“Trusting the body” and “looking to the
future”: the meaning of recovery after a heart
attack
Angela Tod
Research Fellow (Nursing)
School of Nursing and Midwifery,
University of Sheffield
a.tod@sheffield.ac.uk
0114-2229775
22/07/04
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Presentation Overview
• Project overview
• Background
• Results
• Key messages
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Project Overview
Ø Stage 1
Ø Stage 2
Ø Overcoming barriers to accessing
cardiac rehabilitation services
Ø MI recovery experience and ability
to access services
Ø South Yorkshire Coalfields
Health Action Zone
Ø Identify barriers to
accessing current services.
Ø Patients, staff and carers
Ø Tod, Lacey, McNeill (2002)
JAN 40(4), 421-431
Ø Explore the patient pathway from
MI to recovery
Ø How do people experience
recovery?
Ø What defines recovery?
Ø What do people need to do to get
to a point of recovery?
Ø What are the related service
needs?
Ø How does this compare to current
services provision and access?
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Cardiac rehabilitation
¤ “the sum of activities required to influence favourably the
underlying cause of the disease, as well as the best
possible, physical, mental and social conditions so that
they (people) may, by their own efforts preserve or
resume when lost, as normal a place as possible in the
community. Rehabilitation cannot be regarded as an
isolated form or stage of therapy but must be integrated
within secondary prevention services of which it forms
only one facet (World Health Organisation, 1993).
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Cardiac Rehabilitation?
Ø Multi-factorial
Ø Multi-disciplinary
Ø Menu based
Ø Individualized / patient focused
Ø Component of secondary prevention
Ø Phases
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Background
Ø Our Healthier Nation / National Service Framework
Ø National and local inconsistencies in content, standard
and quality of services
Ø In the UK there are National and local inequalities in
access to services:
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current service limited to low risk patients
programmes hospital based
some populations excluded
poor access by women, ethnic minority groups and the elderly
non attendance linked to levels of deprivation and education
Ø Literature focuses on adjustment, coping and adaptation
but not recovery
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Local Background
Ø Cardiac rehabilitation in South Yorkshire
Ø Phase 1, Pre discharge
ØMost M.I. patients seen by nurse and/or physiotherapist
Ø Phase 2, First few weeks post discharge
ØLimited community provision by mixture of HV, practice
nurse and district nurses
Ø Phase 3, 6 weeks post-discharge
ØLimited hospital based exercise and education class
Ø Phase 4, long term maintenance
ØScarce provision, patches of activity
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Study one
Ø AIM: To explore what barriers exist for patients accessing M.I.
Cardiac rehabilitation services within the South Yorkshire Coalfields
Ø DESIGN: A qualitative study utilizing semi-structured interviews and
framework analysis techniques
Ø Framework analysis (Ritchie & Spencer, 1994)
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Familiarisation
Developing a thematic framework
Indexing
Charting
Mapping and interpretation
Ø September 2000 to July 2001
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Sample
Ø Staff (15)
Ø Individual interviews,
workplace, 20-30 minutes
Ø Hospital: CR Nurse, CCU
Nurse, Nurse Manager, CR
physio, Physio Manager,
Dietician, Dietetics Manager
Ø Health Authority: Exercise
Development Worker, Public
Health / Health Promotion
Ø Primary Care: Pharmacist,
Practice Nurse, Health Visitor
Ø Other: Fitness Instructor
Ø Group of 7 HV’s
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Ø Patients (20)
Ø Individual interviews, own
home, 20-30 minutes
Ø Range of age, sex, post code,
c.rehab attendance,
occupation
Ø 6-8 months post MI
Ø Exclusion: co=morbidity,
mental distress, unable to be
interviewed / give consent
Ø Group of self help group
volunteers
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Results - themes
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absence and abandonment
waiting and delays
communication and confusion
understanding and expectations
appropriateness
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Absense and abandonment
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Limited service capacity
4 seen by community nurses
3 attended hospital class
Time services absent and needed: post transfer, 2 weeks post
discharge, 6-8 weeks:
“I think as soon as you come out of hospital, you need some sort of guidance
because that is the critical time not six months afterwards”
“I’d done as much exercise as I could and I was waiting for the next bit to kick
in and obviously not hearing anything”
Ø Reassurance
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Exercise advice
Psychological support
Personalised support
Family and partner support
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Waiting, Communication
and Understanding,
Ø Waiting
Ø Limited capacity
Ø Waiting lists
Ø Exclusion criteria
Ø Impact of waiting
Ø Communication systems and processes
Ø Understanding
Ø Of cardiac rehabilitation
Ø Of CHD causes and experience of MI
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Appropriateness
Ø Groups and Location
Ø Women
Ø Commitments and responsibilities
Ø Social norms
Ø Elderly
Ø Routine
Ø Location
Ø Misunderstanding
Ø Men
Ø Macho culture
Ø Stoicism and reticence
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Study two
Ø MI recovery experience and ability to access
services
Ø Explore the patient pathway from MI to
recovery
Ø Research questions
ØHow do people experience recovery?
