PRESENTACIÓN DEL PROYECTO

Current Investigation

The value of the study continues to be important and no similar study design has been published or presented at conferences (including the Vth World Congress of Cardiac Rehabilitation. Bordeaux

1992 ) which would pre-empt the results.

P ro g re ss to d a te

The study commenced in August 1991 and this report describes the work undertaken until January 1993. The first six months were spent setting up the intervention and refining the measures to be used. A nurse counsellor was appointed for the first half of the project. As specified in the design, the counsellors changed during the study in order to control for effects specific to the individual and the second counsellor is currently in post.

A manual, to be used for the intervention, has been written, [ see Appendix 1 for contents page. The manual is available for inspection on request.] The first section describes the philosophy, purpose and goals of the programme. A chapter on the role of the nurse as an educator and counsellor incorporates the principles of learning on which the programme is based. The main sections describe the topics which are covered during the programme including information about CHD, treatment and investigations, personal risk factors and necessary strategies for modifying them ( including relaxation training), resumption of normal activities, problems of returning home and to work and how to manage future symptoms. A list of the educational aids and a resource list is included.

To ensure replicability of tiie intervention the value of the manual has been tested in the induction of the second counsellor.

All of the measures outlined in the proposal have been implemented, are proving successful and are acceptable to the patients. The measures adopted and work done in developing them, are reported in Appendix 2

Subjects

On the basis of previous admission figures, we predicted that the recruitment rate of people who fulfilled the entry criteria would be 10 per month. Recruitment has proceeded on target. Currently 108 patients have been recruited. 75 partners have agreed to participate. We anticipate reaching our target of 120 patients within the specified time. Table 1 presents information relating to this population.

Table 1.

Actual number recruited to date Total108 Male(70 Female38) Subsequently lost to follow up

Deaths 6 (5M F1)

Voluntary withdrawal 6 (4 2)

Moved outwith area 1 ₍₁ 0)

Number currentlv available for follow up 95 160 35)

Partners

As specified in the proposal, partners ( identified by the patient as a person having significant contact ) were also invited to participate in the study. To date 75 partners have agreed to take part. 54 femde partners and 21 mAe partners. The majority (69) were spouses, but also included are 1 son, 2 daughters and 3 girlfriends, all of whom live with or nearby the patient.

Randomisation

As described in the proposal, randomisation has been based on the wards to which the patient is admitted in order to minimise contamination effects between subjects. The wards have been randomly allocated to one of the two CR programmes or to the control group and the ward allocations have been changed periodically. Interviewers have been blind to this random allocation. Table 2 describes die numbers of patients in each group as of 31st January 1993.

Table 2

Number of patients in each group.

Control 37

Minimal programme 42 Extended programme 29

Data collection

Data collection is generally proceeding as scheduled. By Janu^ 31st 1993, 108 patients have been assessed in hospital, 103 subjects had completed the follow-up interview, at home, within 2 weeks of discharge and 84 had been reassessed at 2 months, 52 had completed the 6 month and 10 the 12 month follow up. 5 follow up interviews have been late (longest delay- 1 month) either because of continuing morbidity (readmission/ cardiac surgery) or patient's absence on holiday. These delays will be noted and allowed for in the analysis. [See Appendix 3 for interview schedule.] Partner assessment has proceeded in parallel.

Amlysis

At this stage no data relevant to the evaluation of the different interventions can be reported. Analysis between groups has not yet been performed as this would entail brealdng the blind nature of the study design. However the study allows us to examine important questions about the immediate impact of an MI and these data can be reported whilst remaining blind. These analyses point to the emotional states, knowledge and misconceptions in patients and partners which may subsequently be found important in understanding the impact of CR programmes. The results of this early analysis are reported in this paper.

Analvsis of baseline data: Knowledge and distress of patients and partners.

Analysis of baseline data on the first 50 patients was performed to look at the early levels of distress amongst patients and partners, to elicit their beliefs and misconceptions about a heart attack and to investigate any association between cognitions and distress. These early results were presented at Promoting H^th - an International Research Conference for Nursing, in London, September 1992 and a paper was submitted as an invited chapter in a book to be published based on the conference. ( Copies of the paper are enclosed)

The main results show; First, partners, both male and female have significantly higher levels of distress than patients. Most of the previous research in this area has investigated only the effects on wives. Second, patients, including women, in the present sample generally showed lower levels of anxiety and depression than might have been expected from previous work in this area. Third, people hold a varying range of beliefs and misconceptions which may have implications for future recovery and which need to be addressed if successful rehabilitation is to be achieved.

Table 3 Shows the characteristics of the sample. Table 3

Patients Partners ( n = 50 ) ( n = 40 )

Male 32 12

Female 18 28

Mean Age (range) 57(41-70) 53(28-71) Recruited within 72 hrs of admission

Other misconceptions which may impede resumption of normal activity included the belief that a heart attack means the heart was worn out, that after a heart attack most people never return to their previous level of activity, that sex life had to be modified forever, and that it was important to avoid laughing too hard after a heart attack!. Misconceptions which could result in an ill-advised recovery plan, included the belief that they should return to normal activity immediately on discharge, that it was alright to drive during the first week at home and in not acknowledging that the chances of another heart attack were reduced if necessary lifestyle changes were made. It will be important to assess these cognitions in evaluating the impact of the CR programmes.

Future plans.

Recruitment will be completed at the end of February 1993. Data collection wiH be completed at the end of February 1994. Data analysis and report writing will be performed in the final 6 months, when it will be possible to assess the effects of the cardiac rehabilitation programmes.

Publications.

Foulkes J, Johnston M, Robertson C. ( in press)

Knowledge and Distress: Implications for a Cardiac Recovery Programme.

In Health Promotion and Nursing Research, edited by J.Wilson-Bamett & J Macleod-Clark. [ 4 copies enclosed.]

Attendances at Conferences / Courses.

In the interest of the current research J.Foulkes has attended the following relevant meetings. Presentation of papers are highlighted.

1. Promoting Health:- International Research Conference for Nursing. London. September 1992.