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thesis entitled

THE RELATIONSHIP OF WOMEN'S AGE AND PERCEIVED
SOCIAL SUPPORT TO PERCEIVED CARDIAC REHABILITATION SUCCESS

presented by

Kristin Lee Forester

has been accepted towards fulfillment
of the requirements for

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MSU Is An Afflrmotlvo Adlai/Equal Opportunity Institution
W

 

THE RELATIONSHIP OF WOMEN’S AGE AND PERCEIVED SOCIAL SUPPORT
TO PERCEIVED CARDIAC REHABILITATION SUCCESS

BY
Kristin Lee Forester

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1996

ABSTRACT

THE RELATIONSHIP OF WOMEN’S AGE AND PERCEIVED SOCIAL SUPPORT
TO PERCEIVED CARDIAC REHABILITATION SUCCESS

BY

Kristin Lee Forester

This study was a non-experimental, descriptive,
correlational, secondary analysis of 46 women post acute
myocardial infarction. Subjects were originally recruited
from two community hospitals as part of the ngen's Hear;

-d ' - -- ' . 11° ;’!:°., tat 0! n-- T-. - . o. !'
Agutg_nyggazgial_lnfargtign (Budd, 1991). The goal of this
study was to examine the relationship of the variables age
and perceived social support on perceived cardiac
rehabilitation success. Five age cohorts of women were
identified. Data analysis included Pearson’s product-moment
correlation, analysis of variance, and multiple regression.
Demographic data was utilized to describe five age cohorts
of women. Perceived social support was significantly
related to perceived cardiac rehabilitation success while
age was not. The inverse relationship of age to perceived;
social support and perceived cardiac rehabilitation success
‘was not statistically significant, but was in the direction
expected. Implications for advanced nursing practice and
further research were discussed, including ongoing

assessment of support systems, supportive-educative

telephone program, and more studies of women's perceptions

of cardiac rehabilitation.

To my husband, Robert, and our children, Jeffrey and Nancy,
for their support, patience, and understanding,
throughout this and other academic pursuits.

To my mother, Beverly A. Johnston, and in memory of my
father, Robert E. Johnston, for the values and unconditional
love they gave to me

iv

ACKNOWLEDGEMENTS

To my academic and thesis advisor Rachel F. Schiffman for
her dedication to this project during my Master's
preparation. To Suzanne P. Budd for her sharing her
research with me. And to Sharon King and Jacqueline Wright,
my other committee members and special faculty for their

support and encouragement.

TABLE OF CONTENTS

LIST OF TABLES O O O O O O O O O O O O O O O O O O O O Viii

LIST OF FIGURES O O O O O O O O O O O O O O O O O O 0 0 ix

Introduction . . . . . . . . . . . . . . . . . 1
Background of the Problem . . . . . . . . . . . . 1
Statement of the Problem . . . . . . . . . . . . . 2
Need for Study . . . . . . . . . . . . . . . . . . 4

Conceptual Definitions . . . . . . . . . . . . 4
Perceived Cardiac Rehabilitation Success . . . . . 5
Perceived Social Support . . . . . . . . . . . . . 9
Age 0 O O C C O O O I O O O O O O O O O O O O O O 1 1

Conceptual Model . . . . . . . . . . 14
Modification of the original model . . . . . 19

Review of Literature . . . . . . . . . 22

Social Support . . . . . . . . . .
Age 0 O O O O O O

IIII

IIII
N
\1

Cardiac Rehabilitation Experiences 29
Methods . . . . . . . . . . . . . . . . . . . . . . . . 32
Design . . . . . . . . . . . . . . . . . . . . . 32
Sample . . . . . . . . . . . . . . . . . . . 33
Operational Definitions . . . . . . . . . . . . . 33
Instruments . . . . . . . . . . . . . . . . . . . 36
Data Analysis . . . . . . . . . . . . . . . . . . 38
Limitations . . . . . . . . . . . . . . . . . . . 39
Assumptions . . . . . . . . . . . . . . . . . . 39
Procedures for Protection of Human Subjects . . . 40
Results . . . . . . . . . . . . . . . . . . . . . . . . 40
Sample . . . . . . . . . . . . . . . . . . . . 40
Research Question 1 . . . . . . . . . . . . . . . 46
Research Question 2 . . . . . . . . . . . . . . . 47
Research Question 3 . . . . . . . . . . . . . . . 50
Research Question 4 . . . . . . . . . . . . . . . 51

DiSCUSSion O O O O O O O O O O O O O O O O 0 O 0 O O O 52
Sample . . . . . . . . . . . . . . . . . . . . . . 52
Findings 0 0 O O O O O O O O O O O O O 0 O O O O O 55

vi

Implications . .
Summary . . . . .
APPENDIX A . . .
APPENDIX B . . .
APPENDIX c . . .
APPENDIX D . . .

LIST 01“ REFERENCES

61

71

72

76

84

86

88

LIST OF TABLES

Table 1 - Frequency and Percent of Social-Demographic
Characteristics . . . . . . . . . . . . . . . . .

Table 2 - Frequency and Percent of Distribution of
cahorts O O O O O O O O O O O O O O O O O O O O 0

Table 3 - Frequency of Self Reported Risk Factors . . .

Table 4 - Frequency of Self Reported Chronic Health
Problems and Previous Heart Problems . . . . . . .

Table 5 - Frequency and Percent of Requests for Social
support 0 O O O O O O O O O O O O O O O O O O 0 0

Table 6 - Frequency and Percent of Previous Use of
Community Services . . . . . . . . . . . . . . . .

Table 7 - Means, Standard Deviations, and Ranges for
Total Perceived Social Support (PSS) Scale and
Perceived Cardiac Rehabilitation Success (PCRS)
Total and Subscales . . . . . . . . . . . . . . .

Table 8 - Correlation Coefficients between PCRS Total
and Subscales and P88 Total (n = 46) . . . . . . .

Table 9 - Means, Standard Deviations, and Ranges of
scores on Perceived Cardiac Rehabilitation Success
Total and Subscales by Cohorts . .‘. . . . . . . .

Table 10 - Analysis of Variance for Perceived Cardiac
Rehabilitation Success Total (PCRS) and Subscales
by COhort s O O O O O O O O O O I O O O O O O O O 0

Table 11 - Means and Standard Deviations of Scores on
Perceived Social Support Scale by Cohort . . . . .

