I S S U E S A N D IN N O V A T I O N S I N N U R S I N G P R A C T I C E

You can do it if you set your mind to it: a qualitative study of

patients with coronary artery disease
Eva Bergman BScN RN
Master's Student and Cardiology Consultation Nurse, County Hospital Ryhov, JoÈnkoÈping, Sweden

and Carina BerteroÈ BSc MScN PhD RN RNT

Assistant Professor, Department of Nursing Science, University College of Health Sciences, JoÈnkoÈping, Sweden and,
Department of Medicine and Care, Division of Nursing Science, Faculty of Health Science, LinkoÈping University, LinkoÈping,
Sweden

Submitted for publication 9 October 2000

Accepted for publication 25 September 2001

Correspondence: BERGMAN E. & BERTERO

È C. (2001) Journal of Advanced Nursing, 36(6),
Carina BerteroÈ, 733±741
University College of Health Sciences, You can do it if you set your mind to it: a qualitative study of patients with coronary
Box 1038,
artery disease
551 11 JoÈnkoÈping,
Aims of the study. To gain increased knowledge and understanding of what it
Sweden.
E-mail: carina.bertero@hhj.hj.se means to be af¯icted with coronary artery disease (CAD) and how it affects the life/
lifestyle of the individual.
Background. Research has documented that education, counselling and beha-
vioural interventions are important elements of cardiac rehabilitation and compli-
ance with treatment. Compliance is generally better with medical treatment than
with recommended lifestyle changes. Another in¯uencing aspect is locus of control,
i.e. people's own understanding of control is the foundation for the decisions
patients make more or less consciously regarding compliance with caring/nursing,
treatment and lifestyle changes.
Methods. Eight individuals with diagnosed coronary artery disease were inter-
viewed about their life situation, and the opportunities and obstacles they
encountered in making lifestyle changes. These interviews were transcribed and
then analysed using a hermeneutic approach.
Findings. The ®ndings included three areas: (1) The causes of coronary artery disease
describing different factors, such as heredity, lifestyle and demands. (2) Dif®culties in
the work of rehabilitation, which was explained in terms of informants' feelings of
confusion, uncertainty and sadness. (3) Successful rehabilitation consisted of two
factors: the personality of the individual patient and external support.
Conclusions. Patients may comply well with follow-up visits but less with lifestyle
changes. By identifying different `characteristics', `prerequisites' and `dif®culties'
that describe patients' compliance, it should be possible to make treatment more
individual. Nurses have a signi®cant role in supporting these patients since they are
more accessible than physicians. Nurses also have a responsibility to work together
with patients to empower them, in order to make their lifestyle changes and self-care
activities manageable.

