated by the patients. Only upon probing, very few women mentioned fear or anxiety as a result of the symptoms. Those women stated that their symptoms were so severe that they were afraid to lose consciousness; this fear pushed them to seek help. However, the majority of men did not explicitly admit fear but those who stated that their pain escalated and became unbearable eventually came to the hospital to find out what is going on. In the Lebanese culture, men do not often express fear as they are expected to be stoical and tolerate pain, as was found in Caucasian men (Galdas et al., 2007). Moreover, fear may have been part of the emotional representation of heart disease in men, because, as noted in the results, when they suspected the heart to cause their symptoms, they promptly sought help. Thus, both the severity of symptoms and suspicion of a heart attack may have caused fear in the participants, leading them to come to the hospital. Many themes obtained in this study echo the findings of other investigators. Comparing symptoms with those of others was reported by Pattenden et al. (2002) and Sjöström-Strand and Fridlund (2008). Similarly, attempting a diagnosis of the cause of symptoms was shown to guide the behavioral response in many studies (Arslanian-Engoren, 2005; Kaur et al., 2006; Rosenfeld et al., 2005). Most of the patients did not suspect a heart attack initially, even those with the typical presentation of chest pain; some patients attributed their symptoms to their lungs, suggesting lack of knowledge about the symptoms of AMI. Many patients who had prior AMI or positive family history did not relate their current symptoms to the heart, such as when their current symptoms were different from the past. Similarly, those who experienced AMI in close family members did not necessarily attribute their own
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symptoms to the heart. One patient stated that he thought he was too young to have a heart attack like his father had. It may be that these patients were not taught about the risk of recurrence of cardiac events, or they may be denying that risk (Pattenden et al., 2002; Sjöström-Strand & Fridlund, 2008). The wait and see approach, a major barrier to seeking care, was reported by other investigators (Rosenfeld et al., 2005; Turris & Finamore, 2008). This monitoring before and after trying self-help measures reflects the patients’ attempt at staying in control of their situation, in line with the literature (Arslanian-Engoren, 2005; Herning et al., 2011; Isaksson et al., 2011; Rosenfeld et al., 2005). Being able to tolerate the symptoms supported this sense of control, thus delaying the decision to seek emergency care. Riegel et al. (2011) found that patients who responded rapidly to a second cardiac event after the intervention had lower sense of control than at baseline, suggesting they are developing a more realistic perception of the threat of a heart attack. Consulting someone to validate the felt need to go to the ED was a common approach by participants in this study. This may reflect the collectivist nature of the Lebanese society where social support is very important in people’s lives and major decisions are made with significant others. An alternative explanation is the lack of financial resources, although this was not reported except for one patient who said that he was worried that his insurance card may have expired. The fact that most insurance companies in Lebanon do not cover emergency services except in case of hospitalization might have prevented participants from going to the ED. Triggers of the decision to seek care, namely, the severity of symptoms and their attribution to the heart, parallel those reported by others (ArslanianEngoren, 2005; Herning et al., 2011; Sjöström-Strand & Fridlund, 2008). In this study, recommendations by physicians to go to the hospital were an important trigger to seek emergency care. Direct calling of physician specialists is common among the Lebanese, thus people consult doctors over the phone and often follow their advice. Recommendations made by general practitioners, however, were often not adequate, for they asked patients to do tests and report back to them, thus contributing to delay in coming to the ED. These physicians did not relay the urgency of prompt management of AMI. Patients’ response to symptoms was influenced by their thoughts about their families. Often patients did not want to trouble their families and waited before telling them about their symptoms, consistent with other studies (Herning et al., 2011; Sjöström-Strand & Fridlund, 2008). Yet, some patients changed their minds when they considered their role in providing for their family, as was found in a study in Hong Kong (Kaur et al., 2006). However, once the family knew about the situation, the decision to seek care was a collective one. Those present took turns getting more information from the
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patient, calling acquaintances or physicians for help, and then taking the patient to the hospital. In some cases, the family forced the decision despite resistance by the patient, as found by Arslanian-Engoren (2005). This approach reflects the Lebanese culture where health decisions become a family responsibility (Kulwicki, 2003), as opposed to Western cultures where the individualistic approach to managing life events is more common. In brief, the unique findings of this study revolve around the perception of heart attack as a life threatening event that require going to the hospital, consulting with others and seeking their advice for action before making a final decision, and the key role of the family in the decision process. Thus, any counseling regarding AMI and how to respond to it must target the family. For those patients who consulted with general practitioners, the findings suggest the need to educate those practitioners about AMI diagnosis to reduce delay in getting proper treatment.
Study Limitations The sample is limited to two hospitals in Beirut; however, its distribution was similar to that of a national study of AMI patients (Sawaya et al., 2000) in Lebanon in terms of demographic and clinical characteristics. The study may be limited by recall bias; this was addressed by interviewing patients within 72 hr of admission soon after they became stable.
