561129 research-article2014
WJNXXX10.1177/0193945914561129Western Journal of Nursing ResearchSkaggs and Yates
Article
Functional Status and Search for Meaning After Percutaneous Coronary Intervention
Western Journal of Nursing Research 1–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914561129 wjn.sagepub.com
Brenda G. Skaggs1 and Bernice C. Yates2
Abstract The purpose of this study was to determine the differences in the search for meaning and functional status (psychological and physical) between persons who undergo percutaneous coronary intervention and have recurrent angina symptoms and those who do not have recurrent symptoms. Participants (224; 147 male, 77 female) who underwent PCI completed the following study materials: Meaning in Heart Disease instrument, Hospital Anxiety and Depression Scale, and SF36v2™. Persons with recurrent angina symptoms (40% of the sample) were more likely to have higher disrupted meaning, greater anxiety, greater depression, lower physical functioning, and greater use of meaning-based coping (searching for answers and refocusing global meaning) compared with individuals without recurrent symptoms. Interventions are needed to identify the risk of recurrent symptoms after percutaneous coronary intervention and provide coping and cognitive behavioral interventions focused on managing the psychological and physical disruptions. Keywords angina, search for meaning, physical functioning, psychological functioning, percutaneous coronary intervention
1Department 2University
of Veterans Affairs Medical Center, Oklahoma City, OK, USA of Nebraska Medical Center, Omaha, USA
Corresponding Author: Brenda G. Skaggs, Chief Nurse, Ambulatory Care, Department of Veterans Affairs Medical Center, 921 N. E. 13th, Oklahoma City, OK, USA. Email: [email protected]
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When individuals experience a significant life event such as the onset of a life-threatening illness, it often interferes with their pursuit of goals, the fulfillment of a sense of purpose, and a sense of meaning in life. The onset of coronary heart disease (CHD) is likely considered a significant event in the lives of most people. Even more difficult may be the situation where individuals undergo percutaneous coronary intervention (PCI) for CHD but have recurrent angina after the procedure. Recurrent angina is an unanticipated event that makes people question what is happening and poses an obstacle in the person’s recovery experience. While findings from the literature suggest that individuals with ongoing symptoms of heart disease may experience difficulties with psychological and physical functioning (Alsen, Brink, Persson, Brandstrom, & Karlson, 2010; Skaggs et al., 2007), there is minimal knowledge about the process of understanding what has happened, trying to make the event fit in with life, and/or changing the purpose and direction of life all of which represent the search for meaning. Nurses are in a key position to assist those with recurrent angina symptoms throughout the process of searching for meaning. Furthermore, developing the knowledge base related to the experience of persons with recurrent angina after PCI is imperative so that specific interventions may be developed to assist persons with the return of symptoms after PCI to work through the process of searching for meaning. Thus, the purpose of this study is to examine the search for meaning by comparing the differences between PCI patients who have angina after PCI and those who do not have angina in their search for meaning, physical functioning, and psychological functioning.
Searching for Meaning The search for meaning has been defined as a process focusing on minimizing disrupted meaning (disruption of the life experience) and involves a person’s appraisal of a significant life event in light of one’s purpose/goals, values, and beliefs (global meaning) through searching for answers and refocusing global meaning (Lazarus, 2001; Park, 2010; Skaggs & Barron, 2006). Furthermore, when an unexpected event (e.g., myocardial infarction [MI], PCI, recurrent angina symptoms) occurs, people evaluate the event in terms of significance and impact on their life’s global meaning (Lazarus, 2001; Park, 2010). Each person has unique beliefs, values, goals, and purpose in life, which define the concept of global meaning (Park, 2010). When the event is perceived as insignificant or positive, the event may be ignored. However, when the event is appraised as significant, negative, and/or a threat, the life experience is disrupted (disrupted meaning), and the person responds by searching for meaning using meaning-based coping techniques to change
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the meaning of the event (searching for answers) or changing global meaning (refocusing global meaning; Park, 2010; Skaggs & Barron, 2006). In terms of heart disease, disrupted meaning refers to the interruption in global meaning (Skaggs et al., 2007) caused by the person’s perceived meaning of the impact of heart disease on the life experience. Searching for answers refers to the meaning-based coping activities of determining why heart disease occurred, who or what is responsible for the heart disease, and the impact of the heart disease on the future (Skaggs et al., 2007). Refocusing global meaning refers to meaning-based coping activities aimed at the individual’s evaluation and revision of priorities, goals, and beliefs (Skaggs et al., 2007). Although few studies were found examining the search for meaning in cardiovascular patients, it has been examined through similar concepts such as dealing with life’s challenges, searching for answers, and trying to regain normalcy. Persons who had experienced MI perceived the MI as having challenged day-to-day life (Brink, Karlson, & Hallberg, 2006). The challenge was met with coping strategies aimed at minimizing consequences of the MI, redesigning, as well as finding meaning and purpose in day-to-day life (Brink et al., 2006), and searching for answers about what may have caused the MI and what the future held in terms of daily and working life (Alsen, Brink, & Persson, 2008). In contrast, some persons were less reflective and did not spend time thinking about their heart disease (Alsen et al., 2008). Still others who continued to have angina symptoms tried to live as normally as possible (Alsen et al., 2008). In other chronic illness conditions (e.g., cancer, HIV/AIDS, trauma survivors, etc.), the process of finding meaning has been examined as benefit finding (Stewart & Yuen, 2011). Individuals who were able to identify benefits associated with the illness were better adjusted, had lower morbidity over time, and had better spiritual and mental well-being (Stewart & Yuen, 2011). Measuring the process of the search for meaning has been inconsistent across studies (Park, 2010). Previously used measures examined components of the search for meaning (Fjelland, Barron, & Foxall, 2008; Park, 2010), but those measures were not designed specifically for use with cardiac patients. Components of the search for meaning were identified through many qualitative studies involving cardiac patients (Alsen et al., 2008; Brink et al., 2006). A qualitative measure, the Meaning in Heart Disease instrument (MHD), was developed as a measure of the search for meaning specific to the heart disease experience (Skaggs et al., 2007). While there are minimal findings related to the search for meaning by those individuals who underwent PCI with recurrent angina symptoms, there is evidence that the presence of angina symptoms may have an impact on the outcomes of psychological and physical functioning (Alsen et al., 2010; Skaggs et al., 2007). Persons who experienced a return of angina symptoms