Keywords: coronary artery disease, compliance, locus of control, rehabilitation,

lifestyle changes

Ó 2001 Blackwell Science Ltd 733

E. Bergman and C. BerteroÈ

motivation and acceptance of compliance is affected by

Introduction
insight into their problem and disease, and whether they
Research has documented that education, counselling and understand and accept the intention of the treatment (Lassen
behavioural interventions are important elements of cardiac 1989). In Sweden there is a Health and Medical Act (SFS
rehabilitation. A multiplicity of education and counselling 1982, p. 763) pointing out patients' right to receive infor-
concerning lifestyle changes and relaxation techniques are mation about their disease and status so that they can take an
associated with decreased mortality, decreased morbidity active part in decisions concerning investigation and treat-
with coronary artery disease, retardation of arteriosclerosis ment. This Health and Medical Act aims for partnership
and reduction of emotional stress (United States [US] Depart- between patient and health care professional. Patients who
ment of Health & Human Service 1995). The overall aim of perceive their own activity as vitally important are willing to
our study was to gain increased knowledge and under- carry through the treatment they have been prescribed. They
standing of what it means to be af¯icted by coronary artery perceive their effort as essential for successful treatment
disease, how it affects the life of the individual and any (Mabeck 1995). Compliance with medical treatment is
lifestyle changes. We also aimed to describe how these generally better than compliance with suggested lifestyle
patients divided into compliers or noncompliers, and what it changes (Becker 1985, Mabeck 1995). About 50% of all
is that seems to determine their compliance or noncompli- patients studied follow prescribed diets, but considerably
ance. In this article, participants' perceptions of the process fewer follow advice about giving up smoking, decreasing
and effects of changing their lifestyle are described. The alcohol consumption and increasing physical exercise. One
recent literature points to different aspects concerning cause of poor compliance or noncompliance could be that
recovery from myocardial infarction. Ben-Sira and Eliezer personnel do not make sure that patients understand or
(1990) show that this can be hindered by different demands accept the well-motivated advice. Another reason could be
and facilitated by personal resources. These personal that patients do not perceive the advice as good, and
resources can be forti®ed by support from a partner, but this therefore might not see the reason for following it (Mabeck
support depends on the relationship between the couple. 1995). Patients who are noncompliant with treatment
According to a study by Johnson and Morse (1990), patients perceive themselves as less vulnerable and less threatened
diagnosed with myocardial infarction employ varied strat- by their disease. They also seem to be less worried about their
egies to regain control and reduce stress. These include health and have less con®dence in modern medical treatment
seeking reassurance and information from health care profes- than patients with high compliance (RydeÂn & StenstroÈm
sionals. Another study by Scherck (1992) shows that myocar- 1994). Patients are rational: they comply with treatment
dial infarction patients use support seeking, optimism, when they perceive a health bene®t and fail to comply when
confrontation, self-reliance, ventilation of feelings, and the consequences of compliance out-weigh the expected
`thinking things through' as strategies to handle the diagnosis bene®ts (Kaplan & Simon 1990).
and new situation. Spousal support improves emotional and
cognitive readjustment, self-esteem, mastery, coping with
Locus of control
physical restrictions, and adherence to risk-reduction behav-
iours and lowers stress in myocardial infarction patients Locus of control is described on two different dimensions,
(Frasure-Smith 1991). external and internal locus of control (Rotter 1954). People
who have external understanding of control believe that
what individuals themselves do has no great importance for
Background
their well-being. Instead they locate control over their own
health to destiny, circumstances or other important people,
Compliance
for example. An internal locus of control means that people
Compliance with treatment is concerned with how well have a greater tendency to acknowledge their own role in
patients follow prescriptions. Compliance with treatment can in¯uencing their situation, for example, health. They view
vary greatly from less than 1±90% (Aronson & Hardman their own contribution as important to their own health
1992, Mertens 1993, Mabeck 1995). Factors that in¯uence (Rotter 1954).
patients' compliance with treatment include duration of A study by De Vellis et al. (1980) showed that patients
treatment, frequency of medication dosage, multiple medica- with an internal locus of control are more likely to be
tions, side-effects of medication and quality of the consulta- engaged in preventive behaviour/lifestyle changes. This study
tion (Lassen 1989, Wren & Brown 1990). Patients' also showed that those who had a greater internal locus of

734 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741
Issues and innovations in nursing practice A qualitative study of patients with CAD

control were less willing to follow medical prescriptions and Population and selection
more willing to seek information about their disease. People A purposeful sample was selected (Couchman & Dawson
with high internal control could be more motivated to take 1995). Interviewees had to (a) have coronary artery disease
actions which lead to good health, but at the same time and (b) be registered as a patient at the County Hospital
comply less with prescribed medical treatment (RydmeÂn & during the period November 1997 to April 1998. Purposeful
StenstroÈm 1994). Extreme external or internal understanding sampling was used, as we wanted a maximum of variations,
of control leads to unrealistic behaviour. A balanced under- e.g. demographic, characteristics such as age, gender, educa-
standing of control gives the individual the best conditions tion and occupation.
for managing the situation, and includes that individual's The 16 patients involved as a sample in the present study ±
own capacity, their perception of support, and their con®d- seven women and nine men ± received mailed information
ence in others (Rotter 1954). describing the study, its aim, structure and voluntary nature. A
The concepts `compliance' and `locus of control' are reply coupon and envelope with return postage were enclosed.
interconnected and interdependent. Locus of control is the Eight patients abstained from participation in the study.
foundation for decisions patients more or less consciously The interviewees ± three women and ®ve men ± were aged
make regarding compliance with caring/nursing, treatment between 49 and 68 and had received their diagnosis
and lifestyle changes. 5±8 months before the interview. Table 1 describes the
The aim of the present study was to gain increased interviewees.
knowledge and understanding of what it means to have
coronary artery disease, how it affects the life of the Ethical issues
individual, and any lifestyle changes. It was also to identify Permission to carry out the study was received from the clinic
the in¯uencing factors and what impact they have on and from the Research Ethics Committee, Faculty of Health
compliance/locus of control. Sciences, LinkoÈping University. The study was carried out
from June to August 1998.

