Eva Brink

Person-Centered Care — Ready for Prime Time

Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the focus and mainstay of care in long-term illness.

Health experiences of first-time myocardial infarction: Factors influencing women's and men's health-related quality of life after five months

Health-related quality of life (HRQL) is a measure intended to mirror health experiences. The object of this study was to explore health-related quality of life in first-time myocardial infarction patients, five months after the heart attack. The sample consisted of 114 consecutive patients (37 women and 77 men) admitted to the coronary care unit of a rural hospital. Quality of life was measured using the SF-36 questionnaire, which yields eight multi-item scales and two summary measures of physical and mental health. The physical and mental component scores were negatively affected in both women and men. Women differed from men and reported significantly poorer physical health. Multiple regression analyses revealed that the coping strategies minimization (positively) and fatalism (negatively) were associated with HRQL. Depression and health complaints also impacted quality of life. The conclusion is that assessment of health-related quality of life could be a complement to other outcome measurements when evaluating the life consequences of a first-time myocardial infarction. In the early stage of the recovery process, the health complaints assessment is an important indicator of decreased quality of life.

The influence of personality traits on reported adherence to medication in individuals with chronic disease : An Epidemiological study in West Sweden

Background Limited research exists exploring the influence of personality on adherence behaviour. Since non-adherence is a major obstacle in treating prevalent chronic diseases the aim was to determine whether personality traits are related to reported adherence to medication in individuals with chronic disease. Methodology/Principal Findings Individuals with chronic disease (n = 749) were identified in a random population sample of 5000 inhabitants aged 30–70 in two municipalities in West Sweden. Data on five personality traits, Neuroticism, Extraversion, Openness to experiences, Agreeableness, and Conscientiousness, and medication adherence behaviour was collected by questionnaires. Statistical analyses resulted in a negative relationship between Neuroticism and medication adherence (P<0.001), while both Agreeableness (P<0.001) and Conscientiousness (P<0.001) were positively related to adherence. At high levels of Conscientiousness, low adherence was related to higher scores in Neuroticism. At high levels of Agreeableness, low adherence was related to low scores in Conscientiousness and high scores in Openness to experiences. Conclusions This study demonstrated that multiple personality traits are of significant importance for adherence behaviour in individuals with chronic disease. The findings suggest that several personality traits may interact in influencing adherence behaviour. Personality traits could putatively be used to focus efforts to educate and support patients with high risk of low medical adherence.

To Be Stricken with Acute Myocardial Infarction: A Grounded Theory Study of Symptom Perception and Care-seeking Behaviour.

The process of perceiving symptoms of illness is complex, and many patients delay seeking care when symptoms of acute myocardial infarction occur. However delayed treatment can have great consequences for the prognosis. This article reports on a grounded theory study, the aim of which was to increase our understanding of the individual’s thoughts, feelings and actions at the onset of an acute heart attack. Qualitative analysis of semi-structured interviews revealed four different ways of perceiving the onset of symptoms: understanding, misinterpretation, amazement and disregard. The symptom perception categories were related to two core categories labelled health beliefs and acute reactions. Some persons were aware of risks for coronary heart disease and were ready to seek care immediately. Several others had illusions of invulnerability. Such illusions caused people to delay seeking care at the onset of symptoms of myocardial infarction.

Disturbed sleep, fatigue, anxiety and depression in myocardial infarction patients.

Background: Disturbed sleep has been linked to increased morbidity, mortality and depression and worsened health-related quality of life in patients with chronic illness. Few studies of readjustment after coronary artery disease have explicitly focused on sleep disturbance. Aim: To explore associations between disturbed sleep, fatigue, anxiety and depression, and to assess to what extent fatigue four months post-MI could be explained. Method: The sample included 204 consecutive patients, ≤ 80 years of age who answered questionnaires about disturbed sleep, fatigue, anxiety and depression four months after MI. Results: The variables anxiety, depression and disturbed sleep were all associated with fatigue. The regression model accounted for 46% of the variance in fatigue with depression and disturbed sleep as predictors. Infarct size measured by conventional biochemical markers, left ventricle ejection fraction and history of previous MI were not correlated with disturbed sleep, fatigue, anxiety or depression. Conclusions: From knowledge about associations between disturbed sleep, fatigue, anxiety and depression after MI, cardiac nurses could be trained to observe such symptoms. Optimal care for sleep disturbance may include actions to reduce anxiety and depression as well as self-care advices about sleep hygiene in order to improve sleep quality and reduce fatigue.

General self-efficacy and health-related quality of life after myocardial infarction

Fatigue after myocardial infarction (MI) has been found to be distressing. A persons self-efficacy will influence his/her health behavior and plays an active role in tackling illness consequences. This study investigated associations between fatigue, disturbed sleep, general self-efficacy, and health-related quality of life (HRQoL) in a sample of 145 respondents admitted to hospital for MI two years earlier. The aim was to identify the predictive value of general self-efficacy and to elucidate mediating factors between self-efficacy and HRQoL. General self-efficacy measured four months after MI was positively related to HRQoL after two years. In tests of indirect effects, fatigue meditated the effects between self-efficacy and the physical and the mental dimension of HRQoL, respectively. The indirect effect of disturbed sleep went through that of fatigue. To conclude, patients who suffer from post-MI fatigue may need support aimed at helping them increase their self-efficacy as well as helping them adapt to sleep hygiene principles and cope with fatigue, both of which will have positive influences on HRQoL.