ØHow do people conceptualise recovery?
ØWhat do people need to do to get to a point of recovery?
ØWhat are the related service needs?
ØHow does this compare to current services provision and
access?
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Sample and Methods
Ø Sample
Ø Members of phase 4
or cardiac support
groups
Ø Four groups (3-9)
Ø Recruited from group
workshop in study one
and from support
groups
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Ø Methods
Ø Semi-structured interviews
Ø Testing experience
compared to study one
participants
Ø Exploring recovery
Ø Framework analysis
Ø Grounded theory
Ø Open/axial/selective
coding
Ø Theoretical sampling of
stage one participants
Ø Constant comparison and
testing of data
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Pathway from MI to
recovery
MI
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Recovery process mediated
by coping mechanisms
RECOVERY
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Paradigm model
Paradigm model of Straus & Corbin 1990 used to structure findings
Causal conditions? phenomenon ? context ? intervening conditions
? action / interactional strategies ? consequences
Heart attack ? Heart attack recovery ? Recovery experience ?
Stage one 1) South Yorkshire Culture 2) Services to support recovery ?
Recovery coping mechanisms ? Extent of recovery (against certain
Characteristics that were seen to define recovery)
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Recovery experience
(context)
Ø Different person
Ø Sudden, out of the blue
Ø Emotional:
ØFrightened, vulnerable, irritable, depressed, anxious,
frustrated, loss
Ø Physical:
ØTired, fatigued
Ø Understanding:
Ø uncertain, confused, forgetful, questioning
Ø Why me? Am I allowed? Ought I to?
Ø Social:
Ø Isolated, restricted, mollycoddled, no-control
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SY society and services
(intervening conditions)
ØSouth Yorkshire culture
ØMacho
ØStoical
ØTraditional roles / commitments
ØCardiac rehabilitation services
ØGap between service need and experience
demonstrated in Study one.
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Recovery coping mechanisms
(action/interactional strategies)
Ø Taking control
Ø Getting information
Ø Getting on with it / resuming activities
Ø Attribution
Ø Seeking explanations
Ø Comparing
Ø Redefining
Ø Reset limits
Ø Reprioritise
Ø Set new targets / goals
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Elements of recovery
How do people characterise recovery
Confidence
Control
Information/knowledge
Looking to the future
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Trusting the body
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What service is needed to
facilitate recovery?
Ø What did people require from the service in order to help them
them mobilize their recovery / coping mechanisms and to move
along the pathway to recovery?
Ø Nature of the service: continuity, individualized:
Ø Listening
Ø Taking time
Ø Personalized information and care
Ø Content of the service: explanations, someone to talk to, home
visit, assessment/monitoring, meeting others in the same position
Ø Staff attitude: honesty, knowledgeable, reassuring, caring
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What service did they
receive?
Ø But experience of access matched that of
participants in study one:
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Limited capacity
Unmet expectations
Lack of continuity
Poor communication
No time
Waiting lists
Access filters
Inappropriate
Ø Highlights the potential that, without appropriate
content & processes, services may delay people in
achieving recovery
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Key messages
ØService structure and process need to
reflect recovery process
ØNeed for service redesign
Ø primary care based
Ø assessment / triage
Ø individualized care
ØValue of Framework analysis vs Grounded
theory
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