The study
Interviews
After informed consent was given, eight persons were inter-
Method
viewed. Two interviews were conducted in patients' own
In order to gain a deeper understanding, interviews with a homes and the remaining six in different consultation rooms
qualitative research approach were used, followed by a at the hospital. The same interviewer (EB) conducted all
hermeneutic analysis and interpretation. Hermeneutics is one interviews. A general interview guide approach was used,
way to discover what is common to all modes of under- consisting of three to eight research questions covering the
standing. The reasonable hermeneutic assumption on which area under study (Patton 1989). This kind of interview is
to proceed is that we are dealing with a discussion. We move much like a conversation, even though interviewers have a list
within the live play of risking assertions, of assuming and of issues about particular topics that they want to cover
rejecting, all the while proceeding on our way to reaching an (Patton 1989). An ethical consideration in nursing research
understanding (Gadamer 1989). is the question of invading the privacy of the informant.

Table 1 Details of the eight interviewees with coronary artery disease who answered questions about how the disease affected their life

Patient Sex Age* (Years) Disease Marital status Occupation

A Female 56 MI Married Sick-listed

B Female 68 MI ´ 3 Married Pensioner
C Female 63 MI, PTCA Widow Sick-listed
D Male 63 MI ´ 4 Married Pensioner
E Male 49 MI, CABG Cohabitating Employee
F Male 60 Angina pectoris, CABG Married Pensioner
G Male 50 MI Married Employee
H Male 60 MI Married Employee

Age*: The interviewees' age when the interview was carried out.
MI: Myocardial infarction; PTCA: Percutaneous transluminal coronary angiography; CABG: Coronary artery by-pass grafting.

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741 735
E. Bergman and C. BerteroÈ

The interviewer should feel when a topic is too emotional to and analysed from the interpreter's horizons of meaning.
pursue in the interview (Kvale 1996). It is important that the Interpretation involves continuous dialectical movement
interviewer is skilled at behaving in a way, which is sensitive, between the two horizons. Analysis must function on both
nonjudgmental and supportive, so the interview is proceeding levels/horizons, giving an adequate account of the entire text
(Couchman & Dawson 1995). The following topics were and then identifying categories/themes, in order to reach the
focused on during the interview: (a) Have you any thoughts hermeneutic circle; where both parts and the whole are
about the way you got this coronary artery disease? (b) Please important in understanding (Gadamer 1989, Draper 1997).
tell me about the possibilities of changing your life/lifestyle Principle four: Interpretation involves the fusion of the
since your diagnosis. (c) Please tell me about dif®culties/ horizons of the interpreter and the text. One of the strengths
obstacles you have met when changing your life/lifestyle as a of the hermeneutic approach is that it permits the researcher
result of your diagnosis. (d) Has anything been missing in the to respect and maintain the perspective of the informant while
post treatment/rehabilitation since your diagnosis? The inter- concurrently approaching the text from a different horizon of
viewee or the interviewer often spontaneously raised topics meaning. Each phrase and sentence from the transcribed
related to these questions. The interview was tape-recorded interviews was reviewed to analyse and interpret the data, in
and transcribed verbatim, and lasted 30±85 minutes. order to interpret and understand from the two different
Con®dentiality was ensured so that participants might not be horizons of meaning (Gadamer 1989, Draper 1997). The
identi®ed by descriptions of what they have done or quotations fundamental idea was to ®nd and sort out utterances (mean-
of what they said. When describing the participants, names ingful statements), which described the cause of illness, its
and other unique characteristics are not presented. prospects and its dif®culties/obstacles in different subclusters,
clusters and superior clusters. Hermeneutics is relevant as a
qualitative approach because it contributes to our under-
The guiding principles of hermeneutic analysis
standing of the nature of human beings (Gadamer 1989,
Four principles guided the hermeneutic analysis, but these did Draper 1997). Our prejudices cannot be bracketed, since it is
not reduce the analytical activity to a linear process in terms of them that we understand whatever and whenever
(Gadamer 1989, Draper 1997). we understand (Connolly & Keutner 1988, Gadamer 1989).
Principle one: Transcribed interviews are treated as text
for hermeneutic analysis. The transcribed material was read
Findings
several times in order to get a general picture of what the
informants were recounting. The ®rst analytic task is to
Causes of coronary artery disease
develop a sense of the whole of the text (Gadamer 1989,
Draper 1997). Three major clusters were identi®ed as causes of the disease
Principle two: Interpretation is not an arbitrary activity. (Figure 1). These clusters are not easy to demarcate from one
A single text is open to many different interpretations, and another since they affect and interact with one another, the
each of them may be valid in principle. The reason for this is
that the meaning of a text is the outcome of the fusion of the
horizons of text and interpreter. The principle of under-
standing as the fusion of horizons means that researcher
rejects that there is a single correct interpretation of text.
Consequently, interpretations that proceed from different
perspectives may be equally acceptable, but it does not follow
that all interpretations are equally valid. The validity of the
interpretations of data in this study is defended on the
grounds that they are the result of a systematic approach and
the interpretations could always be arbitrated for or against
various interpretations. The researcher's task is to show that
their interpretation is more probable than other possible
constructions (Ricoeur 1981, Gadamer 1989, Draper 1997).
Principle three: Interpretation consists of two elements: a
descriptive phase that proceeds from the horizon of meaning Figure 1 Causes of coronary artery disease as described by the
of the text, and another phase in which the text is interpreted informants.