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were more likely to report a decrease in quality of life (physical and psychological) when compared with their counterparts or to the general population (Brorsson, Bernstein, Brook, & Werko, 2001). For those who experienced recurrent angina symptoms, repeat vascularization (PCI or coronary artery bypass graft surgery [CABG]) may have been required (Loponen et al., 2009). Persons who underwent repeat vascularization within 6 months after PCI had greater physical limitations, more frequent angina symptoms, and lower health-related quality of life than those who did not have repeat vascularization (Neil et al., 2002; Rinfret et al., 2001). Psychological functioning has been defined as an individual’s “psychological attitudes and behaviors, including distress and well-being” (Patrick & Erickson, 1993, p. 77). Two indicators of emotional distress, anxiety and depressive symptoms, are considered negative alterations in affect or mood (Riegel & Gocka, 1995). Anxiety may be an immediate response to the onset of heart disease and may co-exist with depression, or depression may occur later in recovery as anxiety subsides (Doerfler & Paraskos, 2004). In several studies, emotional distress was related to poorer outcomes such as poorer physical health and quality of life in persons who underwent repeat PCI or who had ongoing angina symptoms (Alsen et al., 2010; Boehm & Kubzansky, 2012). In addition, those persons who believed their own behavior contributed to the cause of the heart disease were more likely to have poorer mental health (Lau-Walker, Cowie, & Roughton, 2008). Those who underwent repeat PCI exhibited worse emotional functioning than those who did not undergo repeat PCI (Rinfret et al., 2001). Ongoing angina symptoms were associated with emotional distress (Mayou et al., 2000). Stress or worry was cited as the most common causal attribution by persons who had experienced MI, and persons who had an anxious mood were more likely to associate the MI with stress (Cameron, Petrie, Ellis, Buick, & Weinman, 2005). Persons who reported anxiety after a PCI felt unable to get back to living life as before the PCI and experienced uncertainty over what the future would hold (Higgins, Dunn, & Theobald, 2000). Physical functioning is defined as an individual’s ability to carry out activities of daily living (e.g., mobility, self-care; Patrick & Erickson, 1993) and the person’s perception of their ability to function physically (Ades et al., 2002). Limitations in physical functioning may have been the result of angina symptoms, but some individuals may have self-limited activities because of concern for their health and safety or due to the advice of others (Higgins et al., 2000). Those who underwent repeat revascularization procedures or surgery within 6 months after PCI had greater physical limitations, more frequent angina symptoms, and lower quality of life than their counterparts (Neil et al., 2002).
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More than 950,000 PCI procedures were performed in the United States in 2010 (Go et al., 2014). Considering that up to 40% or more of individuals who underwent PCI had a return of angina symptoms (Loponen et al., 2009), examining the search for meaning and functional outcomes in this population is important to the development of specific interventions to promote wellbeing. Exploring the differences in the search for meaning as well as validating what is known about the differences between those who have a recurrence of angina symptoms after PCI and those who do not is a critical step in the development of interventions for this population.
Purpose This secondary analysis was undertaken to determine differences in the search for meaning, psychological functioning, and physical functioning between persons who undergo PCI and have a return of symptoms and those who do not have a return of symptoms. The specific research question was as follows: What are the differences between persons who undergo PCI and have a return of symptoms and those who do not within the first year after PCI in the following variables: A. The search for meaning (disrupted meaning, searching for answers, and refocusing global meaning), B. Psychological functioning (SF36v2™ mental component score, Hospital Anxiety And Depression scale [HADS-Anxiety and HADSDepression]), and C. Physical functioning (SF36v2™ physical component score [PCS])?
Method The findings reported here are from a secondary analysis of data collected for the purpose of testing the psychometric properties of the MHD (Skaggs et al., 2007). Using a cross-sectional design, a convenience sample was recruited from a population of individuals who underwent PCI during the year previous to enrollment at one of two regional medical centers in the south central United States. Persons were included in the sample if they were oriented to time, place, and person; spoke English; and had access to a telephone. Persons were excluded if they experienced any of the following: (a) physical or cognitive difficulties that may have interfered with the search for meaning related to heart disease, (b) had a Charlson Comorbidity Score (CCI; Charlson,
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Pompei, Ales, & MacKenzie, 1987) of 6 or greater, (c) were under the care of a mental health professional for psychiatric disorders, or (d) had previously undergone CABG or were awaiting open heart surgery.
Instruments Data collected during this study included measures to determine the incidence and frequency of angina, sample characteristics, and the outcome measures of the search for meaning, psychological functioning, and physical functioning. The Anginal Frequency subscale of the Seattle Angina Questionnaire (SAQ; Spertus et al., 1995) was used to divide the sample into two groups. The Anginal Frequency subscale, comprised of two items, quantifies the frequency of angina and nitroglycerin use during the 4 weeks prior to completion of the measure. A higher score indicates a lower frequency of angina and nitroglycerin use. Reliability and validity of the scale has been supported (Spertus et al., 1995). Those who reported no angina within the 4 weeks prior to completing the SAQ were included in the angina-free group, while all others were included in the angina group. The CCI, a weighted index used to assess for the presence of health conditions unrelated to CHD (Riedinger et al., 2001), has demonstrated predictive and concurrent validity (Charlson et al., 1987). An investigator-developed demographic form was used to collect information to describe the sample. Search for meaning. The 29-item MHD (Skaggs et al., 2007) was developed to measure the search for meaning as it relates to the heart disease experience. Scores from three of the MHD scales (disrupted meaning, refocusing global meaning, and searching for answers) were used for this secondary analysis. One MHD scale was not used for this analysis, “ignoring heart disease,” because the scale did not reflect meaning-based coping as anticipated. All scales are Likert-type and are scored on a 1 to 6 scale with a higher score indicating greater disruption in the life experience or greater use of the meaning-based coping processes (refocusing global meaning or searching for answers). The scales of the MHD have satisfactory reliability support (α ≥ 0.82 for all three scales) as well as content validity and construct validity (factor analysis and convergent). Functional status (physical and psychological functioning). The SF36v2™ is a self-report measure considered to be a comprehensive measure of functioning and well-being. The SF36v2™ is comprised of eight subscales that are reflective of two components of functional status (physical component summary [PCS] and mental component summary [MCS]; Ware & Kosinski,
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2001). Each component summary reflects the unique contribution of the eight subscales of the SF36 to either physical or mental functioning. Each component summary is scored using a norm-based approach with a potential score of 0 to 100. A higher score indicates better physical or mental functioning. The SF36v2™ has been widely used in studies of heart disease and has received satisfactory reliability and validity support (Alsen et al., 2010; LauWalker et al., 2008; Ware & Kosinski, 2001). For this study, all scales comprising the PCS and MCS demonstrated good reliabilities (α > .84). The Hospital Anxiety and Depression Scale (HADS) was developed for the screening of non-psychiatric patients (Zigmond & Snaith, 1983) and consists of an anxiety subscale (HADS-A) and a depression subscale (HADS-D). Each subscale is comprised of 7 items with a possible score of 0 to 21 (measured on a 4-point scale) with a score greater than 10 indicative of mood disturbance. The English version of the HADS has demonstrated adequate internal consistency reliability (HADS-A: 0.76-0.93, HADS-D: 0.72-0.90), and construct validity has been supported (Bjelland, Dahl, Haug, & Neckelmann, 2002). For this study, alpha coefficients were 0.89 for the HADS-A and 0.85 for the HADS-D.