Conclusion The findings of this study add to the literature on the phenomenon of seeking care for AMI and the underlying decision process. The contextual and cultural characteristics of the Lebanese patients that shape their experiences in the setting of AMI revealed some unique findings that can inform practice. Patients in this study appraised their symptoms to figure out their cause. They waited, consulted with others, and monitored their symptoms, trying some relief measures till they eventually decided to come to the hospital. Throughout the process, the patient’s family played an important supportive role. There is a need for education about the variability of symptoms of AMI and the importance of early treatment. Nurses must ask their patients about their experience to identify their perceptions and misconceptions about AMI, and counsel them accordingly about how to manage recurring coronary events. The counseling must include the family. General practitioners need to be trained in recognizing signs and symptoms of AMI and recommending the appropriate course of action, as they are the first medical contact for patients of low socioeconomic status or with no
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direct access to a cardiologist. In addition, paramedics need training so that they can provide advanced cardiac life support promptly. Furthermore, insurance companies must be urged to cover the expenses of emergency services. Delay in seeking care for AMI has grave consequences on patients’ outcomes. Health care professionals are responsible to educate people when to suspect a heart attack and how to respond, taking into consideration the sociocultural context and available health care services. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References Abba, A. A., Bani, B. A., Rahmatullah, R. A., Khalil, M. Z., Kumo, A. M., & Ghonaim, M. A. (2003). Door to needle time in administering thrombolytic therapy for acute myocardial infarction. Saudi Medical Journal, 24, 361-364. Arslanian-Engoren, C. (2005). Treatment seeking decisions of women with acute myocardial infarction. Women & Health, 42(2), 53-70. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.1191/1478088706qp063oa Caldwell, M. A., & Dracup, K. (2008). Patient delay in seeking care in cardiac illness. In D. K. Moser & B. Riegel (Eds.), Cardiac nursing: A companion to Braunwald’s heart disease (pp. 737-742). Philadelphia, PA: Saunders. Diefenbach, M., & Leventhal, H. (1996). The common-sense model of illness representation: Theoretical and practical considerations. Journal of Social Distress and the Homeless, 5(1), 11-38. Dracup, K., McKinley, S., Riegel, B., Moser, D. K., Meischke, H., Doering, L. V., . . . Pelter, M. (2009). A randomized clinical trial to reduce patient prehospital delay to treatment in acute coronary syndrome. Circulation: Cardiovascular Quality and Outcomes, 2, 524-532. Galdas, P., Cheater, F., & Marshal, P. (2007). What is the role of masculinity in white and south Asian men’s decisions to seek medical help for cardiac chest pain? Journal of Health Services Research & Policy, 12, 223-229. Harralson, T. L. (2007). Factors influencing delay in seeking treatment for acute ischemic symptoms among lower income, urban women. Heart Lung, 36(2), 96-104. Herning, H., Hansen, P. R., Bygbjerg, B., & Lindhatt, T. (2011). Women’s experiences and behavior at the onset of symptoms of ST elevation acute myocardial infarction. European Journal of Cardiovascular Nursing, 10, 241-247.
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Higginson, R. (2008). Women’s help seeking behavior at the onset of myocardial infarction. British Journal of Nursing, 17, 10-14. Huijer, H. A.-S., Noureddine, S., & Dumit, N. (2005). Nursing in Lebanon. Applied Nursing Research, 18, 63– 64. Isaksson, R. M., Brulin, C., Eliason, M., Näslund, U., & Zing5mark, K. (2011). Prehospital experiences of older men with a first myocardial infarction: A qualitative analysis within the Northern Sweden MONICA study. Scandinavian Journal of Caring Science, 25, 787-797. Jabbour, S., Giacaman, R., Khawaja, M., & Nuwayhid, I. (2012). Public health in the Arab world. New York, NY: Cambridge University Press. Kainth, A., Hewitt, A., Sowden, A., Duffy, S., Pattenden, J., Lewin, R., . . . Thompson, D. (2004). Systematic review of interventions to reduce delay in patients with suspected heart attack. Emergency Medical Journal, 21, 506-508. Kaur, R., Lopez, V., & Thompson, D. R. (2006). Factors influencing Chinese patients’ decision-making in seeking early treatment for acute myocardial infarction. Research in Nursing & Health, 29, 636-646. Khraim, F. M., & Carey, M. G. (2009). Predictors of pre-hospital delay among patients with acute myocardial infarction. Patient Education and Counseling, 75, 155-161. Khraim, F. M., Scherer, Y. K., Dorn, J. M., & Carey, M. G. (2009). Predictors of decision delay to seeking health care among Jordanians with acute myocardial infarction. Journal of Nursing Scholarship, 41, 260-267. Kulwicki, A. (2003). People of Arab heritage. In L. D. Purnell & B. J. Paulanka (Eds.), Transcultural health care: A culturally competent approach (2nd ed., pp. 90-105). Philadelphia, PA: F.A. Davis. Nallamothu, B. K., Fox, A. A. A., Kennelly, B. M., Van De Werf, F., Gore, J. M., Steg, P. G., . . . Eagle, K., on behalf of the GRACE investigators. (2007). Relationship of treatment delay and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The global registry of acute coronary events. Heart, 93, 1552-1555. Norving, B., Puska, P., & Mendis, S. (2011). Global atlas on cardiovascular disease prevention and control. Geneva, Switzerland: World Health Organization. Retrieved from http://whqlibdoc.who.int/publications/2011/9789241564373_ eng.pdf Noureddine, S., & Arevian, M. (2004). Occupational Health Nursing in Lebanon. AAOHN Journal, 52, 193 - 198. Noureddine, S., Adra, M., Arevian, M., Dumit, N. Y., Puzantian, H., Shehab, D., & Abchee, A. (2006). Delay in seeking health care for acute coronary syndromes in a Lebanese sample. Journal of Transcultural Nursing, 17, 341-348. O’Donnell, S., & Moser, D. K. (2012). Slow-onset myocardial infarction and its influence on help-seeking behaviors. Journal of Cardiovascular Nursing, 27, 334-344. Pattenden, J., Watt, I., Lwein, R. J., & Stanford, N. (2002). Decision making processes in people with symptoms of acute myocardial infarction: A qualitative study. British Medical Journal, 324, 1006-1009.