Table 12 - Analysis of Variance for Perceived Social
Support by Cohorts . . . . . . . . . . . . . . . .

Table 13 - Analysis of the Effect of perceived Social

support and Age on Perceived Cardiac
Rehabilitation Success . . . . . . . . . . . . . .

viii

41

43

43

43

44

45

47

47

48

49

50

51

52

LI ST OF FIGURES

Figure 1 - A model of women's self-definition in
ad“ 1 thOOd O O O O O O O O O O O O O O O I O O O O 1 7

Figure 2 - An adaptation of a model of women's self-
definition in adulthood, using the concepts of
age, perceived social support, and perceived
cardiac rehabilitation success . . . . . . . . . . 20

ix

Introduction

Wists

I Cardiac rehabilitation is an important treatment
component for men and women recovering from a coronary
event, such as bypass surgery, myocardial infarction, and
coronary angioplasty. Unfortunately, women tend to do more
poorly than men after a coronary event. One of the reasons
may be the way in which women are rehabilitated. The
purpose of this study was to investigate women's perceptions
of their ability to achieve the goals of cardiac
rehabilitation and some of the factors that may influence
positive outcomes.

Cardiac rehabilitation programs were developed to help
restore normal physical, psychological, and social
functioning for individuals who have experienced a coronary
event. The importance of rehabilitation programs has
increased as more people are surviving coronary events
because of advances in life saving treatments (Fleury, 1993;
Wenger, 1988). Cardiac rehabilitation programs have
traditionally focused on the middle-aged male, historically
considered to have the highest risk for heart disease. But
current research on women's health indicates that
significant numbers of women also have heart disease
(American Heart Association (AHA), 1992; Barry, 1993;
Coglianese, Sollano, & Bilodeau, 1992). The latest research

shows that cardiovascular disease (CVD) is an equal

1

2

opportunity disease, killing almost equal numbers of men and
women annually. According to the Cardiology Preeminence
Roundtable (1994), recent studies examining the relationship
between gender and CVD revealed some startling statistics:

(1) Heart Attack is the single largest killer of women;

(2) 478,000 women versus 448,000 men died from CVD in 1991;

(3) 1 of 7 women aged 45 to 64 has some form of CVD (p. 1).

More women die annually from heart disease than from
all forms of cancer combined. Although men tend to have
heart attacks at a younger age, women catch up at age 70 and
surpass men after age 75. Women have lower chances of
surviving a heart attack than men. Studies show that 39% of
women die within the first year after a heart attack
compared to only 31% of men (AHA, 1992). During the first
four years following a heart attack, the rate of having a
second attack is 20% for women compared with 16% for men
(AHA, 1992). Clearly women have as much or more to fear
from CVD as do men.
WW
Current statistics indicate that the typical female

patient with cardiovascular disease has a different profile
than the typical male patient. Women tend to be older when
they develop heart disease, have more comorbid conditions
that complicate their treatments and have a different
psychosocial make-up. Women are described as having more
anxiety, depression, sexual dysfunction, and return to work

less often than men following a myocardial infarction. Loss

3
of spouse, lack of social support, and inadequate finances
are problems more frequently found in women than men. How
these factors affect cardiac rehabilitation has not been
systematically evaluated (Baker, Packard, Wenger, &
Clarkson, 1988). Because of changes in national policy
regarding gender bias in health related research, women are
now included in research that affects their health (National
Institutes of Health (NIH), 1991). To better serve the
needs of women, contemporary researchers are recommending
further study to specifically evaluate women's cardiac
rehabilitation needs. Therefore, for this study, age and
women's perceptions of social support were investigated as
two factors that may influence the feelings women have about
their cardiac rehabilitation experience.

Questions answered in this study were:

(1) Is there an association between women's perceived
social support and perceived cardiac
rehabilitation success?

(2) Is there an association between women's age and
perceived cardiac rehabilitation success?

(3) Is there an association between women's age and
perceived social support?

(4) To what extent and in what manner are women's age
and perceived social support related to perceived

cardiac rehabilitation success?

W

According to Wenger (1988) "the present trend is toward
rehabilitative services appropriate for each patient's
specific characteristics and needs, rather than enrollment
of the patient in a structured and relatively inflexible
regimen. Each coronary patient can and should have his or
her specific rehabilitation needs addressed" (p. 13). In
order to provide better health care for women, it is
important to evaluate their treatment needs. As mentioned
earlier, the purpose of this study was to investigate
women's perception of their rehabilitation success. This
study emphasized women's perception of the social support
received from family, friends and health care professionals
during recovery and how these perceptions are associated
with age. Improved understanding of these relationships may
result in changes in cardiac rehabilitation programs that
better serve the specific needs of women. Advanced practice
nurses (APN) in primary care settings have the opportunity
to care for women on a continuing basis. They can be
influential in evaluating women's needs, recommending and
assisting in the development of cardiac rehabilitation
programs for women.

Conceptual Definitions

The concepts in this study were perceived cardiac
rehabilitation success, perceived social support, and age.
Each concept was defined in the following section by looking

at the components of each concept.

5

One component common to cardiac rehabilitation success
and social support was "perceived". To perceive, explains
the origin of the thought processes that form the
conceptualization of cardiac rehabilitation success and
social support. Therefore, perceive will be defined first
and independently of the other components.

To perceive was defined as the ability to grasp
mentally, take note of, recognize, observe and to become
aware of through sight, hearing, touch, taste, or smell
(Guralnik, 1976). Perception is an important concept to
consider in health care. Current studies on health
promotion, disease prevention, and stabilization of chronic
illnesses are beginning to acknowledge the importance of
knowing the person’s point of view or perception of their
health in order to offer more effective treatment
interventions for maintenance of health.

ce ve d ac e a t' n c e

The conceptualization of perceived cardiac
rehabilitation success (PCRS) involves understanding how
perceive, cardiac rehabilitation, and success relate to each
other. The components of this concept are discussed and
then refined into a conceptual definition.

Cardiac Rehabilitation, According to Kemp (1985)
rehabilitation means to "re-habilitate or make capable of
living again" (p. 647). Another definition is to restore,
or put back in good condition, to bring or restore an

optimum state of health (Guralnik, 1976). The components of

6
rehabilitation include stabilization of the primary problem,
prevention of secondary complications, restoration of lost
functional abilities, adaptation of persons to environments,
adaptations of environments to persons, promotion of family
adaptation and accommodation (Brummel-Smith, 1990).