Procedures Institutional review board approval was received for this secondary analysis. Re-consent was not required as this was an analysis of de-identified data from the original study. Institutional review board approval was obtained for the original study from all participating sites. All potential participants who had undergone PCI within the year previous to the start of the study were mailed an invitation to participate in the study. Individuals who were interested in participating returned a response card to the investigators. Respondents were contacted by phone, screened for eligibility, and provided an explanation of the study. For those giving verbal consent, study materials (all measures and the written consent forms) were sent to participants via the mail with instructions to complete and return to the investigators via the mail. Telephone calls and reminder letters were used to increase the response rate. Medical records were reviewed to collect comorbidity and heart disease severity data.
Data Analysis The Student t test was used to determine the differences between groups for the search for meaning and functional status. Differences in demographic and clinical characteristics between groups were examined using the Student t
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testfor continuous variables while chi-square analysis was used for dichotomous variables. Statistical significance was set at the .05 level.
Results The sample consisted of 224 participants (91 with a return of angina symptoms; 133 without a return of angina symptoms) who had undergone PCI within the year previous to recruitment. For analysis of the PCS and MCS, only 223 participants were included due to missing SF36v2 data from one participant. There were no differences between groups regarding gender with approximately one third of each group comprised of women. The group without angina symptoms was more likely than the group with angina symptoms to be younger (p < .01) and Caucasian (p < .05). There were no differences between the groups with regard to the comorbidity (CCI) score (no angina symptoms m = 1.87; recurrent angina symptoms m = 1.64; p > .05).
Research Question A: Search for Meaning Significant differences were found between groups for all aspects of the search for meaning (see Table 1). Compared with individuals without angina, those who continued to experience angina symptoms had higher scores on searching for answers, refocusing global meaning, and disruption in global meaning.
Research Question B: Psychological Functioning Similarly, significant differences were found for all measures of psychological functioning. Compared with individuals without angina symptoms, those who continued to experience angina symptoms had significantly lower levels of psychological functioning on the SF36v2™ MCS and higher levels of anxiety and depressive symptoms on the HADS.
Research Question C: Physical Functioning Physical functioning was measured with the SF36v2™ PCS. Persons who continued to experience angina symptoms had lower levels of physical functioning compared with those without angina symptoms. With group sizes of 133 for the group without angina symptoms and 91 for the group with angina symptoms, all the group differences achieved effect sizes that were d ≥ .50 (range = .50-.97). With power ≥ 0.95, the sample was deemed adequate for this secondary analysis.
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Skaggs and Yates Table 1. Comparisons of the Search for Meaning, Physical Functioning, and Psychological Functioning Between Those Without a Return of Angina Symptoms and Those With a Return of Angina Symptoms. Symptoms Characteristic Search for meaning Disrupted meaning (MHD)a Refocusing global meaning (MHD)a Searching for answers (MHD)a Physical functioning (PCS; SF36v2)b Psychological functioning Anxiety (HADS-Anxiety)c Depressive symptoms (HADS-Depression)c Psychological functioning (MCS)d
No Angina M (SD)
Return of Angina M (SD)
t test
2.33 (1.0) 3.72 (1.2) 3.30 (1.1) 44.93 (11.2)
3.46 (1.3) 4.29 (1.1) 4.06 (1.2) 34.92 (10.83)
−7.11* −3.56* −4.83* 6.66*
4.68 (3.7) 2.98 (2.9)
7.22 (5.0) 5.68 (4.07)
−4.19* −5.46*
52.52 (10.0)
45.62 (14.69)
3.90*
Note. Persons without angina symptoms n = 133; persons with angina symptoms n = 91. df = 222. = Meaning in Heart Disease instrument; possible range for each scale 1-6. bPCS = physical component score; possible range 0-100. cHADS = Hospital Anxiety and Depression Scale; possible range for each scale 0-21. dMCS = mental component score; possible range 0-100. *p < .001. aMHD
Discussion The purpose of this study was to determine the differences in the search for meaning, psychological functioning, and physical functioning among persons who underwent PCI and had a return of angina symptoms and those who did not have a return of angina symptoms. The findings from this secondary analysis support the idea that the return of angina symptoms is viewed as a significant, negative event that disrupts the life experience and starts the process of searching for meaning that for some, as we suggest, may lead to decreased physical and psychological functioning. This finding supports previous reviews related to searching for meaning (Park, 2010; Skaggs & Barron, 2006). Persons who had a return of angina symptoms were much more likely to experience a disruption in the life experience in terms of beliefs, values, life purpose, and goals. This suggests that the reoccurrence of symptoms may be viewed as a threat that may propel one to find a way to change the meaning of the heart disease or change global meaning (Lazarus, 2001). Thus, it is intuitive that those with recurrent angina symptoms would be much more