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Polit, D. F., & Beck, C. T. (2011). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Riegel, B., Elmi, A., Moser, D. K., McKinley, S., Meischke, H., Doering, L., . . . Dracup, K. (2011). Who listens to our advice? A secondary analysis of data from a clinical trial testing an intervention designed to decrease delay in seeking treatment for acute coronary syndrome. Patient Education and Counseling, 85, e33-e38. Rosenfeld, A. G., Lindauer, A., & Darney, B. G. (2005). Understanding treatment delay in women with acute myocardial infarction: Descriptions of decision making. American Journal of Critical Care, 14, 285-293. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. Sawaya, J. I., Jazra, C., Farhat, F., Alam, S., Eid, E., & Sabra, R. (2000). In-hospital mortality after acute myocardial infarction in Lebanon: Incidence, associations, and influence of newer treatment regimens. Lebanese Medical Journal, 48(2), 63-69. Sjöström-Strand, A., & Fridlund, B. (2008). Women’s descriptions of symptoms and delay reasons in seeking medical care at the time of a first myocardial infarction: A qualitative study. International Journal of Nursing Studies, 45, 1003-1010. Turin, T. C., Kita, Y., Rumana, N., Nakamura, Y., Takashima, N., Sugihara, H., . . . Ueshima, H. (2011). Time lag to hospitalization and the associated determinants in patients with acute myocardial infarction: The Takashima AMI Registry, Japan. Emergency Medical Journal, 28, 239e-241e. Turris, S. A., & Finamore, S. (2008). Reducing delay for women seeking treatment in the emergency department for symptoms of potential cardiac illness. Journal of Emergency Nursing, 34, 509-515. Yu, L. T., Zhu, J., Mister, R., Zhang, Y., Li, J. D., Wang, D. L., . . . Flather, M. (2006). The Chinese registry on reperfusion strategies and outcomes in ST-elevation myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi, 34, 593-597.
Author Biographies Samar Noureddine, PhD, RN, FAHA, is a professor at the Hariri School of Nursing, American University of Beirut. She is fellow at the American Heart Association and member of the Science Committee of the Cardiovascular Council of Nursing and Allied Professionals of the European Society of Cardiology. Her area of specialty is cardiovascular health promotion and risk reduction and her studies address health seeking behaviors in patients with coronary artery disease. Nuhad Y. Dumit, PhD, RN, is an assistant professor at the Hariri School of Nursing, American University of Beirut. Her area of research interest is outcomes research, with a focus on qualitative methods. Mohammad Saab, RN, MSN, is a clinical instructor at the Hariri School of Nursing, American University of Beirut. His clinical interest is in palliative care. His research is focused on qualitative methods.
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CNRXXX10.1177/1054773814548508Clinical Nursing ResearchNoureddine et al.
Article
Deciding to Seek Emergency Care for Acute Myocardial Infarction
Clinical Nursing Research 2015, Vol. 24(5) 487–503 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814548508 cnr.sagepub.com
Samar Noureddine, PhD, RN, FAHA1, Nuhad Y. Dumit, PhD, RN1, and Mohammad Saab, RN, MSN1
Abstract The purpose of this qualitative descriptive study was to explore how patients who experience acute myocardial infarction (AMI) decide to seek emergency care. Fifty patients with AMI were interviewed at two hospitals in Lebanon. The perspective of 22 witnesses of the attack was also sought about the cardiac event. The themes that transpired from the data were as follows: making sense of the symptoms, waiting to see what happens, deciding to come to the hospital, and the family influenced the decision to seek care. The witnesses of the cardiac event, mostly family members, supported the decision to seek emergency care. Deciding to seek emergency care for AMI is complex. Nurses must solicit their patients’ perception of the cardiac event to provide them with tailored education and counseling about heart attack symptoms and how to respond to them in case they recur. Family members must be included in the education process. Keywords coronary artery disease, acute care settings, qualitative, patient education
1American
University of Beirut, Lebanon
Corresponding Author: Samar Noureddine, Professor, Hariri School of Nursing, American University of Beirut, Maamari Street, Beirut 1107 2020, Lebanon. Email: [email protected]
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Heart disease is the leading cause of morbidity and mortality worldwide (Norving, Puska, & Mendis, 2011), including Lebanon (Jabbour, Giacaman, Khawaja, & Nuwayhid, 2012). Prompt treatment of acute myocardial infarction (AMI) is essential for its effectiveness, because delayed treatment is significantly related to increased mortality (Nallamothu et al., 2007). The time from symptom onset till arrival to the hospital is called delay time and most of it is accounted for by how long it takes the patient to decide to seek emergency care. Western countries reported median delay times near 2 hr (Dracup et al., 2009; Turin et al., 2011) versus 3.5 to 5 hr in Asia (Abba et al., 2003; Khraim, Scherer, Dorn, & Carey, 2009; Yu et al., 2006), including 4.5 hr in Lebanon (Noureddine et al., 2006). The Ministry of Public Health (MOPH) regulates health care in Lebanon. Eighty percent of the MOPH budget is allocated to subsidize private hospitals for the treatment of patients who cannot afford to pay (Huijer, Noureddine, & Dumit, 2004). Other patients have private health insurance or are covered through their employers (Noureddine & Arevian, 2004); yet most insurance plans do not cover care provided in the emergency department (ED) unless the patient gets admitted to the hospital. There is no national emergency medical system. The Lebanese Red Cross offers emergency services at no cost, but without provision of advanced cardiac life support due to restrictive laws, making it crucial that AMI victims reach the hospital promptly.