Cardiac rehabilitation is defined by many authors as
the process of adjustment after a cardiac event. Cardiac
rehabilitation programs incorporate specific processes to
enable recovery from a cardiac event. These include
Iassessment of the patient's functional status and
application of measures designed to enhance and maintain a
desirable level of physical, social, and psychological
functioning. In the past cardiac rehabilitation programs
were developed primarily for middle aged men who were
recovering from an acute myocardial infarction or coronary
artery bypass surgery. Today, however, increasing numbers
of patients (men and women) diagnosed with angina pectoris,
those treated with coronary angioplasty and stent placements
are being referred to structured programs. Additionally,
more elderly patients are being recommended for cardiac
rehabilitation because research results indicate the
benefits of exercise, education, and social support even in
4 old age. The ideal rehabilitative program is incorporated
into the plan of care during the acute hospitalization, and
involves the patient’s family and social environment as a

support system, and continues in the outpatient practice

7
setting and community (Johnson & Morse, 1990; Squires, Gau,
Miller, Allison, & Lavie, 1990; Wenger, 1994).

Structured rehabilitation programs are arbitrarily
divided into four phases. The phases are progressive and
represent increased activity tolerance and ability to manage
life style changes related to heart disease.

Phase 1 is initiated during the acute hospitalization.
Tasks during this phase include patient and family
education, progressive ambulation, psychosocial and
vocational assessment, and interventions as needed. Most
patients with an uncomplicated MI are discharged in five to
seven days and continue with their Phase 1 activities at'
home.

Phase 2 is the early post-hospitalization phase. It
usually begins 2-3 weeks after discharge from the hospital
(and typically lasts for 8-12 weeks. This is considered to
be the most critical stage of rehabilitation because
patients are receptive to changes in life-style and are
motivated by a clear recognition of the acute event. The
major activity of this phase is supervised exercise
conditioning. Patient and family education programs
accompany the exercise training. These programs emphasize
diet management, medication management, safe physical
activity levels, risk factor identification and
modification, and life style changes.

Phase 3 is similar to Phase 2. This stage generally

continues for 9 months after completion of phase 2. The

8
program may be continued at the same medical site, or at a
community or private fitness center, with the patient
monitoring his/her own progress.

Phase 4 is the long-term maintenance program. It
consists of continuing efforts to modify risk factors.
Yearly evaluations including exercise testing are
recommended for most patients. This phase is primarily
self-motivated.

Not all patients participate in structured programs.
Some will recover at home with recommendations from their
cardiologist or primary care physician. Others may enroll
in programs at health and fitness organizations with
permission from their health care provider.

The success of the entire rehabilitation process is
seen in patients who have assimilated the principles of
cardiac rehabilitation and have successfully made the life
style changes recommended to promote cardiovascular health.
(Squires et a1., 1982; Wenger, 1994; Wenger, Hellerstein,
Blackburn, & Castranova, 1982).

Success, The final part of this concept is success,
which is a favorable or satisfactory outcome or result
(Guralnik, 1976). There is much emphasis placed on outcomes
in healthcare. Currently the trend is to develop
interventions and treatments that can be measured in terms
of outcome success.

The definition of PCRS for this study means the

individual has taken in or has grasped (perceived) the

9

concept of optimizing her health, specifically her cardiac
health (cardiac rehabilitation) and feels that the results
or outcomes are positive and satisfactory (success).
EEIC:1!§Q.§Q§1§1.§BRRQI§

The conceptualization of perceived social support
includes the definition of perceived and social support.
Of interest in this study is how the women perceive their
social support related to their age and cardiac
rehabilitation.

§Q§i§l_§uppgzt‘ This was defined as the assistance a
person receives from others. House, Umberson, & Landis,
(1988) used the term social support to refer to the
"positive, potentially health promoting or stress-buffering,
aspects of relationships" (p. 294). Wallston, Alagna,
DeVillis, & DeVillis (1983) described social support as "the
comfort, assistance, and/or information one receives through
formal or informal contact with individuals or groups" (p.
369). Cohen and Syme (1985) define social support quite
simply "as the resources provided by other persons" (p. 4).

House and Kahn (1985) explain that social support
refers to a number of different aspects of social
relationships which they call the "domain of social support"
(p. 84). Within this domain they identify three ways to
conceptualize and operationalize the term social support.
First, is the existence, quantity or category of social
relationships such as marriage, friendship, or

organizational membership. Terms such as social integration

10
or isolation are most often used to refer to the existence
or quantity of these relationships. Second, is a person's
social network, which refers to structures that exist among
a set of relationships such as density, homogeneity, or
range. And third, is the functional content of
relationships, or types of social support contributed by
others, such as affirmation, affective and emotional
concern, instrumental or tangible aid, information and
reciprocity. House and Kahn (1985) state, "It is necessary
to consider all three aspects of social relations-quantity,
structure, and function- because they are logically and
empirically interrelated" (p. 85).

It is well documented in the literature that social
support is an important part of recovery from a cardiac
event. According to Moser (1994) "...adequate social
support is positively associated with many physical and
psychological indicators of successful recovery. Cardiac
patients with low levels of social support are at risk for
further cardiac events and decreased physical and mental
well-being during convalescence" (p. 28). Because of its
importance in successful rehabilitation there is much
interest in finding ways to evaluate and optimize a person's
support system.

ISocial support is a concept that has a value attached
to it by the individual. In order for the APN to evaluate a
person's support system, it is necessary to understand the

individual's perception of the quantity, structure, and

11
functional content of their social support system. Once,
the individual's social support system is clarified, then
the APN can develop interventions based on the strength and
weaknesses of the individual's social support system.

For this study, perceived social support was defined as
the women's recognition and awareness (perceived) of the
quantity, structure, and functional content of her social
support system (social support) during her cardiac
rehabilitation experience.

m

The conceptualization of age for this study took into
consideration the biological, psychological, and
sociological aspects of the aging process in women. Age is
defined by Webster's New World Dictionary as "the time that
a person or being has existed since birth or beginning" and
aging is "to grow old or show signs of growing old"
(Guralnik, 1976, p. 25).