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likely than their counterparts to search for answers about why the symptoms recurred, who or what may be responsible for recurrence, and the impact of the symptoms on the life experience. Those with angina are also likely to work to bring congruence between expectations for one’s life and the impact of heart disease. While quantitative studies of the search for meaning in persons who underwent PCI were not found, the findings from the present study do support reported findings with those who experience MI. Persons who had experienced an acute MI questioned their illness and actively sought to comprehend their situation with heart disease including the cause of their illness, what life would be like, and what the future held; worked to minimize the consequences of the MI; made changes in the day to day life; and sought meaning and purpose in life (Alsen et al., 2008; Brink et al., 2006). We suggest that, on discharge from the hospital, the person who underwent a PCI may or may not have been told that angina symptoms could recur. The symptoms of angina (e.g., chest discomfort, shortness of breath, weakness, etc.) differ among individuals with up to 50% of all persons who experience acute MI having atypical symptoms or no symptoms at all (Anderson et al., 2007). In addition, some persons experiencing angina-type symptoms were found to be free of cardiac disease (Sheps, Creed, & Clouse, 2004). The ambiguity and uncertainty surrounding the signals presented by the recurrence of symptoms could be distressing and prompt the person to self-limit physical activities (Ades et al., 2002) and resist seeking medical advice for their symptoms. In any case, the person may also need more medical treatment if they really do have angina; and if the symptoms are not anginal, appropriate diagnosis and treatment may provide relief for the symptoms and ultimately relief for the reduced psychological and physical functioning. When the symptoms are not cardiac in origin, the offering of reassurance regarding symptoms is needed as well as encouragement to engage in normal activities. Persons in this study who had a return of angina symptoms were more likely to have decreased functioning, both physical and psychological, than those who did not have a return of angina symptoms. We suggest that the recurrent angina symptoms may indeed be deemed a threatening event associated with fear and anxiety that disrupts the life experience. As mentioned, the angina symptoms may not be due to heart disease, but the ambiguity and uncertainty may lead to poorer functioning, which, in turn, could be due to self-limitation. Testing a conceptual model that provides clarity to these relationships as well as the relationship with the components of the search for meaning would also provide the theoretical underpinnings for the development of interventions to assist persons with recurrent angina symptoms. In the development of effective interventions, it is of great importance to know where to target the intervention.
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We believe that developing and testing intervention strategies focused on supporting meaning-based coping would be an appropriate avenue for future research to improve psychological and physical functioning after PCI. In chronic illness conditions, individuals who were able to identify benefits associated with the illness were better adjusted, had lower morbidity over time, and had better spiritual and mental well-being (Stewart & Yuen, 2011). In intervention studies, women with breast cancer who wrote about benefits from having cancer had fewer symptoms, fewer medical appointments, and better heart rate response to stress than women in the control group (Low, Stanton, & Danoff-Burg, 2006). Intervention strategies that helped patients find meaning (benefits) were gratitude (Low et al., 2006), cultivating sacred moments (Goldstein, 2007), and pleasurable and meaningful acts (Peterson, Park, & Seligman, 2005). In a review of interventions to increase physical activity in cardiac patients, Ferrier, Blanchard, Vallis, and Giacomantonio (2011) found that interventions that included the development of coping plans were consistently shown to be very effective at increasing and maintaining physical activity; however, this approach was only used after cardiac rehabilitation. Because these are fairly brief interventions, they could be easily incorporated into routine inpatient cardiac care and reach a large percentage of people with CHD, thereby increasing their physical activity. This study is limited due to the fact that it is a comparison of two naturally occurring groups of a sample recruited for a study that was cross-sectional by design. The convenience sample was predominantly male and Caucasian. The sample was heterogeneous with the participants at different stages of recovery from the PCI, and both the age and race of the two groups were significantly different. In addition, comorbidities such as chronic pain and mobility limitations may have affected the meaning of the heart disease experience. This study is also limited by the self-report of participants. Our assumption is that those reporting symptoms believed the symptoms to be angina in nature. We were unable to objectively validate whether the selfreport of angina symptoms were due to CHD, and we must consider that self-report bias may exist (Boehm & Kubzansky, 2012). Finally, this analysis is limited because baseline measures were not available for the outcomes and inference that those with recurrent angina symptoms may have had poorer outcomes because of the angina cannot be made. The findings of this study are significant in that they provide insight into difficulties that persons with ongoing angina symptoms may be experiencing with regard to meaning as well as physical and psychological functioning. We find it imperative that persons with angina be followed closely for symptom relief and for psychological and physical functioning difficulties and be afforded support during times of difficulty. For immediate clinical practice, discharge from
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inpatient care should ensure that education regarding the possibility of future angina and actions to be taken by the patient is provided. In addition, the provision of close follow-up is important for this population. Future research should focus on the development of specific interventions to strengthen an individual’s meaning-based coping skills as well as on identifying the relationships between the search for meaning and psychological and physical outcomes. Acknowledgment The authors extend thanks to the staff of the Department of Veterans Affairs Medical Center, Oklahoma City, for support throughout the course of this study.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Sigma Theta Tau International, Doris Bloch Research Award and the NASA Nebraska Space Grant Fellowship Program.