Research on Delay Several factors associated with prolonged delay in seeking care during an AMI were identified in quantitative studies, such as female gender, old age, and comorbidity. Moreover, patients were found to delay longer when their symptoms developed slowly or were intermittent, did not match their expectation of an AMI, or were attributed to non-cardiac causes (Caldwell & Dracup, 2008; Khraim & Carey, 2009; Turin et al., 2011). Qualitative investigators studied the delay phenomenon mostly in women (Arslanian-Engoren, 2005; Harralson, 2007; Herning, Hansen, Bygbjerg, & Lindhatt, 2011; Higginson, 2008; Rosenfeld, Lindauer, & Darney, 2005; Sjöström-Strand, 2008; Turris & Finamore, 2008); few included men (Galdas, Cheater, & Marshal, 2007; Isaksson, Brulin, Eliason, Näslund, & Zingmark, 2011), while others included both genders (Kaur, Lopez, & Thompson, 2006; O’Donnell & Moser, 2012; Pattenden, Watt, Lwein, & Stanford, 2002). Patients were found to cluster in groups: Self-managers versus those who relinquish the decision to others (Rosenfeld et al., 2005), with the need to maintain control contributing to delay in seeking care (Higginson, 2008; Isaksson et al., 2011; Kaur et al., 2006; Turris & Finamore, 2008). Perception
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of one’s risk for AMI (Harralson et al., 2007; Herning et al., 2011), the role of witnesses of the attack (Herning et al., 2011; Sjöström-Strand & Fridlund, 2008), and cultural values (Galdas et al., 2007) also influenced delay. Many studies on delay used the Common Sense Model of Illness Behavior (Diefenbach & Leventhal, 1996), which stipulates that patients evaluate their symptoms, respond to them, and appraise the outcome of their action, until they finally decide to seek emergency care. Most intervention studies that used community educational campaigns did not achieve reduced delay time (Kainth et al., 2004). Similarly, a randomized controlled trial titled Patient Response to Myocardial Infarction Following a Teaching Intervention Offered by Nurses (PROMOTION) that tested an individualized one-on-one education and counseling intervention in patients with acute coronary syndrome failed to reduce delay (Dracup et al., 2009). In Lebanon, data on delay in seeking care for AMI is raising researchers’ interests because this problem adversely affects patients’ outcomes. To develop an effective intervention tailored to the context and beliefs of Lebanese patients, an in-depth understanding of the delay phenomenon is needed. The aim of this qualitative study was to explore the decision-making processes of patients as they experienced symptoms of an AMI and related factors.
Method A qualitative descriptive design was used that is best suited for studying decision-making processes, so patients’ experiences are understood holistically from their perspective. Qualitative description was sought to capture the meanings patients attribute to these experiences (Sandelowski, 2000), which could be missed in quantitative studies of Lebanese cardiac patients.
Sample A convenience sample of 50 patients admitted to coronary care with a diagnosis of AMI was recruited from two hospitals in Beirut, Lebanon, a 350-bed tertiary center, and a 200-bed community hospital. Inclusion criteria were age 21 years or older, diagnosis of AMI, and admission through the ED. Patients who were transferred from other institutions, had cognitive deficits, psychiatric illness, or hemodynamic instability were excluded. In the tertiary hospital, 35 eligible participants were approached; 8 refused participation as they were tired or anxious and 2 were lost to follow up. In the community hospital, 3 out of 30 eligible patients refused participation and 2 were lost to follow up. The final sample included 50 patients. In addition, a witness of the AMI was interviewed to explore his or her perspective of the
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event. Person triangulation was attempted through interviewing witnesses in both recruitment hospitals, to obtain a comprehensive description of the cardiac event and validate the patients’ data, assuming that they may have forgotten some aspects of their experience due to its acute nature. Out of a total of 33 witnesses (3 coworkers, 1 neighbor, and 29 family members), 22 were available for interview: 9 from the tertiary center and 13 from the community hospital; of those, 16 were the patients’ spouses, 5 were their children, and 1 was the patient’s brother. Only in three instances, the symptoms occurred at work and the witness was a coworker; nevertheless, the coworkers were not available to be interviewed.