Literature on the subject of age describes aging as a
phenomenon that has three dimensiOns: biological,
sociological, and psychological. "The biologist is often
concerned with ’longevity and the antecedents of death'”
(Cunningham & Brookbank, 1988, p. 2), "the sociologist tends
to focus on social roles and the relationship the aged have
with society, while the psychologist is concerned with
individual adaptability and adjustment" (Stokes, 1992, p.
2). The interesting thing about the aging process is that

no one individual ages in the same way. It has been said

12
that there is more variability between 65 year olds than
there is between 20 year olds. Thus, making the study of
aging individuals an interesting challenge. Clearly the
variability in adult development needs to be understood when
evaluating the older person.

Big;ggiga1_agingL This is defined as those changes
which are inevitable, and irreversible, and occur with the
passage of time. Biological aging is not the same for each
organism, nor do the systems of the organism age at the same
rate. "The process of biological aging not only differs
from species to species but also from one human being to
another...no two individuals will age identically. Varying
degrees of physiological changes, capacities, and
limitations will be found in one age group. The rate of
aging among different body systems within one individual may
vary, with one system showing marked decline while another
demonstrates no significant change" (Eliopoulos, 1993, p.
16).

2gyghglggigal_agingL As a person can seem older or
younger than their biological age, they may also seem
younger or older acting because of their psychological age.
Stokes (1992) suggests, "Reduction in enthusiasm for life,
withdrawal from activity and lowering of morale may be less
often the effect of physical aging than an attitude to
oneself as aged and without value. Later life is not viewed

as a time for growth and achievement" (p. 19). This point

13
of view may describe people who are unable to adapt to
change as they age.

Another way of describing adult psychological aging is
Continuity Theory. Continuity Theory, an adult development
theory, proposes that as people age, they strive to maintain
their personality. They do so by adapting to changes that
occur as they age. These changes may be physiological
and/or sociological changes (usually both). The ability to
achieve a sense of self, as life changes, is correlated with
positive life satisfaction. Atchley (1994) states, ”there
is more continuity than discontinuity of self and
personality with aging, and each becomes more stable with
age...Most people enter later life with a stable personality
and positive self-esteem... Adaptation is the core of adult
development according to continuity theory" (p. 148-149).

Sociological aging, The society we live in defines age
specific tasks and roles. Birren (Schroots & Birren, 1990)
introduced the term 'social age', which refers to age
acquired social habits and status. An individual is
expected to fulfill certain social roles and expectancies
based on age. The roles and expectations may vary depending
on the person's culture or social group (Schroots & Birren,
1990). Neugarten and Datan (1973) proposed that certain
social roles are age-graded. For example, school years,
marriage, parenthood, retirement, and widowhood have
socially acceptable age ranges where each role behavior is

expected to be achieved. If the person is 'on-time', their

14
adjustment is usually not as traumatic because the events
and changes are anticipated and have society's approval.
However, if a person is 'off-time', their behavior is not
consistent with the 'expected sequences and rhythms of life'
and their adjustment may be more difficult. When behavior
occurs outside the accepted span of chronological years, it
is deemed inappropriate and is not sanctioned (Neugarten &
Datan, 1973).

Clearly age is a multifaceted concept. For this study
the concept of age was defined as zepgeeeneing: (1) the
physical condition of each woman based on her normal
biologic changes (biological), (2) her personality structure
and stability (psychological), and (3) her social roles
related to "on-time or off-time" of events (sociological).

Conceptual Hodel

The conceptual model used for this study was the
"Women’s Self-Definition in Adulthood Model" developed by
Peck (1986). The model is based on current research on
adult development specific to women. The model recognizes
the impact of relationships and the timing-of—events in a
social context on a women's development. "Implicit in this
model is the assumption that a woman is self-reflective,
capable of understanding her own behavior, and able to
communicate her sense of self to another" (Peck, 1986, p.
277).

Two conceptual frameworks were influential in the

development of this model. The first, is a psychological

15
model of adult development proposed by Bernice Neugarten
(1968, 1973). The timing-of-events concept stresses the
importance of social-historical context on the development
of adults rather than chronological age. Neugarten found
that when adult women defined their age in a social-
historical context, they did so in terms of family events,
whereas men defined their age by events outside the family
(Neugarten, 1968; Neugarten & Datan, 1973).

The second influential concept in this model is
Gilligan's (1982) study of relationships and attachments.
Gilligan's findings indicate that female adult development
is based on maintaining relationships and attachments,
rather than individualization and separateness, which is the
basis of male adult development. Gilligan's study proposed
that women perceived their identity in connection with
someone else, a concept that needs to be considered when
evaluating normal female adult development (Gilligan, 1982).

A developmental model specific to adult women is
appropriate to use when identifying needs of adult women
going through a cardiac rehabilitation program. It is
critical to the treatment of adult women that their
development is understood. Androcentric models of
development are inflexible and inappropriate for women.

Even though women are assuming more roles previously held by
men such as self-support, careers, and heads of households
these roles become part of their self-definition as women.

This model is flexible enough to handle new roles and other

16
changes in women's development. Models of adult female

development support women's roles, life circumstances, and

socialization.
The model has three main parts, eeeiel;hietgzigal_§img
dimension. W. and stilt-gem (see

Figure 1). The social-historical time dimension relates to
the timing of events theory, the sphere of influence relates
to the relationships and attachments theory. Self-
definition refers to a woman's knowledge of herself as an
individual-in-society.

The model (see Figure 1), conceptually shaped like a
cylinder, is depicted in a cross sectional view. The outer
wall is the social-historical time dimension. The outer
wall described by Peck (1986) as flexible is represented by
a wavy line. The flexibility of the wall represents
favorable or unfavorable opportunities for women at a
particular point in time. According to Peck (1986) this
dimension can be "perceived as the social, emotional, and
political context within which a woman is allowed to define
herself at any given point in time" (p. 278).

The inner layer of the cylinder is the sphere of
influence (see Figure 1). The sphere of influence consists
of the sum of a woman's relationships. Conceptually similar
to House and Kahn's (1985) "domain of social support" it
includes all three aspects of social relationships;
quantity, structure and function, at varying levels of

closeness. It also includes the woman's work, not just the

17

 

 

 

 

    

 

 

 

 

 

F
/ \\
/ \
\ \
4" Self Definition fl \
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/K

i

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i

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2 «72-- 6 \

O ’9- \

r / ..

a: “‘-
E / .- /\

I H
3 — _ __ _
" 9’
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Sphere of Influence
Figure 1, A model of women's self-definition in adulthood

(Peck, 1986).