736 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741
Issues and innovations in nursing practice A qualitative study of patients with CAD

clusters `lifestyle' and `demand' especially seem to have a Several informants stated that, besides heredity, lifestyle
signi®cant relationship and interaction with each other. might be a contributory cause of their coronary artery
disease. There are sign's of resignation in those who are living
Heredity with the knowledge that parents and/or siblings have already
Informants stressed the importance of heredity for falling ill, died of the disease. Several interviewees expressed that they
and described heredity as impossible to in¯uence, calling it `a often thought about starting a healthier life, but it had simply
family characteristic'. They referred to both one and two not become a reality due to lack of time or energy in setting
former generations who had a myocardial infarction and/or about making lifestyle changes.
were affected by vascular spasm (angina pectoris). Several
informants had relatives who died around the age of 60, and Demands
they experienced this as an early departure from life. This fact The demands on patients come from different directions and
made a profound impression on informants' consciousness hence this cluster is divided into three subclusters: demands
about their own disease and future prospects. of self, demands of others and employer demands. The
One woman had experienced a dramatic event, which had, demands of others and employer demands might appear to be
and still has, a signi®cant meaning for her belief in heredity the same but they come from different sources.
and coronary artery disease. She expressed it in this way:
Demands of self. Demands of self include all the demands
¼so when my father came in¼she was sitting by the telephone, dead.
that informants consciously or unconsciously make upon
He put her on the ¯oor, but he did not know if she was dead or not. //
themselves. These demands include supporting and encour-
¼I was shocked, I had not calculated on my mother dying at that
aging their spouse, children, parents, friends and work-mates
age, I just could not imagine¼
in different situations throughout life. Own demands also
touch upon success in professional life and being a model for
Lifestyle
younger colleagues. One informant expressed it like this:
Several informants mentioned smoking as a possible cause of
coronary artery disease, and mentioned that smoking occurs ¼I place these demands on myself¼make great demands upon
in connection with stress and when they have problems myself¼
relaxing:
I am awake 1 hour before the alarm clock, and then I feel this `®st',
¼I did not smoke at work¼but when I came home at we usually call it, which you get in your stomach¼
18.00±19.00¼then I could smoke 17 cigarettes¼it was cigarette
Sometimes care of the family and friends becomes so
after cigarette¼
burdensome that it becomes absurd to manage. There is no
That smoking is unhealthy is well known by the informants, time left for recovery or for enjoying life. One interviewee
even though this awareness had come at different stages. stated that `you can never show your own happiness,
One continued smoking after his ®rst myocardial infarction, because they always have sorrows' and she worried for
and only after his third infarction did he understand the them.
extent of the deleterious effects of smoking. Most informants
stated that smoking, together with heredity and being Demands of others. Demands of others, are shown in the
overweight, might be one of the major causes of coronary relationship between informants and relatives with ill health
artery disease. and often relatives demand ®rst priority. One interviewee
Several informants expressed that bad eating habits can commented:
lead to being overweight, high cholesterol levels in blood and
¼it is always my husband, who is in®rm, he needs and wants help
high blood lipids, which in turn is one cause of coronary
with different things, but it should be done at once¼ then I become
artery disease. One woman stated that she sometimes could
overstrained and angry¼
eat a whole bar of fat chocolate, just to put a `gilt edge on her
life', even though she already had problems with high blood
Demands of employers. The third subcluster is employer
lipids and cholesterol. A sedentary life and lack of exercise
demands. It sometimes seems that the employers can be
were mentioned as other causes of coronary artery disease.
remarkably insensitive to, and ignorant about, the necessity
Increased pressure of time caused by the fact that life has
of leisure time.
become far too dictated by routines and too busy was a cause
Having a busy and ful®lled time schedule, being able to
of lack of exercise, according to informants.
manage more in a shorter time, personal computers at home