Data Collection The Institutional Review Boards of the university and both hospitals approved the study. Data were collected between August and December 2010. Eligible patients were recruited in their rooms. Those who agreed to participate were provided with a written informed consent form and interviewed within 72 hr of admission. Data were collected by graduate nursing students trained by the primary investigator who did not work in coronary care, so did not know the participants in advance. Each interview was tape recorded and lasted 20 to 30 min. The opening question was, “Tell me about what happened from the time you first felt your symptoms till the time you arrived to the ED.” Patients told their stories at their own pace. Next, probes were used to elicit information about the time and context of symptom onset, characteristics of the symptoms; whether or not the patient suspected a heart attack; his or her thoughts, feelings, and responses to the symptoms; and how he or she decided to come to the hospital. Demographic and clinical data, and the time of arrival to the ED were obtained from the medical records. Witnesses who accompanied the patient during the attack were informed about the study and invited to participate. Following consent, witnesses were interviewed in the hospital. They were asked about their experience, thoughts, feelings, and their role during the attack. One month after discharge, patients were interviewed at home to validate summaries of the interviews conducted in the hospital. The second interview served mostly as a member check to ensure that the analysis captured the patient’s perspective of the cardiac event.
Data Analysis The interviews were transcribed verbatim and analyzed using thematic analysis (Braun & Clarke, 2006). Each transcript was read and re-read and codes were identified. Next, codes were examined systematically across the data set
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and sorted into categories. The most frequently occurring categories with similar content were further sorted into themes that were reviewed and named and color-coded within the transcripts. Transcripts were also re-read to develop a chronological process connecting the emerging themes, and a summary was prepared for each transcript. Two of the authors analyzed all transcripts independently and discussed the derived themes; there was no disagreement regarding the analyzed data. Interviews were conducted and transcribed in Arabic and the transcripts were analyzed in Arabic. The extracted themes, categories, and excerpts were then translated to English independently by the authors who are bilingual. The English versions were discussed and there was full agreement on the translation.
Results The sample included 50 patients, 25 from each hospital. Demographic and clinical characteristics of patients are shown in Table 1. The majority of the participants were middle-aged (median = 56.5 years; range = 36-81 years) married men, employed, earning less than US $1,000 per month, with up to middle school education and insured. A substantial proportion of the sample was smokers or overweight; had hypertension, hyperlipidemia, diabetes mellitus, history of coronary artery disease, or family history of heart disease. Most patients (72%) had angioplasty and/or stenting; few (12%) had open heart surgery or were treated by medications only (16%). The median delay time from symptom onset to arrival to the hospital was 2 hr 40 min (range = 15 min to 6 days); 36% delayed longer than 6 hr. The majority of patients (64%) decided by themselves to seek emergency care; the rest kept deferring the decision till their symptoms became unbearable or their witnesses forced them to come to the hospital. In some cases, the patient and family collectively made the decision to come to the hospital. Patients were transported to the hospital mostly by their family, except for few patients who drove themselves and one who was transported by an ambulance. The themes that transpired from the data were as follows: (a) making sense of the symptoms, (b) waiting to see what happens, (c) deciding to come to the hospital, and (d) the family influenced the decision to seek care. The data collected from witnesses mostly validated the patients’ stories without adding much new information. Moreover, the last theme on family influence captured the witnesses’ narratives. Table 2 shows the themes and their corresponding categories.
Making Sense of the Symptoms The patients tried to make sense of their symptoms using a number of strategies. As a result of this assessment, most participants concluded a cause of
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Table 1. Sample Characteristics (N = 50). Variable Gender (male) Marital status Married Single Education Up to middle school Secondary University Monthly income $3,000 Age (M ± SD) Body mass index (M ± SD) Current smoking Hypertension Family history of coronary artery disease Hyperlipidemia Diabetes mellitus Previous history of coronary artery disease
Frequency
%
41
82.0
44 4
88.0 8.0
26 13 11
52.0 26.0 22.0
24 10 8
57.1 23.8 19.0 57.68 ± 12.03 27.33 ± 4.49
33 22 20 18 12 11
67.8 44.0 40.0 36.0 24.0 22.0
their symptoms, which was often determined by their location or context. Many patients who had chest pain compared their symptoms with those they experienced before. For example, one patient stated, I had chest pain last month, but it was mild, brief, and went on its own . . . When I used to make an effort, I would feel something over my chest but not longer than 50 seconds . . . This time I did not walk 50 meters when I felt like something over my chest and it lasted 15 to 20 minutes.
Other patients compared their symptoms with those experienced by their acquaintances. One lady who had severe chest pain and numbness in her hands said, I did not think it was the heart but the lungs because I smoke. The pain was in the center of my chest like knives but the heart is to the left. Our relative underwent open heart surgery; he had shoulder pain; I did not have any shoulder pain.
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Noureddine et al. Table 2. Themes and Categories of the Decision-Making Process for Seeking Emergency Care in Patients With AMI. Theme
Categories
Making sense of the symptoms
Waiting to see what happens
Deciding to come to the hospital
The family influenced the decision to seek emergency care
Compared their symptoms with those experienced before Compared their symptoms with those experienced by others Compared their symptoms with those they expected to occur during AMI Considered the location of symptoms Considered the context in which the symptoms occurred Being able to tolerate the pain Monitoring the symptoms after self-help measures Consulting others Not willing to trouble others Not trusting some health professionals Not willing to bother one’s family Triggers to seeking emergency care: Having severe symptoms Experiencing new symptoms Suspecting a heart attack Recommendation of a physician Thinking that one’s family needs him or her Family witnesses supported the patient’s decision to seek care Family witnesses forced the resisting patient to come to the hospital
Note. AMI = acute myocardial infarction.