18
state of being employed but the feelings of satisfaction and
sense of competence a woman receives from her productive
efforts. Relationships are described as bidirectional,
meaning the woman both influences and is influenced by her
relationships.

There are two important characteristics of the sphere
of influence, {legieiligy and eleeeieLEy. Flexibility is
the ability of the woman to expand her sphere of influence
to take on new relationships or contract her sphere of
influence to prevent new relationships. Flexibility also
includes a woman's ability to redistribute her emotional
involvement in order to receive support and reaffirmation of
the self when necessary. Elasticity "refers to the degree
to which particular relationships in the sphere are
responsive to the woman's changing needs, motivation, and
self definition" (Peck, 1986, p. 280). Elasticity is the
firsthand way that a woman can see the results of her own
influence on the people around her. Therefore, she can see
herself as having some control over the degree to which
other's needs and expectations affect her functioning.
Elasticity gives her the ability to separate other's
concerns from her own.

Woman's self-definition is portrayed as a funnel-shaped
force emerging through the sphere of influence (see Figure
1). With the passage of time the funnel widens, indicating
increased clarity and understanding of self-definition. The

process of self-definition is pictured by the spiraling

19
arrows. The spiraling arrows indicate the woman's constant
process of monitoring her own growth and change against the
possible impact upon her valued relationships. Self-
definition or how a woman sees herself in society is
strongly influenced by social-historical time and the
elasticity and flexibility of the sphere of influence.
MW].

The original model was modified (adapted) to fit the
variables in this study (see Figure 2). The cardiac event,
although not a variable in this study is the precipitating
event and falls within the social-historical time dimension.
Events that occur in the outer wall effect women's
relationships and self-definition. Additionally events that
fall in the outer wall are influenced by the time in which
they occur. For example because of increased awareness of
women’s risk for heart disease, more is being done for women
now than in the past. The variable ege also fits into this
part of the model.

The roles of women as they age in society are affected
by the time in which they live. As different cohorts of
women move through this time dimension their feelings about
themselves as they age are strongly influenced by what is
happening culturally, economically, and politically.

The variable 221931!§Q_§221§1_§BEQQI§ fits into the
sphere of influence (see Figure 2). All the relationships a
woman has in her sphere of influence have the potential to

influence her recovery from a cardiac event. Some she will

20

 

 

 

. Cardiac la) - .
ueb dink, .
Wm Success m0” ‘

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. . \KQQ
Self Definition 99..»

 

     
   

 

 

Sphere of Influence

 

(bulb!) 66v ->

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I

I

I
Q)
E
-F
I'—
P
4'6
0
.P
L.
O
4.)
(D
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F-
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(D

 

 

Sphere of Influence

 

. An adaptation of a model of women’s self-
definition in adulthood, using the concepts of age,
perceived social support, and perceived cardiac
rehabilitation success (Peck, 1986).

21
consider supportive and others she may feel are barriers to
recovery. Bidirectional relationships are represented by
small arrows within the sphere of influence. Because
relationships are bidirectional the woman may have to
redistribute her emotional involvement (flexibility) in
order to receive the support and affirmation she needs for
recovery. She may also expand her sphere of influence to
include new relationships important to her recovery. These
relationships may include members of her health care team
and/or peers in her rehabilitation group. Additionally, as
a woman proceeds through her rehabilitation she will look at
which relationships are responsive to her changing needs,
motivations, and change in self definition (elasticity).
Elasticity of the sphere of influence allows the woman to
look at what her rehabilitation needs are and differentiate
her needs from the needs of those close to her. If the
sphere is very elastic, then the woman can see that she has
some control over the changes she needs to make in order to
recover successfully. If she does not have elasticity, then
she may feel anxious and depressed if her needs conflict
with the needs of others in her sphere of influence. The
APN in primary care can work with the woman to help identify
and normalize her feelings regarding the change in her
health status and the impact it has on her ability to
maintain her roles. The woman may need support as she
redefines roles and relationships. Additionally, the

members of the woman's support system may need to be

22
included in counseling, especially if they are the source of
the stress.

MW is a concept
that is internalized by the woman. It becomes part of her
self-definition (see Figure 2). This variable represents a
positive health/treatment outcome. As such it is vulnerable
to what is happening to the woman in the social-historical
time dimension (age) and the sphere of influence (perceived
social support).

This model provides the APN with a framework for caring
for women with heart disease. The APN, using this model is
aware of the importance of social-historical changes in
woman's health care, can advocate for the most current
health care available, including cardiac rehabilitation
programs that fit women's needs. The model recognizes that
women's attitudes about health care may effected by their
place in time. Awareness of this effect prepares the APN to
suggest treatments that are acceptable to different age
cohorts of women. As the model implies» women's
relationships form a basis for their self-definition. The
APN can identify relationships and associations in a woman's
life that may have an effect on her rehabilitation outcomes.
This is a theoretical model that when applied to practice
provides a framework for treatment and further research.

Review of Literature
The review of literature for this study included

research on age and social support as factors in the cardiac

23

rehabilitation success of women. It was found that research
that investigates these variables was focused primarily on
men. Of the studies that included both genders, the women
were underrepresented. Studies limited to female subjects
were few and generally had small sample sizes. Additionally
many studies compared men and women on variables that were
not equal at baseline in both groups, examples are exercise
tolerance, number of comorbid conditions, age, and social
support systems, resulting in the appearance of better
outcomes for men than women. Studies that had only men as
subjects were not included in this review. Studies that
included both genders or only women and investigated the
variables age and social support were included.
W

Friedman (1993) tested the relationship between social
support (emotional and tangible) and psychological well-
being (affective and life-satisfaction) in a sample of 80
older women with heart disease. The study was based on
Cantor's (1979) model that proposes that older adults
compensate for loss or absence of support sources from a
hierarchy of supportive relationships. The hierarchy of
relationships was defined from top to bottom as: spouse,
children, distant relatives, friends, neighbors, and formal
organizations. The results of the study showed that
emotional support received from other than family members

was related to lower positive affect. Likewise, tangible

24
support received from nonfamily members was related to lower
life satisfaction.