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741 737
E. Bergman and C. BerteroÈ

and pressure to achieve reinforce feelings of employer

demands:

the pressure from the company that I shall achieve//¼being

compared with the statistics¼

These demands, which are experienced as `must' and

`should', lead to irritation, anger, agitation/anxiety, sleep-
lessness, lack of time and total exhaustion. Demands create
stress in the individual, which gives them a feeling of
`working full out'. One informant described this as `is like a
war inside me'. All these demands that have to be ful®lled
emphasize lack of time, and informants stated that they do
not give themselves time for pleasure and recreation. There is
Figure 2 Informants' description of the prerequisites for life style
no time for recovery, which in turn creates problems later on, changes.
manifested as disrupted relationships with family members,
colleagues or close friends. In the worst cases, those disrup- External support functions as a buffer, providing energy
tions could lead to social isolation. to struggle when informants' own energy is diminished.
Several informants described external support as a welcome
help in re-building health. Their own decision to start this
Dif®culties in rehabilitation
work of rehabilitation is the most signi®cant and domin-
After diagnosis of coronary artery disease, informants ating factor, and is a prerequisite for successful rehabilit-
describe several dif®culties in relation to rehabilitation and ation.
lifestyle changes, social life and return to work. When the The time following hospitalization was devoted to re¯ec-
transcripts were analysed and interpreted, confusion, uncer- tion upon the hospital stay. Informants were satis®ed that the
tainty and sadness were found throughout the interviews. personnel were competent, and they were treated very
Thoughts about the fact that life would never be the same quickly. Due to the fact that the hospital invested many
again had taken a place in their awareness. Several of the resources in them, they felt obliged actively to participate in
interviewees talked about their future with tears in their eyes their own work of rehabilitation. One woman stated:
and expressed grief over their lost health. Their heart was no
¼it is a motivation also¼well, if you demand a lot of resources,
longer healthy, and a reconciliation and adaptation to the sick
people want you to recover and become healthy, you do not want to
heart must be made. They must adapt to their sick heart, learn
spoil it the following week¼
to interpret the signals from the heart and be able to listen to
it. Their entire life is disrupted and previous strategies for Informants take their own decisions about different actions.
living must be reconsidered. They must reorient themselves Some men expressed this attitude as follows: `¼you can do it
and changes must be made so that life will function in another if you set your mind to it¼' and `¼there must be some
way than before. It is dif®cult to ®nd the way to adapt to a bloody-mindedness!'
future that is different from that which was expected. Many informants stated that they had made a decision to
Confusion was found in the interviews as informants change their way of living, and stated that the disease gave
described their unknown future and sadness over lost health. them a different perspective on life and future life should
This confusion seemed to be an obstacle which must be include time for recreation and pleasure. Several stated that
overcome in order to go further in the work of rehabilit- life should not be rushed through and work in the future
ation. would not be allowed to have such a prominent place as it
previously had. They tried to change the pace of work, tasks
or working hours, which demanded will and commitment
Prerequisites for successful rehabilitation
from employers, colleagues and informants.
Two prerequisites for successful rehabilitation and reorien- Time to rest is an important part of rehabilitation after the
tation were identi®ed. These were the individuals themselves disease, and holidays become vitally important, affording
and external support. External support comes from three time for recreation and for family and friends.
different directions: family, health care system, and employer Some informants had managed to change their lifestyle
and work-mates (Figure 2). with respect to stopping smoking and using alcohol, a