Other participants compared their symptoms with what they expect an AMI would feel like. One participant who had severe left arm pain said, I know people during a heart attack have chest pain but did not expect there will be arm pain like this . . . Initially, when I had arm pain, I let it pass thinking arthritis and did not do anything; I did not think of the heart until the pain moved to my chest.
Most of the patients whose symptom was epigastric pain thought that the cause was their stomach. One patient reported, “I felt nauseated and the tip of my stomach hurt me, so I thought it was my stomach, an ulcer or something . . . I took a medication for the stomach.” The context of symptoms also
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influenced what participants thought to cause their symptoms. One patient with pressure like chest pain stated, “We had our relatives visit us a few days ago and all of them had the flu, so when I had the symptoms I thought I got the flu . . . I took two paracetamol tablets.” Once the patients came up with a self-diagnosis, they tried self-help measures to relieve their symptoms, and then monitored their effect. The assumed cause of symptoms often persisted even when their symptoms changed or were not relieved by self-help measures. The patient above who thought his symptoms were due to the flu started having severe chest pain at 11:00 p.m., with dyspnea and numbness of the hands. Although his pain radiated to his shoulder and arms and was not relieved by paracetamol and herbal tea, his flu diagnosis remained; so he just rested and waited till morning before calling his son to take him to the hospital. Otherwise, when patients could not guess what caused their symptoms, they told someone to take them to the hospital. For instance, the patient whose chest pain was much more prolonged than before could not guess the cause but felt “something was not right,” so he decided to come to the hospital.
Waiting to See What Happens Another common theme was waiting to see what happens, which patients attempted initially when the symptoms started, and after trying some action to relieve them. For example, one participant who experienced chest pain, cold sweating, and some nausea at work, stated, I came home because I felt there is something abnormal . . . I sat on the bed and waited to see what is going to happen; will the symptoms resolve or become stronger? If they go it means, this was due to an air draft from the AC and so I would rest and skip work tomorrow . . . I took my baby aspirin as a precaution . . . the sweating stayed for about 2 hours then stopped, but the pain remained over the center of my chest. My wife started calling the neighbors by phone to ask them what to do, then went to a nearby pharmacist and described my symptoms to him . . . he said it may be a heart condition . . . It was then that I considered coming to the hospital.
In describing their waiting, patients often referred to being able to tolerate the symptoms, not willing to trouble others especially when symptoms occurred at night, and sometimes lack of trust in health care providers. One participant was having dyspnea and intermittent chest pain for a number of days. The day prior to admission around midnight the pain recurred with burning and radiation to the left arm. He said “The pain was burning over my
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chest but bearable. I kept fighting till 4:00 a.m. in the morning. Then, I got tired . . . So I slept the whole day.” Another patient who had prior open heart surgery started having chest pain after a late dinner. He reported having had this pain on and off for 4 months: the pain was mild compared to my symptoms 10 years ago before the surgery . . . it was bearable . . . I was stubborn and did not want to go to the hospital until my family called my doctor who came and examined me and insisted that I go to the ED.
Thinking about one’s family acted as a barrier to the decision to seek emergency care. One patient was having shortness of breath and heartburn for some time. Then, the chest pain started and was increasing in severity; he said, “The pain started at midnight, then at 1:00 a.m., it became very strong; the family was asleep I did not want to wake them up so I waited.” Women, who often depended on others for transportation to the hospital, were concerned about bothering their children, so they waited before calling them about their symptoms. One widow who lives with an 8-year-old daughter and has two married daughters who lived with their families nearby said, “It was nighttime and I did not want to worry my daughters so I waited till morning.” Lack of trust in some health care providers made some patients wait before seeking care. One patient had the symptoms at 2:00 a.m., and initially thought it was from his reflux disease; then when the symptoms radiated laterally to both sides, he went with his wife over brochures they had about heart attack and became convinced that this was happening. Nevertheless, they waited till 9:00 a.m. next morning to see his physician in the clinic, because the patient did not want to be treated by medical students in the ED, but rather by his own cardiologist. Other participants did not trust general practitioners; so they double checked with a cardiologist before coming to the hospital. One patient who developed severe chest pain went to his family physician who suggested that he have chest X ray and ECG. Rather than doing the test immediately, the patient waited a few days before coming to the emergency room. He said, “The family doctor stated this may be a heart attack but I wanted to be sure, so I saw another doctor who is a cardiologist. He asked that I must come to the hospital.” This pattern was noted mostly in the community hospital group; participants from that hospital often consulted their general practitioner about their symptoms. The practitioner recommended having ECG and cardiac biomarker tests and asked them to report the results back to him. One participant, for instance, took 2 days to do the tests, then another day to report to the physician, who then referred
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him to a cardiologist who ordered immediate hospitalization. These instances contributed to delay in seeking emergency care.
Deciding to Come to the Hospital Patients eventually realized the seriousness of their symptoms and decided to come to the hospital. Factors that triggered the decision to seek emergency care included the severity and novelty of symptoms, suspecting a heart attack, the recommendation of a physician, and thinking that one’s family needs him or her. One participant had his symptoms at night, so he drank water and thought he would wait till morning and if they did not subside then he would get checked. However, the symptoms became more severe; he stated, “I could not tolerate the symptoms anymore”; this was when he decided to go to the ED. Another participant had severe epigastric pain and heartburn while lying down. He called his brother to come take him to the hospital. Upon probing, he stated, This is not the first time I get this pain. However, before I used to have it only when I walk uphill but then it would quickly go when I rest . . . this time the pain was very severe so I decided to come to the hospital . . . I wanted to get rid of this pain.