Validation of the Revised Illness Perception Questionnaire (IPQ-R) in a sample of persons recovering from myocardial infarction--the Swedish version.

When peoples health is threatened, they generally develop illness perceptions to make sense of their illness. The Illness Perception Questionnaire (IPQ-R), developed by Moss-Morris et al (2002), has been widely used in many countries to measure such representations. However, since studies in this crucial research area are lacking in Sweden a Swedish version of IPQ-R was validated with a focus on the seven subscales: timeline acute/chronic, timeline cyclical, consequences, personal control, treatment control, illness coherence and emotional representations. Using confirmatory factor analysis, the aim of the present study was to validate the internal structure of the Swedish version in a sample of 202 persons (144 men and 58 women) who had been diagnosed with myocardial infarction four months earlier. Additionally, inter-correlations among the seven subscales and external concurrent validity were also investigated. The results of confirmatory factor analysis revealed that, in line with the English version of the IPQ-R, the specified seven-factor model had a satisfactory fit. One item was however not considered reliable and was therefore excluded from the instrument. The internal consistency (Cronbachs alpha coefficients) and the inter-factor correlations were relatively similar to those reported in the validation study of the original English IPQ-R. In tests of concurrent validity, the seven IPQ-R subscales were, as hypothesized, mainly associated with external variables. To conclude, the Swedish version of the IPQ-Rs seven dimensions, with one item removed, (total 37 items) was found to be a reliable and valid measure of illness perception.

Dimensions of the Somatic Health Complaints Questionnaire (SHCQ) in a Sample of Myocardial Infarction Patients

A short health complaints measure may provide information on the degree of recovery from acute myocardial infarction. The present study therefore evaluated a questionnaire–called the Somatic Health Complaints Questionnaire (SHCQ)–that includes 13 items concerning health problems common in cardiac patients. The sample included 114 patients in total, 37 women and 77 men, who had suffered a first-time myocardial infarction 5 months prior to the testing. Confirmatory factor analysis was performed to examine whether the factor structure replicated the hypothesized hierarchical model. The results indicated that SHCQ represents four dimensions: breathlessness, fatigue, pain and unrest. It was also found that SHCQ may be treated as one general concept. It is a brief and easily administered questionnaire and may therefore be a useful tool in secondary prevention work, identifying patients at risk for possible negative consequences of a first-time myocardial infarction.

Associations between depression, fatigue, and life orientation in myocardial infarction patients.

Background: The possible preventive and treatment measures for post-myocardial infarction fatigue may rely on gaining insight into the psychosocial factors associated with fatigue. One such factor may be life orientation, that is, having an optimistic versus pessimistic view of life. Optimists expect things to turn out for the good, whereas pessimists generally expect that bad things will happen to them. Objective: The aim of this study was to explore the relations among life orientation (optimism-pessimism), depression, and fatigue after a first-time myocardial infarction. Methods: The sample included 98 patients in total, 33 women and 65 men, who had suffered a first-time myocardial infarction 1 year before the testing. Linear and curvilinear regression analysis models were used to describe and explore the associations between the variables. Results: A nonlinear relationship between postmyocardial fatigue and life orientation was found. The interpretation was that a pessimistic view of life could have more negative consequences for postmyocardial fatigue than an optimistic view of life could have positive consequences. The association between depression and fatigue was weak, supporting the notion that fatigue may be experienced by myocardial infarction patients without coexisting depression. Conclusion: Post-myocardial infarction fatigue must be investigated further and explicitly focused upon. One way to decrease postmyocardial fatigue could be to focus on steps that cause the most pessimistic individuals to feel less pessimistic.

The Cardiac Self-Efficacy Scale, a useful tool with potential to evaluate person-centred care

Background: Cardiac self-efficacy is a person’s belief in his/her ability to manage the challenges posed by a coronary disease, and its role has been evaluated in several coronary populations using the Cardiac Self-Efficacy Scale (CSE Scale). Self-efficacy has an important role in person-centred care, however there is a lack of appropriate instruments that evaluate person-centred interventions. Aim: The purpose of this study was to validate the CSE Scale by examining its psychometric properties as a first step in evaluating a person-centred care intervention in persons with acute coronary syndrome (ACS). Methods: The study sample consisted of 288 persons (72 women, 216 men) who completed the Swedish version of the CSE Scale two months after hospitalisation for an ACS event. Construct validity was psychometrically evaluated using confirmatory factor analysis. Additionally, convergent and discriminant validity were tested using correlation analyses. Results: The results revealed that the CSE Scale was represented by three dimensions (control symptoms, control illness and maintain functioning). The analyses also showed that the CSE Scale is suitable for providing a total summary score that represents a global cardiac self-efficacy dimension. Evaluation of convergent and discriminant validity showed the expected correlations. Conclusion: The CSE Scale is a valid and reliable measure when evaluating self-efficacy in patients with ACS. It also seems to be a useful tool to promote person-centred care in clinical practice since it may offer useful guidance in the dialogue with the patient in the common creation of a personal health plan.