Persons diagnosed with CAD (coronary artery disease) necessitate years of treatment to control symptoms and at the same time remain employed in addition to carrying out their regular role in the family unit. Due to the augmentation of concern, their personality is negatively affected, with many of them experiencing diminished self-image. (Conn, Taylor, & Casey, 1992). Cardiac therapy programs thus intend to assist these persons to retain or recover their self-care capability and prepare them to deal with physical and psychosocial issues (Brewer & Hoeman, 1996).
Because of the failure of adherence of fifty percent of the people involved in the long term cardiac therapy programs which intend to help them achieve rehabilitation goals, there is a high rate of attrition among such people, stressing the need for continued research into self-care behaviors which can enhance the capabilities of these individuals to adhere to the regimens of the specified programs. The cost of health care and rehabilitation of these people has increased tremendously in recent years resulting in the reduced number of deaths attributed to CAD. For example, in 1996, $118.2 billion was spent on direct and indirect costs of treating CAD (American Heart Association, 2000) which continue to increase annually.
Because of the great physical and emotional impact of CAD in addition to the exorbitant cost of caring for its survivors, it becomes imperative to identify the factors which influence adherence and self-care behaviors in the current populace and prioritize healthcare research. A study developed and implemented within Orem’s (1995) ‘Self-Care Deficit Theory of Nursing’ revealed factors that control men’s observance to cardiac therapy by suggesting that investigating an individual’s experiences with health and illness helps involve that person with his or her care.
Concerning cardiac therapy programs, the investigation of these factors can help rehabilitation nurses in the identification of factors that may potentially influence the client’s adherence to the prescribed cardiac therapy program which will enable rehabilitation nurses to use a wide-ranging, descriptive approach to reduce descriptions from cardiac therapy clients of their experiences, to better comprehend the meaning the experience has to the client.
When rehabilitation professionals perceive the individual’s experience, they can identify the conditions and factors in the client’s life that may facilitate or inhibit the adherence to, the cardiac therapy program. Identifying these factors is important because meeting the requirements of the prescribed program can help individuals achieve maximal cardiac efficiency and promote independence which in turn can affect the individual’s self-care agency.
As a smaller number of people die from cardiac disease, and as the numbers of cardiac therapy programs augment, rehabilitation nurses will be progressively more involved in their design and implementation. The rationale behind this study is to formulate valuable contributions by gaining awareness of the factors that influence men’s adherence to cardiac therapy in addition to offering directions for involvements centered on self-care and providing an impetus for further research. The study will help the rehabilitation nurses in developing a successful program by establishing the client’s health experience and the client’s ability to engage in self-care.
The study will universally aid all rehabilitation professionals in the identification of factors in the client’s life that may influence his or her ability to engage in self-care, and in determining whether those factors may potentially facilitate or inhibit that self-care.
The main research question is: ‘What self-care factors are most often reported by men with CAD as facilitating and inhibiting their adherence to a cardiac therapy program?’ The proposed hypothesis is: ‘Identification of Specific self-care factors, possessed by all the men and responsible for facilitating and inhibiting adherence to cardiac therapy.’ The independent study variables include the relation between attitudes, intentions, and the supposed notions of persons about adherence to cardiac therapy programs (Miller, Johnson, Garrett, Wickoff, & McMahon, 1982; Miller, Wickoff, McMahon, & Garrett, 1985; Miller, Wickoff, Garrett, McMahon, & Smith, 1990; Miller, et al., 1989).
They also include the actions of persons which are directed toward themselves or toward environmental features which may control factors that may promote, adversely affect or interfere with functions to contribute to life, self-maintenance, or personal well-being. The dependent study variables are the programs offered by way of cardiac therapy phases II-IV, which includes supervised exercise, assistance with medication management, stress management, lifestyle modification, smoking cessation, and diet modification.
Men enrolled in phase II received constant cardiac monitoring during their exercise sessions. Men enrolled in phase III received cardiac monitoring monthly and as needed during their exercise programs. Finally, men in Phase IV received an initial exercise prescription and then exercise at the cardiac therapy facility at their leisure. There was systematic collection and observation of data by the nurses to identify and analyze data of potential informants who met the inclusion criteria.