738 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741
Issues and innovations in nursing practice A qualitative study of patients with CAD

decision they made themselves. It is signi®cant that they

Discussion
understand why smoking is unhealthy and how it affects
their health, if the results are to be successful. Pointers In our opinion qualitative interviews followed by a herme-
and prohibitions are not successful. Instead there should neutic interpretation are a good means of contributing to
be appropriate information from staff. Improvement in our understanding of the nature of human beings and how
diet was a change that seemed more dif®cult to manage, illness affects our lives. Informants described what coronary
and often the cause of not changing or improving the diet is artery disease means to them in their own words and from
found in lack of time or the fact that they have got into their own experience. Findings in qualitative studies cannot
a rut. be generalized, but a clear `picture' can be visualized of how
Most informants expressed a feeling of wellness once they human beings are affected by disease and how they
started to exercise, which consisted mostly of walking. experience it, the care and lifestyle changes. Transferability
Others had discovered what a fantastic and beautiful experi- of the ®ndings should be assessed and evaluated in the light
ence it is to cycle, it gives pleasure both to body and soul, and of the biographical and disease characteristics of the sample.
time to think. One man stated: Perhaps it is as Morse (1991) states, that the speci®c
knowledge gained in one setting may be transferred to
I almost never cycled before¼nowadays I go out cycling and
others.
looking around a bit¼cycling is unbelievable fun¼cycling and
Most of the informants described heredity as the cause of
enjoying life.
their coronary artery disease, and they have seen a progres-
Support in the form of information and easy access to the sion of the disease in others towards life long handicap or,
health care system was of great importance to informants. in some cases, sudden death. This apprehension about
Several informants expressed that just knowing that you heredity being impossible to in¯uence is there in their
could easily get in touch with competent personnel by consciousness and could seem true, but it is not the same
telephone gave a certain feeling of security in this new thing as believing that being taken ill again cannot be
situation. Some stated that these conversations with compe- prevented or postponed. There is a strong need for infor-
tent personnel were healing and comforting and that it mation/teaching about the importance and possibility of
`unburdened the mind'. affecting the course of disease and these ®ndings match with
Knowledge about coronary artery heart disease seemed to what Friedman and Ulmer (1985) found. The message that
be a prerequisite for successful lifestyle change. To know how the relapse can be prevented or mitigated may be the most
the heart works, what has happened to it, what a myocardial important message of all.
infarction is or what vascular spasm is gives a stable Feelings of confusion, grief and feelings that life will never
foundation for continuing rehabilitation. be the same again are apparent when informants talk about
Informants expressed a fear of starting everyday life again their lost health. Many also experience harassment, fear of
and that they need help to understand the connection relapse and death. It is generally known that patients with
between work, rest and recreation, and early follow-up at coronary artery disease often suffer a depression afterwards
the hospital is of great value. In addition to feelings of not (Frasure-Smith et al. 1993, 1995, Ladwig et al. 1994).
being forgotten, it gives a feeling of security knowing that on Depression can adversely affect illness behaviour (Ladwig
being discharged from hospital there is an appointment et al. 1994) and may affect the patients in many varying
scheduled for physical examination in a couple of weeks and aspects, for example, changing lifestyle. In a study by
time to ask questions. Ziegelstein et al. (2000), it was shown that cardiac patients
Informants perceived drugs as a help to recover. It was of who had symptoms of depression reported lower adherence to
great importance to them to know why these drugs are a low-fat diet, regular exercise, reducing stress and increasing
prescribed, what effects they have and what kind of side- social support. Patients with major depression also reported
effects can be expected, both short-term and long-term. lower compliance in taking prescribed medications.
Although several drugs could cause different side-effects, Another factor that makes rehabilitation hard is being
informants were prepared to submit themselves to the `set apart in life', without the everyday contact and
medical treatment if the physician prescribed it. To manage relationships with friends and colleagues. Things that
a successful rehabilitation, there is a need for support from previously were obvious and taken for granted must now
families, employers, colleagues and the health care system, be re-assessed. This re-assessment is something affecting
but also a need for understanding and motivation in patients not only the patient but also the whole family and circle
themselves. of friends and colleagues. Compliance with treatment is