Primomo, Yates, and Woods (1990) explored who in a
woman's social support network provides what kind of support
in relation to psychosocial adjustment for women with
chronic illness. The women in the study had nonmetastatic
breast cancer, diabetes, and fibrocystic breast disease.
None were cardiac patients, but heart disease, also a
chronic illness may result in similar needs for social
support. Sources of social support identified in this study
included partner, family, friends, and others. Types of
support included affect, affirmation, aid, illness
confident, and reciprocity. The psychosocial adjustment
variables were depression, family demands of illness,
marital quality, and family functioning.

According to Primomo et al. (1990), when compared to
other types of support the partner was found to provide
significantly more (p < .001) affective support,
affirmation, tangible aid, and was more likely to be
confided in about the illness and to reciprocate. After the
partner, the family provided a significantly greater amount
of affectional support than either friends or others.
Friends were found to provide more affirmation than did
family and more affective support than others. Women
reported confiding about their illness to others (such as
health care providers, counselors, religious officials) more

than family or friends. As in the Friedman (1993) study,

25
social support is identified as an important factor for
women with chronic diseases.

, Thompson and Heller's (1990) study compared measures of
network embeddedness (size, composition, and frequency of
visits) and perceived social support with measures of
physical and mental health. Their responses came from a
sample of 271 community dwelling older women. The results
of this study supported the importance of network size,
composition, and frequency of interaction for both mental
and physical well-being in this sample of women. It also
indicated that regardless of a women's perception of social
support, there was a minimum amount of network embeddedness
necessary for mental and physical well-being.

Fleury (1993) explored the role of social support
networks in influencing wellness motivation within the
context of cardiac rehabilitation. The sample consisted of
24 individuals (17 men and 7 women) who were participating
in a cardiac rehabilitation program. Qualitative data were
collected that resulted in a detailed desoription of the
role of social networks in influencing wellness motivation.
Social networks were described as having two interactive
patterns: enabling and limiting. Behaviors viewed as
enabling change were those that members of the social
network performed that facilitated and sustained maintenance
of risk factor modification for cardiac rehabilitation.
Enabling behaviors were categorized as emotional support,

appraisal support, problem solving, and instrumental

26
support. Limiting behaviors were perceived as those that
blocked the achievement of valued goals of life style
change. Limiting behaviors were labeled as value conflict
and maintenance of boundaries. The two categories were not
found to be mutually exclusive, illustrating the complexity
of behaviors that occur during times of change and
transition within social networks.

Budd (1991) investigated factors thatinfluence the
recovery and rehabilitation process for women after a
myocardial infarction. Based on Bandura's (1986) Self-
efficacy Theory and Orem's (1971) Self-care Theory, three
instruments were developed to measure women’s knowledge,
self-efficacy, and perceived success related to cardiac
disease and rehabilitation. Forty-six women aged 40 to 87
years of age participated in the study. The women were
interviewed in person at the hospital prior to discharge and
again by telephone ten weeks after discharge by the nurse
investigator. Results of the study showed significant
relationships between self-efficacy and rehabilitation
success and social support and rehabilitation success.
Knowledge was not significantly related to rehabilitation
success.

Friedman (1993), Primomo et al. (1990), and Thompson
and Heller (1990) evaluated social support and its influence
on the concepts of life satisfaction and well-being. All
three studies identified that there is an relationship

between the type of support, and the person who provides the

27

support, to positive outcomes. Because cardiac
rehabilitation success is considered a positive outcome, and
restoration of mental and physical well-being is a goal of
cardiac rehabilitation, these studies support the need for
evaluation of social support for cardiac rehabilitation.

Fleury (1993) and Budd (1991) looked more specifically
at social support in the context of cardiac rehabilitation.
Fleury looked at heart patients perceptions of how their
support systems influenced their wellness motivation for
cardiac rehabilitation. Budd (1991) correlated perceptions
of social support and perceptions of rehabilitation success.
Fleury (1993) found that patients were able to differentiate
between two kinds of support, that which helped motivate
them to change their life style and that which interfered.
Budd (1991) found that patients who believed their support
system was good also felt they were doing better in their
rehabilitation efforts. Both studies demonstrated that
patients perceptions of their support system are important
in the rehabilitation experience.
has

Ades, Polk, Waldmann, and Coflesky (1992) identified
that older women are less likely to participate in cardiac
rehabilitation programs than older men, and that older women
who do participate in exercise based rehabilitation programs
show significant differences in their pre and post exercise
program variables. The sample included 226 men and women

all 62 years or older who had been diagnosed with a

28
myocardial infarction or had bypass surgery. All patients
were eligible for cardiac rehabilitation upon discharge from
the hospital. After their first outpatient physician visit
the subjects were interviewed by a cardiac rehabilitation
nurse to evaluate the strength of physician recommendation
for an exercise based outpatient rehabilitation program.
Strength of physician recommendation was scored on a scale
from 1 to 5. Lower scores connoted that the physician did
not recommend rehabilitation and higher scores represented
strong recommendation. By stepwise logistic regression
analysis, the strength of the physician recommendation was
the most powerful predictor of participation for the entire
group (n = 226). However, physicians recommended
participation more strongly to older men than to older women
despite similar clinical profiles.

Of the subjects recommended for rehabilitation at
discharge from the hospital (a = 226), only 57 enrolled in
the cardiac rehabilitation program. Of the subjects who did
participate (men = 39 and women = 18) the women were less
fit at the beginning than the men, but performance
improvements were as significant for the women as for the
men after 12 weeks of exercise rehabilitation.

This study demonstrates the need for further evaluation
of the perception of age and recovery from a cardiac event.
Health care providers may be affected by negative
stereotypes about aging and the efficacy of cardiac

rehabilitation even in old age.

29
WW

Schuster and Waldron (1991) examined the gender
differences in exercise tolerance, self-efficacy, and
anxiety, and the relationships of these variables to
attendance at rehabilitation sessions. Frequency
distributions on the major variables showed that men
attended more regularly than women, men achieved a higher
activity tolerance than women, more women expressed low
self-efficacy than men, and women were more anxious than
men. The authors also identified that women did not enter
cardiac rehabilitation programs in proportion to the
expected ratio based on coronary morbidity data.