The factors that facilitate adherence to cardiac therapy programs are described in the Self-Care Deficit Theory of Nursing (Orem, 1995). The fundamental idea of this framework is that within the context of daily living, adults and growing persons execute cultured actions which are intended toward them. Their involvement in and subsequent achievement of a cardiac therapy program can thus help individuals with CAD achieve self-maintenance and well-being.
The rules of this framework were used to lay down the basic concepts in the successful designing and completion of the program. According to the literature review, heart disease is the principal cause of death worldwide and the most common cause of hospitalization among older adults (Kane, Ouslander, & Abrass, 1999). Coronary artery disease (CAD) is the most recurrent cause of immobilization in the United States, with approximately 5.4 million new cases diagnosed yearly (Rhodes, Morrissey, & Ward, 1992).
An increased survival rate has led to the development of numerous cardiac therapy programs in the United States which encourage lifestyle changes to promote a healthier lifestyle to decrease cardiac risk factors, and that is harmonious with the goals of Healthy People 2010 (Healthy People, 2000). Since Cardiac therapy is a primary and regular part of client management after a cardiac event it centers on an individual’s optimal corporeal, psychosocial, professional, and recreational status (Brewer & Hoeman, 1996; McMahon, Miller, Ringel, & Garrett, 1988).
Persons who adhere to a prescribed therapy program are likely to have positive outcomes. Despite the involvement of clients in cardiac therapy, many individuals enrolled in these programs fail to recover to their full potential (Boogaard & Briody, 1985; King & Teo, 1998). Further, as per the review, in 1996, $118.2 billion was spent in direct and indirect costs of treating CAD (American Heart Association, 2000) and costs continue to increase yearly. Because of the tremendous physical and emotional impact of CAD, and the exorbitant cost of caring for its survivors, identifying the factors that influence adherence and self-care behaviors in this populace must become a priority in healthcare research.
For this study, analysis of the transcribed interviews followed the protocols in Colaizzi’s (1978) method analysis. The steps involved reading the entire descriptions to obtain a sense of the whole, extracting significant statements and phrases pertaining directly to the experience of men with CAD who were participating in a cardiac therapy program and formulate meanings and clustering them into themes from the significant statements and phrases and integrating the results into an exhaustive description of the phenomenon.
When the need arose returned to the informants for validation of their experience and for any additional data to incorporate into the experience. In their data analysis, the authors considered only the comments of the informants, thus avoiding the risk that their predetermined ideas might bias the information. To prevent this bias, eidetic reduction or bracketing was used in this study, both before data were collected and during data analysis. The aim was to examine prejudices and commitments and bracket them out so the phenomenon could be seen as it is and not as it is reflected through preconceptions (Cohen, 1987). Thus, in this study, both investigators could interpret the men’s stories without letting personal beliefs bias the information (Munhall, 1994).
In designing cardiac therapy programs, rehabilitation professionals understood the client’s perception of his or her current health state and his or her experiences with health and illness. These experiences influenced how clients dealt with their current health situation and treatment plan. Age is related to a person’s behavior and it influences his or her self-care behaviors (Orem, 1995). Age has varied meanings in society, and nurses must be aware of these meanings and influences when they are developing cardiac therapy programs indicating age as an inhibitory factor. Family system factors involve the impact of the family unit on all aspects of health and illness, including the treatment plan (Orem, 1995).
During data collection, three of the five participants’ wives accompanied their husbands to the exercise sessions three times weekly and asked the therapy director questions about the programs. These actions showed involvement in the care provided by members of the informants’ families and the informants too overwhelmingly reported the influence of their families as a facilitative factor.
Patterns of living encompass all the actions people perform daily including, patterns of activity, rest, nutrition, recreation, and healthcare practices (Orem, 1995), and are recognized as inhibitory. Environmental factors such as physical, chemical, biological, and social influences and can affect the completion of the therapeutic self-care demand (Orem, 1995) and this basic conditioning factor was classified as an inhibitory factor and was related specifically to the factors that inhibited adherence to the supervised exercise portion of the therapy program.
Resource availability and adequacy involve the means people have to meet their requisites for self-care (Orem, 1995) and is classified as inhibitory; the rationale for this classification was that at the time data were collected, four of the five informants knew that they would be unable to continue into phases III or IV of the program because their insurance would no longer pay the costs. Although these informants planned to continue exercising independently at home, the authors suspected that the lack of professional support and the loss of the camaraderie experienced during the structured program ultimately would inhibit further adherence to the program.