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741 739
E. Bergman and C. BerteroÈ

dif®cult (Mabeck 1995), and the ®ndings in this study some knowledge about the disease and its treatment. It
con®rm this statement. should be a matter of course that relatives are present
Several of the drugs used in current treatment have side- when patients are discharged or make another visit to
effects such as tiredness, nausea and very low pulse rate. hospital.
These side-effects can be hard to accept when patients return
to work, since they are obstacles to ful®lling different
Conclusion
demands at work. Information about the effects of drugs
and their impact on the heart and health is of vital import- Patients may comply well with follow-up visits but less well
ance for patients' understanding and compliance. However, with lifestyle changes. By identifying different `characteris-
compliance with medical treatment tends to be higher than tics', `prerequisites' and `dif®culties' that describe compli-
compliance with lifestyle changes, and health care providers ance, it should be possible to make treatment more
must explain why patients should make these changes in life individual. Knowledge about coronary artery disease needs
and enhance them to make changes. to be increased, providing a better understanding of the
In the present study, it was found that informants who necessity of lifestyle changes and medical treatment. They
expressed that they were victims of circumstances had more and their relatives need extensive help to ®nd alternative
dif®culties changing their lifestyle than those who did not solutions in their work of rehabilitation and to see the
perceive themselves as victims. One explanation for this opportunities available.
could be that those who perceived themselves as victims had Nurses have an important task in supporting these patients
lived their whole life with this conception of not being able to since they are more accessible than physicians and nurses
affect their situation. This conception could be called a kind have a responsibility to work together with patients to enable
of learned helplessness, which makes it extremely dif®cult to them to empower themselves to make life-style changes and
take responsibility for lifestyle changes. This is also con®rmed self-care activities manageable.
in the literature (De Vellis et al. 1980, Aronsson & Berglind
1990), in that one's own decisions' and volition are of vital
Acknowledgement
importance in making changes. The foundation for the active
work of rehabilitation is the belief that `I can' (Rotter 1954). Valuable ®nancial contributions from FORSS made this
As well as this belief, there must be support and guidance in study possible. We thank all the individuals with coronary
the work of change. The role of social support is signi®cant in artery disease who participated in the interviews. We also
our study, which is in accordance with other studies thank Maurice Devenney for revising the English in the
(Fridlund et al. 1993, Fridlund & the MISS-study groups manuscript.
1997). Moreover the accessibility of the health care system is
of great importance for patients and their relatives, as is an
References
early follow-up visit to the hospital. The ®ndings of the
present study are consistent with what studies by Keeling and Aronson J.K. & Hardman M. (1992) ABC of monitoring drug
Dennison (1995) and Linden (1995) show, namely that therapy. Patient compliance. British Journal of Medicine 305,
1009±1011.
regular phone calls or visits by nurses increased myocardial
Aronsson G. & Berglind H. (1990) Handling Och Utrymme (in
infarction patients' con®dence, adjustment, and satisfaction Swedish). Studentlitteratur, Stockholm.
with health care. Becker M.K. (1985) Patients adherence to prescribed therapies.
Active rehabilitation demands a great deal of work, Medical Care 23, 593±555.
patience and persistence, and it is very great important to Ben-Sira Z. & Eliezer R (1990) The structure of readjustment after
heart attack. Social Science and Medicine 30, 523±536.
inform patient about this. It is also important that they
Connolly J.M. & Keutner T. (1988) Hermeneutics Versus Scienc?
understand that the signi®cance of their own contribution.
University of Notre Dame Press, Notre Dame, IN, USA.
This is well described by Rotter (1954) with respect to the Couchman W. & Dawson J. (1995) Nursing and Health-Care
concept `locus of control'. The health care system has an Research, a Practical Guide. Bailliere Tindall, London.
important task in informing these individuals about their De Vellis R.F., De Vellis B.M., Wallston B.S. & Wallston K.A. (1980)
ability to affect their coronary artery disease via different Epilepsy and learned helplessness. Basic and Applied Social
Psychology 1, 241±253.
kinds of treatments and lifestyle changes. Patients described
Draper P. (1997) Nursing Perspectives on Quality of Life. Routledge,
two important factors for a successful rehabilitation: `my London.
own decision' and external support. If the family or Frasure-Smith N. (1991) In-hospital symptoms of psychological
colleagues are to be able to offer support, they also need stress as predictors of long-term outcome after acute