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Mayou, R. A., Gill, D., Thompson, D. R., Day, A., Hicks, N., Volmink, J., & Neil, A. (2000). Depression and anxiety as predictors of outcome after myocardial infarction. Psychosomatic Medicine, 62, 212-219. Neil, N., Ramsey, S. D., Cohen, D. J., Every, N. R., Spertus, J. A., & Weaver, W. D. (2002). Resource utilization, cost, and health status impacts of coronary stent versus “optimal” percutaneous coronary angioplasty: Results from the OPUS-I trial. Journal of Interventional Cardiology, 15, 249-255. Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136, 257-301. doi:10.1037/a0018301 Patrick, D. L., & Erickson, P. (1993). Health status and health policy: Quality of life in health care evaluation and resource allocation. New York, NY: Oxford University Press. Peterson, C., Park, N., & Seligman, M. E. P. (2005). Orientations to happiness and life satisfaction: The full life versus the empty life. Journal of Happiness Studies, 6, 25-41. doi:10.1007/s10902-004-1278-z Riedinger, M. S., Dracup, K. A., Brecht, M. L., Padilla, G., Sarna, L., & Ganz, P. A. (2001). Quality of life in patients with heart failure: Do gender differences exist? Heart & Lung, 30, 105-116. doi:10.1067/mhl.2001.114140 Riegel, B., & Gocka, I. (1995). Gender differences in adjustment to acute myocardial infarction. Heart & Lung, 24, 457-466. Rinfret, S., Grines, C. L., Cosgrove, R. S., Ho, K. K. L., Cox, D. A., Brodie, B. R., . . . Cohen, D. J. (2001). Quality of life after balloon angioplasty or stenting for acute myocardial infarction: One-year results from the Stent-PAMI trial. Journal of the American College of Cardiology, 38, 1614-1621. doi:10.1016/S07351097(01)01599-6 Sheps, D. S., Creed, F., & Clouse, R. E. (2004). Chest pain in patients with cardiac and noncardiac disease. Psychosomatic Medicine, 66, 861-867. Skaggs, B. G., & Barron, C. (2006). Searching for meaning in negative events: A concept analysis. Journal of Advanced Nursing, 53, 559-570. Skaggs, B. G., Yates, B. C., Hertzog, M., Barron, C. R., Norman, J., & Pozehl, B. (2007). Meaning in heart disease: Measuring the search for meaning. Journal of Nursing Measurement, 15, 145-160. Spertus, J. A., Winder, J. A., Dewhurst, T. A., Deyo, R. A., Prodzinski, J., McDonell, M., & Fihn, S. D. (1995). Development and evaluation of the Seattle Angina Questionnaire: A new functional status measure for coronary artery disease. Journal of the American College of Cardiology, 25, 333-341. Stewart, D. E., & Yuen, T. (2011). A systematic review of resilience in the physically ill. Psychosomatics, 52, 199-209. doi:10.1016/j.psym.2011.01.036 Ware, J. E., & Kosinski, M. (2001). SF36 Physical & Mental Health Summary scales: A manual for users of version 1. Lincoln, RI: QualityMetric. Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.
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WJNXXX10.1177/0193945914561129Western Journal of Nursing ResearchSkaggs and Yates
Article
Functional Status and Search for Meaning After Percutaneous Coronary Intervention
Western Journal of Nursing Research 1–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914561129 wjn.sagepub.com
Brenda G. Skaggs1 and Bernice C. Yates2
Abstract The purpose of this study was to determine the differences in the search for meaning and functional status (psychological and physical) between persons who undergo percutaneous coronary intervention and have recurrent angina symptoms and those who do not have recurrent symptoms. Participants (224; 147 male, 77 female) who underwent PCI completed the following study materials: Meaning in Heart Disease instrument, Hospital Anxiety and Depression Scale, and SF36v2™. Persons with recurrent angina symptoms (40% of the sample) were more likely to have higher disrupted meaning, greater anxiety, greater depression, lower physical functioning, and greater use of meaning-based coping (searching for answers and refocusing global meaning) compared with individuals without recurrent symptoms. Interventions are needed to identify the risk of recurrent symptoms after percutaneous coronary intervention and provide coping and cognitive behavioral interventions focused on managing the psychological and physical disruptions. Keywords angina, search for meaning, physical functioning, psychological functioning, percutaneous coronary intervention
1Department 2University
of Veterans Affairs Medical Center, Oklahoma City, OK, USA of Nebraska Medical Center, Omaha, USA
Corresponding Author: Brenda G. Skaggs, Chief Nurse, Ambulatory Care, Department of Veterans Affairs Medical Center, 921 N. E. 13th, Oklahoma City, OK, USA. Email: [email protected]
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When individuals experience a significant life event such as the onset of a life-threatening illness, it often interferes with their pursuit of goals, the fulfillment of a sense of purpose, and a sense of meaning in life. The onset of coronary heart disease (CHD) is likely considered a significant event in the lives of most people. Even more difficult may be the situation where individuals undergo percutaneous coronary intervention (PCI) for CHD but have recurrent angina after the procedure. Recurrent angina is an unanticipated event that makes people question what is happening and poses an obstacle in the person’s recovery experience. While findings from the literature suggest that individuals with ongoing symptoms of heart disease may experience difficulties with psychological and physical functioning (Alsen, Brink, Persson, Brandstrom, & Karlson, 2010; Skaggs et al., 2007), there is minimal knowledge about the process of understanding what has happened, trying to make the event fit in with life, and/or changing the purpose and direction of life all of which represent the search for meaning. Nurses are in a key position to assist those with recurrent angina symptoms throughout the process of searching for meaning. Furthermore, developing the knowledge base related to the experience of persons with recurrent angina after PCI is imperative so that specific interventions may be developed to assist persons with the return of symptoms after PCI to work through the process of searching for meaning. Thus, the purpose of this study is to examine the search for meaning by comparing the differences between PCI patients who have angina after PCI and those who do not have angina in their search for meaning, physical functioning, and psychological functioning.