Data were obtained from individual audiotaped interviews with five men 60 to 70 years of age in northwestern Ohio were analyzed using Colaizzi’s (1978) method all of whom were married, retired; three were previously employed in blue-collar occupations and two in white-collar positions. Concerning health history, in various combinations, four had sustained a myocardial infarction; one experienced sudden cardiac arrest; one was Post-Cerebral-Vascular Accident (CVA); two were post-percutaneous-transluminal-coronary angioplasty, and one was post-coronary-artery-bypass-graft surgery.
The study was conducted on persons with pre-decided criteria of a male between 60 and 70 years of age, diagnosed with CAD within the past 2 years, enrolled in phase II and III in the cardiac therapy program with the ability to speak and write in English along with willing to participate in the study. A study similar to this one, with a larger sample that includes men and women, would enhance the transferability of the results to other populations.
The 1-hour interviews were conducted in a private, quiet, well-lit room at the cardiac therapy center. Written informed consent to participate in the study was obtained before the tape recorder was started. The informant was then asked: “What helps you to participate or prevents you from participating in the cardiac therapy program?” The remainder of the time was devoted to the informant’s responses. Reflective silence was permitted and after the interview, the informants were told that they would be contacted a second time for any information that they would like to add or to clarify any points that needed to be clarified making the setting appropriate for accurate results.
In their data analysis, the authors considered only the comments of the informants, thus avoiding the risk that their preconceived ideas might bias the information. Specific procedures were used by the authors of this study who have experience, through formal research education and supervision, in qualitative methods. Before beginning data collection, they jointly reviewed the interview procedure.
The first author, as primary investigator, collected data with purposively selected men at an outpatient cardiac therapy program at a northwestern Ohio rehabilitation hospital. With purposive sampling, the investigator could select informants based on her judgment about which men would be most representative of the population. Together, the therapy director and the investigator described the study to potential clients. They were assured that their decision to participate or not to participate would not affect their treatment and that all data would be reported as group responses. Written informed consent to participate in the study was obtained before the tape recorder was started. Informants were told that the tape could be stopped any time they desired thus protecting the rights of the subjects. In the interviews, the informants did not directly discuss developmental state.
Their life experiences were predominantly positive, which may have influenced their adherence to the therapy program. In addition, they were cognitively developed, mature adults who could read, write, and speak the language and act as their self-care agents in promoting and maintaining their health and well-being. Therefore, the developmental state can be justifiably classified as a facilitative factor. Data analysis procedures are appropriate for the data collected because the authors independently read all verbatim transcripts of the audiotapes to establish a baseline impression of the entire dialogue.
Each then reread the transcripts and extracted significant statements relating to self-care factors most often reported as facilitating and inhibiting adherence to the therapy program. The statements were then clustered into components of self-care agency and then into facilitative and inhibitory basic conditioning factors. Throughout this process, differences in coding or categorizing the data were discussed until agreement was reached.
These themes were reviewed with the informants, who had no new information to offer. With institutional review board approval and before data collection, the investigator who collected the data observed phases II and III of the cardiac therapy program at the center. She reviewed male clients’ charts with the cardiac therapy director to identify potential informants who met the inclusion criteria. The 1-hour interviews were conducted in a private, quiet, well-lighted room at the cardiac therapy center.
The informant was then asked: “What helps you to participate or prevents you from participating in the cardiac therapy program?” this seems the accurate procedure for answering the research question. This study elicited critical descriptions of factors that either facilitated or inhibited the informants’ ability to perform self-care activities required by a prescribed cardiac therapy program. Concerning cardiac therapy programs, the exploration of these factors can help rehabilitation nurses identify factors that may potentially influence the client’s adherence to the prescribed cardiac therapy program.
Conversely, information about an individual’s experience with cardiac therapy and the factors responsible for facilitating and inhibiting adherence to a therapy program is extremely limited proving to be its limitations. Until these factors are studied and reported in the literature, the foundation of cardiac therapy programs will not be true based upon, or be sensitive to, the specific needs of the CAD population. Consequently, cardiac therapy programs designed to help persons modify their lifestyles to achieve their highest possible levels of functioning will fall short of their potential.