740 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741
Issues and innovations in nursing practice A qualitative study of patients with CAD

myocardial infarction in men. American Journal of Cardiology Lassen L. (1989) Compliance i Almen Praksis (in Danish). Istitute for
67, 121±127. almen medicin, KoÈpenhamn.
Frasure-Smith N., Lesperance F. & Talajic M. (1993) Depression Linden B. (1995) Evaluation of a home-based rehabilitation
following myocardial infarction: impact on 6-month survival. programme for patients recovering from acute myocardial infarc-
Journal of the American Medical Association 270, 1819±1825. tion. Critical Care Nursing 11, 10±19.
Frasure-Smith N., Lesperance F. & Talajic M. (1995) Depression and Mabeck C.E. (1995) LaÈkaren Och Patienten (in Swedish). Bonniers,
18-month prognosis after myocardial infarction. Circulation 91, Stockholm.
999±1005. Mertens T.E. (1993) Estimating the effects of misclassi®cation.
Fridlund B. & the MISS-Study Groups (1997) Social network Lancet 342, 418±421.
and support among myocardial infarction women during the Morse J.M. (1991) Strategies for sampling. In Qualitative Nursing
three months following upon a ®rst myocardial infarction. research: A contemporary Dialogue (Morse J.M. ed.), Sage,
VaÊrd I Norden 17, 9±14. Newburry Park, CA, pp. 127±156.
Fridlund B., Stener-Bengtsson A. & WaÈnnman A. (1993) Social Patton M.Q. (1989) Qualitative Evaluation Methods. Sage, Newbury
support and social network after acute myocardial infarction: the Park, CA, USA.
critically ill male patient's need, choice and motives. Intensive and Ricoeur P. (1981) Hermeneutics and the Social Sciences. Cambridge
Critical Care Nursing 9, 88±94. University Press, Cambridge.
Friedman M. & Ulmer D. (1985) Treating Type a Behavior ± You Rotter J. (1954) Social Learning and Clinical Psychology. Prentice
and Your Heart. Ballantine Books, Canada. Hall Inc, NY, USA.
Gadamer H. (1989) Truth and Method (2nd revised edn, translation RydeÂn O. & StenstroÈm U. (1994) HaÈlsopsykologi (in Swedish).
revised by J. Weinsheimer and D.G. Marshall). Crossroad, Bonniers, Gothenburg, Sweden.
New York. Scherck K.A. (1992) Coping with acute myocardial infarction. Heart
Johnson J.L. & Morse J.M. (1990) Regaining control: the process and Lung 21, 327±334.
of adjustment after myocardial infarction. Heart and Lung 19, SFS (1982) Health and Medical Act (in Swedish). Socialdepart-
126±135. ementet, Stockholm, Sweden.
Kaplan R.M. & Simon H.J. (1990) Compliance in medical care: US Department of Health and Human Services (1995) Cardiac
reconsideration of self-predictions. Annals of Behavioral Medicine Rehabilitation. Clinical Practise Guidelines. 17. Caridiacx Reha-
12, 66±71. bilitation AHCPR Publication, Rockville.
Keeling A.W. & Dennison P.D. (1995) Nurse-initiated telephone Wren B.G. & Brown L. (1990) Compliance with hormonal replace-
follow-up after acute myocardial infarction: a pilot study. Heart ment therapy. Maturitas 13, 17±21.
and Lung 24, 45±49. Ziegelstein R.C., Fauerbach J.A., Stevens S.S., Romanelli J., Richter
Kvale S. (1996) Interviews an Introduction to Qualitative Research D.P. & Bush D.E. (2000) Patients with depression are less likely to
Interviewing. Sage Publications, London. follow recommendations to reduce cardiac risk during recovery
Ladwig K.H., Roll G., Breithardt G., Budde T. & Borggrefe M. from a myocardial infarction. Archives of Internal Medicine 160,
(1994) Postinfarction depression and incomplete recovery 1818±1823.
6 months after acute myocardial infarction. The Lancet 343,
20±22.

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(6), 733±741 741