In other cases, the novelty of symptoms took the patient by surprise, triggering the decision to seek care. One patient reported, I started sweating much more than usual. I felt as if someone is pressing hard over my chest and pain over my stomach and back. I felt breathless . . . I have never experienced such symptoms before. I felt there was something abnormal so I left my wife and went down and asked my brother in law to take me to the hospital.
Suspecting a heart attack triggered many of the participants’ decision to come to the hospital. One participant said, “I knew there was something wrong with my heart, so I decided to come to the hospital.” Participants who consulted a physician, especially a cardiologist, decided to come to the hospital upon the physician’s recommendation, as exemplified by the following quote: “The cardiologist said you should go to emergency immediately.” One participant who had his symptoms at work stated, I consulted a work colleague who had a similar experience and he suggested that I go to the ED but I was not convinced, so we called the physician of the bank and described my situation to him. The physician recommended that I go to emergency.
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Consulting physicians over the phone was often a precursor to the decision of seeking emergency care. Another trigger to deciding to come to the hospital was thinking about one’s family. One participant shared his concern about his family: You know I was afraid for I thought this was a heart attack and I have heard about many people dying from it. I was mostly afraid for my son and my wife who is also pregnant. Who will take care of them if something happens to me?
The Family Influenced the Decision to Seek Care Most patients experienced the AMI at home and in the presence of many family members. The narratives of the witnesses corroborated the participants’ interviews. The family witnesses overall supported the patients’ decision to come to the hospital by consulting with others and taking them to the hospital. Witnesses were supportive even when they were hesitant about going to the hospital. For example, one patient had severe epigastric pain; when he said he wanted to go to the hospital, the wife suggested asking a cardiologist first about what to do. She said, “I am afraid of hospitals. You know as they say you go to the hospital for one complaint, they create 100 problems for you.” However, when the patient called his brother to take him to the hospital, the wife agreed to his decision. In other cases, the family forced the resisting patient to come to the hospital by calling a physician acquaintance to come and convince him. One patient had severe chest pain following dinner at his daughter’s house. She said, He was not looking well and asked that we massage him between the shoulders. He was still in pain after that and I told him let me take your blood pressure; you may be having a heart attack . . . His blood pressure was very high yet he still refused going to the hospital. I went to my brother who lived in the top floor to come maybe he can convince him but he could not so I called our family physician who talked to him on the phone but he refused. So the physician came and examined him. He told him you must go to emergency, so my brother took him there.
Discussion This qualitative study explored how patients experiencing AMI in Lebanon decide to come to the hospital and factors that influence the decision. The findings showed that the decision-making process is complex, does not progress in a linear fashion, and is shaped by many considerations. In brief, the most common process involved the patients evaluating their symptoms and
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trying to identify their cause, taking some action to get relief, assessing its results then acting further till they come to the hospital. A lot of waiting and monitoring characterized the experience, and consultations were made with relatives and/or physicians to validate the need to go to the hospital. Thinking about and presence of the family influenced the decision process. The qualitative approach allowed an in-depth evaluation of the decisionmaking process. Confirmability was supported by the agreement between investigators, as their independent interpretations of data were congruent in terms of the themes and categories extracted. The member check conducted with all patients following discharge and the witnesses’ accounts supported the credibility of the results by validating the researchers’ interpretation of data and ensuring a rich data through person (witness) triangulation (Polit & Beck, 2011). The results are overall in line with the Common Sense Model of Illness Behavior (Diefenbach & Leventhal, 1996) in terms of the cognitive appraisal of the threatening symptoms, cognitive and behavioral responses, appraisal of the outcomes, and influential factors involved. However, the emotional reaction to the symptoms was not articulated by the patients. Only upon probing, very few women mentioned fear or anxiety as a result of the symptoms. Those women stated that their symptoms were so severe that they were afraid to lose consciousness; this fear pushed them to seek help. However, the majority of men did not explicitly admit fear but those who stated that their pain escalated and became unbearable eventually came to the hospital to find out what is going on. In the Lebanese culture, men do not often express fear as they are expected to be stoical and tolerate pain, as was found in Caucasian men (Galdas et al., 2007). Moreover, fear may have been part of the emotional representation of heart disease in men, because, as noted in the results, when they suspected the heart to cause their symptoms, they promptly sought help. Thus, both the severity of symptoms and suspicion of a heart attack may have caused fear in the participants, leading them to come to the hospital. Many themes obtained in this study echo the findings of other investigators. Comparing symptoms with those of others was reported by Pattenden et al. (2002) and Sjöström-Strand and Fridlund (2008). Similarly, attempting a diagnosis of the cause of symptoms was shown to guide the behavioral response in many studies (Arslanian-Engoren, 2005; Kaur et al., 2006; Rosenfeld et al., 2005). Most of the patients did not suspect a heart attack initially, even those with the typical presentation of chest pain; some patients attributed their symptoms to their lungs, suggesting lack of knowledge about the symptoms of AMI. Many patients who had prior AMI or positive family history did not relate their current symptoms to the heart, such as when their current symptoms were different from the past. Similarly, those who experienced AMI in close family members did not necessarily attribute their own