Searching for Meaning The search for meaning has been defined as a process focusing on minimizing disrupted meaning (disruption of the life experience) and involves a person’s appraisal of a significant life event in light of one’s purpose/goals, values, and beliefs (global meaning) through searching for answers and refocusing global meaning (Lazarus, 2001; Park, 2010; Skaggs & Barron, 2006). Furthermore, when an unexpected event (e.g., myocardial infarction [MI], PCI, recurrent angina symptoms) occurs, people evaluate the event in terms of significance and impact on their life’s global meaning (Lazarus, 2001; Park, 2010). Each person has unique beliefs, values, goals, and purpose in life, which define the concept of global meaning (Park, 2010). When the event is perceived as insignificant or positive, the event may be ignored. However, when the event is appraised as significant, negative, and/or a threat, the life experience is disrupted (disrupted meaning), and the person responds by searching for meaning using meaning-based coping techniques to change
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the meaning of the event (searching for answers) or changing global meaning (refocusing global meaning; Park, 2010; Skaggs & Barron, 2006). In terms of heart disease, disrupted meaning refers to the interruption in global meaning (Skaggs et al., 2007) caused by the person’s perceived meaning of the impact of heart disease on the life experience. Searching for answers refers to the meaning-based coping activities of determining why heart disease occurred, who or what is responsible for the heart disease, and the impact of the heart disease on the future (Skaggs et al., 2007). Refocusing global meaning refers to meaning-based coping activities aimed at the individual’s evaluation and revision of priorities, goals, and beliefs (Skaggs et al., 2007). Although few studies were found examining the search for meaning in cardiovascular patients, it has been examined through similar concepts such as dealing with life’s challenges, searching for answers, and trying to regain normalcy. Persons who had experienced MI perceived the MI as having challenged day-to-day life (Brink, Karlson, & Hallberg, 2006). The challenge was met with coping strategies aimed at minimizing consequences of the MI, redesigning, as well as finding meaning and purpose in day-to-day life (Brink et al., 2006), and searching for answers about what may have caused the MI and what the future held in terms of daily and working life (Alsen, Brink, & Persson, 2008). In contrast, some persons were less reflective and did not spend time thinking about their heart disease (Alsen et al., 2008). Still others who continued to have angina symptoms tried to live as normally as possible (Alsen et al., 2008). In other chronic illness conditions (e.g., cancer, HIV/AIDS, trauma survivors, etc.), the process of finding meaning has been examined as benefit finding (Stewart & Yuen, 2011). Individuals who were able to identify benefits associated with the illness were better adjusted, had lower morbidity over time, and had better spiritual and mental well-being (Stewart & Yuen, 2011). Measuring the process of the search for meaning has been inconsistent across studies (Park, 2010). Previously used measures examined components of the search for meaning (Fjelland, Barron, & Foxall, 2008; Park, 2010), but those measures were not designed specifically for use with cardiac patients. Components of the search for meaning were identified through many qualitative studies involving cardiac patients (Alsen et al., 2008; Brink et al., 2006). A qualitative measure, the Meaning in Heart Disease instrument (MHD), was developed as a measure of the search for meaning specific to the heart disease experience (Skaggs et al., 2007). While there are minimal findings related to the search for meaning by those individuals who underwent PCI with recurrent angina symptoms, there is evidence that the presence of angina symptoms may have an impact on the outcomes of psychological and physical functioning (Alsen et al., 2010; Skaggs et al., 2007). Persons who experienced a return of angina symptoms
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were more likely to report a decrease in quality of life (physical and psychological) when compared with their counterparts or to the general population (Brorsson, Bernstein, Brook, & Werko, 2001). For those who experienced recurrent angina symptoms, repeat vascularization (PCI or coronary artery bypass graft surgery [CABG]) may have been required (Loponen et al., 2009). Persons who underwent repeat vascularization within 6 months after PCI had greater physical limitations, more frequent angina symptoms, and lower health-related quality of life than those who did not have repeat vascularization (Neil et al., 2002; Rinfret et al., 2001). Psychological functioning has been defined as an individual’s “psychological attitudes and behaviors, including distress and well-being” (Patrick & Erickson, 1993, p. 77). Two indicators of emotional distress, anxiety and depressive symptoms, are considered negative alterations in affect or mood (Riegel & Gocka, 1995). Anxiety may be an immediate response to the onset of heart disease and may co-exist with depression, or depression may occur later in recovery as anxiety subsides (Doerfler & Paraskos, 2004). In several studies, emotional distress was related to poorer outcomes such as poorer physical health and quality of life in persons who underwent repeat PCI or who had ongoing angina symptoms (Alsen et al., 2010; Boehm & Kubzansky, 2012). In addition, those persons who believed their own behavior contributed to the cause of the heart disease were more likely to have poorer mental health (Lau-Walker, Cowie, & Roughton, 2008). Those who underwent repeat PCI exhibited worse emotional functioning than those who did not undergo repeat PCI (Rinfret et al., 2001). Ongoing angina symptoms were associated with emotional distress (Mayou et al., 2000). Stress or worry was cited as the most common causal attribution by persons who had experienced MI, and persons who had an anxious mood were more likely to associate the MI with stress (Cameron, Petrie, Ellis, Buick, & Weinman, 2005). Persons who reported anxiety after a PCI felt unable to get back to living life as before the PCI and experienced uncertainty over what the future would hold (Higgins, Dunn, & Theobald, 2000). Physical functioning is defined as an individual’s ability to carry out activities of daily living (e.g., mobility, self-care; Patrick & Erickson, 1993) and the person’s perception of their ability to function physically (Ades et al., 2002). Limitations in physical functioning may have been the result of angina symptoms, but some individuals may have self-limited activities because of concern for their health and safety or due to the advice of others (Higgins et al., 2000). Those who underwent repeat revascularization procedures or surgery within 6 months after PCI had greater physical limitations, more frequent angina symptoms, and lower quality of life than their counterparts (Neil et al., 2002).
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More than 950,000 PCI procedures were performed in the United States in 2010 (Go et al., 2014). Considering that up to 40% or more of individuals who underwent PCI had a return of angina symptoms (Loponen et al., 2009), examining the search for meaning and functional outcomes in this population is important to the development of specific interventions to promote wellbeing. Exploring the differences in the search for meaning as well as validating what is known about the differences between those who have a recurrence of angina symptoms after PCI and those who do not is a critical step in the development of interventions for this population.
Purpose This secondary analysis was undertaken to determine differences in the search for meaning, psychological functioning, and physical functioning between persons who undergo PCI and have a return of symptoms and those who do not have a return of symptoms. The specific research question was as follows: What are the differences between persons who undergo PCI and have a return of symptoms and those who do not within the first year after PCI in the following variables: A. The search for meaning (disrupted meaning, searching for answers, and refocusing global meaning), B. Psychological functioning (SF36v2™ mental component score, Hospital Anxiety And Depression scale [HADS-Anxiety and HADSDepression]), and C. Physical functioning (SF36v2™ physical component score [PCS])?
Method The findings reported here are from a secondary analysis of data collected for the purpose of testing the psychometric properties of the MHD (Skaggs et al., 2007). Using a cross-sectional design, a convenience sample was recruited from a population of individuals who underwent PCI during the year previous to enrollment at one of two regional medical centers in the south central United States. Persons were included in the sample if they were oriented to time, place, and person; spoke English; and had access to a telephone. Persons were excluded if they experienced any of the following: (a) physical or cognitive difficulties that may have interfered with the search for meaning related to heart disease, (b) had a Charlson Comorbidity Score (CCI; Charlson,
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Pompei, Ales, & MacKenzie, 1987) of 6 or greater, (c) were under the care of a mental health professional for psychiatric disorders, or (d) had previously undergone CABG or were awaiting open heart surgery.