Frenn, Borgeson, Lee, and Simandl (1989) investigated
the recommended life-style changes in a cardiac
rehabilitation program from the client's perspective. The
study was limited to changes in diet, smoking cessation, and
incorporation of exercise. The subjects (a = 10), six men
and four women, between the ages of 40 and 78, were
interviewed while participating in an outpatient cardiac
rehabilitation program. The results of the interviews
indicated that patients perceived that cardiac
rehabilitation programs and the support of family and
friends were influential in their recovery process.

Boogard (1984) hypothesized differences in the
rehabilitation experience for men and women because of sex
role orientation and societal norms. Comparisons were made

between men and women on (1) return to physical activity,

3O
(2) psychosocial aspects, and (3) family interrelationships.
The subjects, (n - 20, 10 males and 10 females), between the
ages of 25 and 55 and had their first MI within the past 3
to 6 months were given a semi-structured interview.

On "return to physical activity", men had decreased
physical activity one week after discharge from the
hospital, compared to women who began light household
activity one week after discharge. On "psychosocial
aspects", both men and women experienced post infarction
depression. But men, did not feel guilty during the
rehabilitation period, whereas women felt guilt about not
being able to fulfill their roles as mothers, wives,
caregivers, and housekeepers. On "family
interrelationships", both men and women felt that their
families perceived them as ill. But women felt that their
families did not "wait on me" while men felt they were often
”waited on".

Boogard's (1984) insights into the differences in
rehabilitation experiences of men and women are important to
consider in the post MI treatment of women. Cardiac
rehabilitation programs developed for women should address
sex role issues, women's definition of self, and perceptions
social support. More research is needed to evaluate how
these variables influence recovery from a cardiac event.

Examination of the literature related to social support
and its impact on recovery from a chronic illness like heart

disease was challenging. Friedman (1993) looked at social

31
support sources and psychological well-being. Primomo et
a1. (1990) looked at relationships between social support
sources, types of support, and adjustment. Thompson and
Heller (1990) perceptions of family support and social
isolation, and Fleury explored social networks and
cardiovascular risk reduction. Budd (1991) described the
concept of self-efficacy and the ability to negotiate social
support for cardiac rehabilitation. All the studies
indicated that women's perception of social support was key
to the research. Different types of social support were
emphasized in each study and operationalized in a different
way. Because of these differences, it is difficult to
generalize findings. As more research is completed and
studies are replicated perhaps more consistent tools for
measuring social support in this population will be
available.

It was found that age as a factor in rehabilitation is
under-researched. Ades et al. (1992) was the only study
that clearly identified age as an important variable for
cardiac rehabilitation.

Limited literature supports the importance of social
support for recovery from illness and motivation for life
style changes that are recommended for cardiac
rehabilitation success (Frenn et al., 1989). Similarly,
limited literature indicates that age is a factor in cardiac
rehabilitation participation and success for women (Ades et

al., 1992). The paucity of research in the area of women,

32
age, social support, and cardiac rehabilitation may be
related to lack of knowledge, interest, and funding in the
past. As the cohort of women influenced by the feminist
movement demand equality for women in all aspects of life,
including research, conceivably there will be more empiric
solutions to the problems facing women.

This study attempted to add to the literature related to
the relationship of age and social support to cardiac
rehabilitation by investigating perceptions of
rehabilitation experiences by different age cohorts of
women.

Methods
Design
This study was a non-experimental, descriptive,
correlational study. It was designed to describe the
association between a woman's age, perceived social support
and perceived cardiac rehabilitation success. This study

was a secondary analysis of data collected for the Women's

ea t tu : Se - f 'c c the ha ' i at o e
E2ll2Eing_A2ute_u222ardial_lnferstien (EQEEDL§_flsart_§tudX)

(Budd, 1991).

The Women's Heert §§ugy (Budd, 1991) was a descriptive
study that explored the factors influencing the perception
of the rehabilitation process and the role of self-efficacy
in recovering post-MI women. The study was based on
Bandura's Self-efficacy Theory (1986) and Orem’s (1971)

Self-Care Theory. Four instruments were developed

33
specifically for the study, the Patient Social-Demographic
Interview (see Appendix A), Knowledge Test, Self-efficacy
Scale and Rehabilitation Success Scale (see Appendix B).
Women were interviewed in person prior to discharge and by
telephone ten weeks after discharge by the nurse researcher.

Sample

Subjects for this study were the same as those in the
EQEEDL§_H§§:&_§§29¥ (Budd, 1991). Forty-six women who were
recovering from myocardial infarctions were recruited for
the original study from two Lansing, Michigan area
hospitals. Thirty-six subjects were from Michigan Capital
Medical Center (formerly Ingham Medical Center) and 10
subjects were from E.W. Sparrow Hospital. The women in the
sample were Caucasian, spoke English and were between the
ages of 40 and 87 years.

0 i n t

Penceiged gendiac Rehabilitation Success, The concept
that the woman has taken in or has grasped the concept of
optimizing her health, specifically her cardiac health and
feels that the results or outcomes are positive and
satisfactory was measured by the Criteria for Rehabilitation
Success Instrument (Budd, 1991) (See Appendix B). This
telephone interview questionnaire includes 58 self-rating
items and 32 open-ended questions. Only the 33 self-rating
items which focused on rehabilitation success were used in
this study to measure the variable Perceived Cardiac

Rehabilitation Success. The questions were divided into

34

five subscales which measure the woman's perception of her
success in dietary management (items 1-5 and 8); management
of medication self-administration (items 10-15); management
of physical activity and exercise (items 18-28, 31 and 33);
risk factor modification (items 35-36); and life-style
readjustment (items 43, 51-54, and 56). The format for the
33 self-rating items was a five point Likert scale. The
women were asked in the telephone interview to rate their
management and experiences related to cardiac
rehabilitation. Perceived Cardiac Rehabilitation Success
ratings ranged from 0 (n2t_at_all) to 4 (nost 9f she

'me ce ent). Women could also choose a nen_enn;ieenle
response.
Mean scores were calculated for the total PCRS and each of
the five subscales. Low scores indicated a poorer
perception of cardiac rehabilitation success than higher
scores.