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symptoms to the heart. One patient stated that he thought he was too young to have a heart attack like his father had. It may be that these patients were not taught about the risk of recurrence of cardiac events, or they may be denying that risk (Pattenden et al., 2002; Sjöström-Strand & Fridlund, 2008). The wait and see approach, a major barrier to seeking care, was reported by other investigators (Rosenfeld et al., 2005; Turris & Finamore, 2008). This monitoring before and after trying self-help measures reflects the patients’ attempt at staying in control of their situation, in line with the literature (Arslanian-Engoren, 2005; Herning et al., 2011; Isaksson et al., 2011; Rosenfeld et al., 2005). Being able to tolerate the symptoms supported this sense of control, thus delaying the decision to seek emergency care. Riegel et al. (2011) found that patients who responded rapidly to a second cardiac event after the intervention had lower sense of control than at baseline, suggesting they are developing a more realistic perception of the threat of a heart attack. Consulting someone to validate the felt need to go to the ED was a common approach by participants in this study. This may reflect the collectivist nature of the Lebanese society where social support is very important in people’s lives and major decisions are made with significant others. An alternative explanation is the lack of financial resources, although this was not reported except for one patient who said that he was worried that his insurance card may have expired. The fact that most insurance companies in Lebanon do not cover emergency services except in case of hospitalization might have prevented participants from going to the ED. Triggers of the decision to seek care, namely, the severity of symptoms and their attribution to the heart, parallel those reported by others (ArslanianEngoren, 2005; Herning et al., 2011; Sjöström-Strand & Fridlund, 2008). In this study, recommendations by physicians to go to the hospital were an important trigger to seek emergency care. Direct calling of physician specialists is common among the Lebanese, thus people consult doctors over the phone and often follow their advice. Recommendations made by general practitioners, however, were often not adequate, for they asked patients to do tests and report back to them, thus contributing to delay in coming to the ED. These physicians did not relay the urgency of prompt management of AMI. Patients’ response to symptoms was influenced by their thoughts about their families. Often patients did not want to trouble their families and waited before telling them about their symptoms, consistent with other studies (Herning et al., 2011; Sjöström-Strand & Fridlund, 2008). Yet, some patients changed their minds when they considered their role in providing for their family, as was found in a study in Hong Kong (Kaur et al., 2006). However, once the family knew about the situation, the decision to seek care was a collective one. Those present took turns getting more information from the
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patient, calling acquaintances or physicians for help, and then taking the patient to the hospital. In some cases, the family forced the decision despite resistance by the patient, as found by Arslanian-Engoren (2005). This approach reflects the Lebanese culture where health decisions become a family responsibility (Kulwicki, 2003), as opposed to Western cultures where the individualistic approach to managing life events is more common. In brief, the unique findings of this study revolve around the perception of heart attack as a life threatening event that require going to the hospital, consulting with others and seeking their advice for action before making a final decision, and the key role of the family in the decision process. Thus, any counseling regarding AMI and how to respond to it must target the family. For those patients who consulted with general practitioners, the findings suggest the need to educate those practitioners about AMI diagnosis to reduce delay in getting proper treatment.
Study Limitations The sample is limited to two hospitals in Beirut; however, its distribution was similar to that of a national study of AMI patients (Sawaya et al., 2000) in Lebanon in terms of demographic and clinical characteristics. The study may be limited by recall bias; this was addressed by interviewing patients within 72 hr of admission soon after they became stable.
Conclusion The findings of this study add to the literature on the phenomenon of seeking care for AMI and the underlying decision process. The contextual and cultural characteristics of the Lebanese patients that shape their experiences in the setting of AMI revealed some unique findings that can inform practice. Patients in this study appraised their symptoms to figure out their cause. They waited, consulted with others, and monitored their symptoms, trying some relief measures till they eventually decided to come to the hospital. Throughout the process, the patient’s family played an important supportive role. There is a need for education about the variability of symptoms of AMI and the importance of early treatment. Nurses must ask their patients about their experience to identify their perceptions and misconceptions about AMI, and counsel them accordingly about how to manage recurring coronary events. The counseling must include the family. General practitioners need to be trained in recognizing signs and symptoms of AMI and recommending the appropriate course of action, as they are the first medical contact for patients of low socioeconomic status or with no
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direct access to a cardiologist. In addition, paramedics need training so that they can provide advanced cardiac life support promptly. Furthermore, insurance companies must be urged to cover the expenses of emergency services. Delay in seeking care for AMI has grave consequences on patients’ outcomes. Health care professionals are responsible to educate people when to suspect a heart attack and how to respond, taking into consideration the sociocultural context and available health care services. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Samar Noureddine, PhD, RN, FAHA, is a professor at the Hariri School of Nursing, American University of Beirut. She is fellow at the American Heart Association and member of the Science Committee of the Cardiovascular Council of Nursing and Allied Professionals of the European Society of Cardiology. Her area of specialty is cardiovascular health promotion and risk reduction and her studies address health seeking behaviors in patients with coronary artery disease. Nuhad Y. Dumit, PhD, RN, is an assistant professor at the Hariri School of Nursing, American University of Beirut. Her area of research interest is outcomes research, with a focus on qualitative methods. Mohammad Saab, RN, MSN, is a clinical instructor at the Hariri School of Nursing, American University of Beirut. His clinical interest is in palliative care. His research is focused on qualitative methods.
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