Instruments Data collected during this study included measures to determine the incidence and frequency of angina, sample characteristics, and the outcome measures of the search for meaning, psychological functioning, and physical functioning. The Anginal Frequency subscale of the Seattle Angina Questionnaire (SAQ; Spertus et al., 1995) was used to divide the sample into two groups. The Anginal Frequency subscale, comprised of two items, quantifies the frequency of angina and nitroglycerin use during the 4 weeks prior to completion of the measure. A higher score indicates a lower frequency of angina and nitroglycerin use. Reliability and validity of the scale has been supported (Spertus et al., 1995). Those who reported no angina within the 4 weeks prior to completing the SAQ were included in the angina-free group, while all others were included in the angina group. The CCI, a weighted index used to assess for the presence of health conditions unrelated to CHD (Riedinger et al., 2001), has demonstrated predictive and concurrent validity (Charlson et al., 1987). An investigator-developed demographic form was used to collect information to describe the sample. Search for meaning. The 29-item MHD (Skaggs et al., 2007) was developed to measure the search for meaning as it relates to the heart disease experience. Scores from three of the MHD scales (disrupted meaning, refocusing global meaning, and searching for answers) were used for this secondary analysis. One MHD scale was not used for this analysis, “ignoring heart disease,” because the scale did not reflect meaning-based coping as anticipated. All scales are Likert-type and are scored on a 1 to 6 scale with a higher score indicating greater disruption in the life experience or greater use of the meaning-based coping processes (refocusing global meaning or searching for answers). The scales of the MHD have satisfactory reliability support (α ≥ 0.82 for all three scales) as well as content validity and construct validity (factor analysis and convergent). Functional status (physical and psychological functioning). The SF36v2™ is a self-report measure considered to be a comprehensive measure of functioning and well-being. The SF36v2™ is comprised of eight subscales that are reflective of two components of functional status (physical component summary [PCS] and mental component summary [MCS]; Ware & Kosinski,
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2001). Each component summary reflects the unique contribution of the eight subscales of the SF36 to either physical or mental functioning. Each component summary is scored using a norm-based approach with a potential score of 0 to 100. A higher score indicates better physical or mental functioning. The SF36v2™ has been widely used in studies of heart disease and has received satisfactory reliability and validity support (Alsen et al., 2010; LauWalker et al., 2008; Ware & Kosinski, 2001). For this study, all scales comprising the PCS and MCS demonstrated good reliabilities (α > .84). The Hospital Anxiety and Depression Scale (HADS) was developed for the screening of non-psychiatric patients (Zigmond & Snaith, 1983) and consists of an anxiety subscale (HADS-A) and a depression subscale (HADS-D). Each subscale is comprised of 7 items with a possible score of 0 to 21 (measured on a 4-point scale) with a score greater than 10 indicative of mood disturbance. The English version of the HADS has demonstrated adequate internal consistency reliability (HADS-A: 0.76-0.93, HADS-D: 0.72-0.90), and construct validity has been supported (Bjelland, Dahl, Haug, & Neckelmann, 2002). For this study, alpha coefficients were 0.89 for the HADS-A and 0.85 for the HADS-D.
Procedures Institutional review board approval was received for this secondary analysis. Re-consent was not required as this was an analysis of de-identified data from the original study. Institutional review board approval was obtained for the original study from all participating sites. All potential participants who had undergone PCI within the year previous to the start of the study were mailed an invitation to participate in the study. Individuals who were interested in participating returned a response card to the investigators. Respondents were contacted by phone, screened for eligibility, and provided an explanation of the study. For those giving verbal consent, study materials (all measures and the written consent forms) were sent to participants via the mail with instructions to complete and return to the investigators via the mail. Telephone calls and reminder letters were used to increase the response rate. Medical records were reviewed to collect comorbidity and heart disease severity data.
Data Analysis The Student t test was used to determine the differences between groups for the search for meaning and functional status. Differences in demographic and clinical characteristics between groups were examined using the Student t
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testfor continuous variables while chi-square analysis was used for dichotomous variables. Statistical significance was set at the .05 level.
Results The sample consisted of 224 participants (91 with a return of angina symptoms; 133 without a return of angina symptoms) who had undergone PCI within the year previous to recruitment. For analysis of the PCS and MCS, only 223 participants were included due to missing SF36v2 data from one participant. There were no differences between groups regarding gender with approximately one third of each group comprised of women. The group without angina symptoms was more likely than the group with angina symptoms to be younger (p < .01) and Caucasian (p < .05). There were no differences between the groups with regard to the comorbidity (CCI) score (no angina symptoms m = 1.87; recurrent angina symptoms m = 1.64; p > .05).
Research Question A: Search for Meaning Significant differences were found between groups for all aspects of the search for meaning (see Table 1). Compared with individuals without angina, those who continued to experience angina symptoms had higher scores on searching for answers, refocusing global meaning, and disruption in global meaning.
Research Question B: Psychological Functioning Similarly, significant differences were found for all measures of psychological functioning. Compared with individuals without angina symptoms, those who continued to experience angina symptoms had significantly lower levels of psychological functioning on the SF36v2™ MCS and higher levels of anxiety and depressive symptoms on the HADS.
Research Question C: Physical Functioning Physical functioning was measured with the SF36v2™ PCS. Persons who continued to experience angina symptoms had lower levels of physical functioning compared with those without angina symptoms. With group sizes of 133 for the group without angina symptoms and 91 for the group with angina symptoms, all the group differences achieved effect sizes that were d ≥ .50 (range = .50-.97). With power ≥ 0.95, the sample was deemed adequate for this secondary analysis.
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Skaggs and Yates Table 1. Comparisons of the Search for Meaning, Physical Functioning, and Psychological Functioning Between Those Without a Return of Angina Symptoms and Those With a Return of Angina Symptoms. Symptoms Characteristic Search for meaning Disrupted meaning (MHD)a Refocusing global meaning (MHD)a Searching for answers (MHD)a Physical functioning (PCS; SF36v2)b Psychological functioning Anxiety (HADS-Anxiety)c Depressive symptoms (HADS-Depression)c Psychological functioning (MCS)d
No Angina M (SD)
Return of Angina M (SD)
t test
2.33 (1.0) 3.72 (1.2) 3.30 (1.1) 44.93 (11.2)
3.46 (1.3) 4.29 (1.1) 4.06 (1.2) 34.92 (10.83)
−7.11* −3.56* −4.83* 6.66*
4.68 (3.7) 2.98 (2.9)
7.22 (5.0) 5.68 (4.07)
−4.19* −5.46*
52.52 (10.0)
45.62 (14.69)
3.90*
Note. Persons without angina symptoms n = 133; persons with angina symptoms n = 91. df = 222. = Meaning in Heart Disease instrument; possible range for each scale 1-6. bPCS = physical component score; possible range 0-100. cHADS = Hospital Anxiety and Depression Scale; possible range for each scale 0-21. dMCS = mental component score; possible range 0-100. *p < .001. aMHD
Discussion The purpose of this study was to determine the differences in the search for meaning, psychological functioning, and physical functioning among persons who underwent PCI and had a return of angina symptoms and those who did not have a return of angina symptoms. The findings from this secondary analysis support the idea that the return of angina symptoms is viewed as a significant, negative event that disrupts the life experience and starts the process of searching for meaning that for some, as we suggest, may lead to decreased physical and psychological functioning. This finding supports previous reviews related to searching for meaning (Park, 2010; Skaggs & Barron, 2006). Persons who had a return of angina symptoms were much more likely to experience a disruption in the life experience in terms of beliefs, values, life purpose, and goals. This suggests that the reoccurrence of symptoms may be viewed as a threat that may propel one to find a way to change the meaning of the heart disease or change global meaning (Lazarus, 2001). Thus, it is intuitive that those with recurrent angina symptoms would be much more
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likely than their counterparts to search for answers about why the symptoms recurred, who or what may be responsible for recurrence, and the impact of the symptoms on the life experience. Those with angina are also likely to work to bring congruence between expectations for one’s life and the impact of heart disease. While quantitative studies of the search for meaning in persons who underwent PCI were not found, the findings from the present study do support reported findings with those who experience MI. Persons who had experienced an acute MI questioned their illness and actively sought to comprehend their situation with heart disease including the cause of their illness, what life would be like, and what the future held; worked to minimize the consequences of the MI; made changes in the day to day life; and sought meaning and purpose in life (Alsen et al., 2008; Brink et al., 2006). We suggest that, on discharge from the hospital, the person who underwent a PCI may or may not have been told that angina symptoms could recur. The symptoms of angina (e.g., chest discomfort, shortness of breath, weakness, etc.) differ among individuals with up to 50% of all persons who experience acute MI having atypical symptoms or no symptoms at all (Anderson et al., 2007). In addition, some persons experiencing angina-type symptoms were found to be free of cardiac disease (Sheps, Creed, & Clouse, 2004). The ambiguity and uncertainty surrounding the signals presented by the recurrence of symptoms could be distressing and prompt the person to self-limit physical activities (Ades et al., 2002) and resist seeking medical advice for their symptoms. In any case, the person may also need more medical treatment if they really do have angina; and if the symptoms are not anginal, appropriate diagnosis and treatment may provide relief for the symptoms and ultimately relief for the reduced psychological and physical functioning. When the symptoms are not cardiac in origin, the offering of reassurance regarding symptoms is needed as well as encouragement to engage in normal activities. Persons in this study who had a return of angina symptoms were more likely to have decreased functioning, both physical and psychological, than those who did not have a return of angina symptoms. We suggest that the recurrent angina symptoms may indeed be deemed a threatening event associated with fear and anxiety that disrupts the life experience. As mentioned, the angina symptoms may not be due to heart disease, but the ambiguity and uncertainty may lead to poorer functioning, which, in turn, could be due to self-limitation. Testing a conceptual model that provides clarity to these relationships as well as the relationship with the components of the search for meaning would also provide the theoretical underpinnings for the development of interventions to assist persons with recurrent angina symptoms. In the development of effective interventions, it is of great importance to know where to target the intervention.
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We believe that developing and testing intervention strategies focused on supporting meaning-based coping would be an appropriate avenue for future research to improve psychological and physical functioning after PCI. In chronic illness conditions, individuals who were able to identify benefits associated with the illness were better adjusted, had lower morbidity over time, and had better spiritual and mental well-being (Stewart & Yuen, 2011). In intervention studies, women with breast cancer who wrote about benefits from having cancer had fewer symptoms, fewer medical appointments, and better heart rate response to stress than women in the control group (Low, Stanton, & Danoff-Burg, 2006). Intervention strategies that helped patients find meaning (benefits) were gratitude (Low et al., 2006), cultivating sacred moments (Goldstein, 2007), and pleasurable and meaningful acts (Peterson, Park, & Seligman, 2005). In a review of interventions to increase physical activity in cardiac patients, Ferrier, Blanchard, Vallis, and Giacomantonio (2011) found that interventions that included the development of coping plans were consistently shown to be very effective at increasing and maintaining physical activity; however, this approach was only used after cardiac rehabilitation. Because these are fairly brief interventions, they could be easily incorporated into routine inpatient cardiac care and reach a large percentage of people with CHD, thereby increasing their physical activity. This study is limited due to the fact that it is a comparison of two naturally occurring groups of a sample recruited for a study that was cross-sectional by design. The convenience sample was predominantly male and Caucasian. The sample was heterogeneous with the participants at different stages of recovery from the PCI, and both the age and race of the two groups were significantly different. In addition, comorbidities such as chronic pain and mobility limitations may have affected the meaning of the heart disease experience. This study is also limited by the self-report of participants. Our assumption is that those reporting symptoms believed the symptoms to be angina in nature. We were unable to objectively validate whether the selfreport of angina symptoms were due to CHD, and we must consider that self-report bias may exist (Boehm & Kubzansky, 2012). Finally, this analysis is limited because baseline measures were not available for the outcomes and inference that those with recurrent angina symptoms may have had poorer outcomes because of the angina cannot be made. The findings of this study are significant in that they provide insight into difficulties that persons with ongoing angina symptoms may be experiencing with regard to meaning as well as physical and psychological functioning. We find it imperative that persons with angina be followed closely for symptom relief and for psychological and physical functioning difficulties and be afforded support during times of difficulty. For immediate clinical practice, discharge from
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inpatient care should ensure that education regarding the possibility of future angina and actions to be taken by the patient is provided. In addition, the provision of close follow-up is important for this population. Future research should focus on the development of specific interventions to strengthen an individual’s meaning-based coping skills as well as on identifying the relationships between the search for meaning and psychological and physical outcomes. Acknowledgment The authors extend thanks to the staff of the Department of Veterans Affairs Medical Center, Oklahoma City, for support throughout the course of this study.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Sigma Theta Tau International, Doris Bloch Research Award and the NASA Nebraska Space Grant Fellowship Program.
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