Penceiyed genial Supngnt, Twenty-one items (6, 7, 9,

16, 17, 29, 30, 32, 34, 37, 38, 39, 40,.44, 45, 46, 47, 48,
49, 50, and 55) measuring women's perceptions of social
support were incorporated into the Rehabilitation Success
Instrument (see Appendix C). The scores for these items
were added together for a total Perceived Social Support
score (PSS). This score was divided by 21 and a mean score
was obtained for each subject. The test and response format
were the same as that of the Rehabilitation Success

Instrument.

35

Age; The variable age was operationalized by cohorts
and chronological age. A cohort is an aggregation of people
having a common characteristic, usually the time period in
which they are born. Each cohort is unique in size, general
health, historical experiences, and role identification.
Cohorts both effect and are effected by the culture in which
they live. According to Cunningham and Brookbank (1988)
much of the aging experience for women is determined by
their cohort, for example, the current group of elderly
women were raised to be more passive and subordinate than
the current group of younger women. As the lives of members
of different cohorts are compared, the principle of cohort
differences surfaces. Because of the effects of social-
historical time on lives, members of different cohorts grow
older in different ways (Riley, 1994). Examples of cohorts
are people born during the depression and people born after
World War II, the "baby boomers.”

For this study the 46 subjects were divided into five
groups. Each group represented a cohort. The women's ages
ranged from 40 to 87 years. The first cohort included women
from 40 to 49 years. The second cohort included women 50 to
59 years. The third cohort included women 60 to 69 years.
The fourth cohort included women 70 to 79 years. The fifth
cohort included women 80 to 89 years. Data collected from
the Patient Social-Demographic Interview (Budd, 1991) were
used to describe the cohorts and chronological ages (see

Appendix A). Chronological age was used to operationalize

36
the variable age for data analysis where the use of groups

was not the most appropriate method for testing.
IDELIBEEDSE

BMW The Rehabilitation
Success Scale (RSS) (Budd, 1991) (see Appendix B) is a 90

item instrument (58 self-rating items and 32 open-ended
questions) administered by telephone interview. Thirty-
three items were utilized to measure a total perceived
cardiac rehabilitation success score and five subscale
scores for this study. The open-ended questions were not
used in this study. Content validity of the RSS was
assessed by experts in cardiac rehabilitation; two experts
were nurses, one expert was a physical therapist, and one
expert was a nurse educator. The Content Validity Index
(CVI) of the self-rating scale was .85. The CVI was not
calculated for the open-ended questions and therefore their
exclusion from this study should not affect content
validity. Cronbach's alpha formula, used to estimate
reliability of the total RSS, was .92 indicating internal
consistency. The Cronbach's alpha for each of the subscales
in the Budd (1991) were: diet management, .64; medication
management, .76; physical activity, .83; risk modification,
.78; and life style changes, .85. The modified
Rehabilitation Success Scale used for this study did not
include 21 items related to social support. The Cronbach's
alpha for the modified scale used in this study was .89 and

for the subscales were: diet management, .57; medication

37

management, .79; physical activity, .81; risk modification,
.63; life style changes .70.

NEW In the
original study (Budd, 1991) the items relating to the
variable social support were incorporated into the subscales
of the Rehabilitation Success Scale and were identified in
the code book for analysis, but not as a separate social
support scale. The Cronbach's alpha for the N888 was .78.
For this study items chosen to operationalize PSS were those
that asked the subject about enlisting help from others
during recovery. These items were believed to measure the
subjects feelings about the social support they received
from others during their rehabilitation (see Appendix C).
The Cronbach's alpha for the modified scale used in this
study was .77.
Social-demographic data for this study was obtained from the
original study using the Patient Social-Demographic
Interview (Budd, 1991). Demographics were used in this
study to measure the variable age, and describe each cohort.
Social-demographic data collected included age in years,
racial or ethnic background, marital status, children,
household make-up, education, occupational status, finances,
risk factors associated with heart disease, symptoms of
heart disease, hospitalizations related to heart disease,

chronic health problems, availability of social support

38
including physical and emotional support, and use of
community health care services (see Appendix A).
Wis

Descriptive statistics on demographics were calculated
for the group for marital status, education, finances,
occupational status, chronic health problems, social support
systems, use of community health services, heart disease
history, and risk factors. Descriptive statistics related
to social support and cardiac rehabilitation success were
also calculated for each of the cohorts. These statistics
were used to help describe these critical characteristics of
each cohort.

The first research question, concerned with the
association between perceived social support and perceived
cardiac rehabilitation success, was answered by Pearson's
product-moment correlations between the mean scores of the
total Perceived Cardiac Rehabilitation Success and subscales
and the mean scores of the Perceived Social Support scale.

The second question, relating to an association between
a women's age and perceived cardiac rehabilitation success,
was answered using analysis of variance to determine if
there was any significant effect of age by cohort on mean
score for the total and subscales of perceived cardiac
rehabilitation success. The third question, relating to an
association between a women's age and her perceived social

support, was also answered using the analysis of variance

39
procedure to determine any effect of age by cohort on mean
perceived social support scores.

The last research question, about the extent and manner
age and perceived social support relate to a woman's
perceived cardiac rehabilitation success, was answered using
multiple linear regression analysis. Of interest was the
weight of the predictor variables, chronological age and
perceived social support, for the prediction of the
criterion variable, perceived cardiac rehabilitation
success.

MM

1. The use of previously collected data (secondary
analysis) limits the interpretation of the variables in this
study. Additional information on how the women felt about
their age in relationship to their health and opportunities
for recovery would have added more depth to the age
variable.

2. The small size of the sample and the lack of ethnic
diversity limits generalization of the results to the
population.

3. Use of the NSSS scale to measure perceived social
support implies the subject is proactive rather than the
more passive concept of perception.

Minus

It was assumed the questionnaires were answered

honestly by the subject without input from family and/or

friends and data were entered correctly.

40
d f u S
Code numbers were the only identifier of subjects for

the present study and therefore anonymity of subjects was

assured. The original research, Wenen'e Heezt SEBQXE Self-
3.1.. 9' ;e1-,_- 12.0 7.19‘ ‘1 e 0 W 1' .1
WW (Budd. 1991) . was granted approval by

each hospital's (Michigan Capital Medical Center and Edward
Sparrow Hospital) Human Subjects Review Committee and from
Michigan State University's Committee on Research Involving
Human Subjects. Approval was also obtained from Michigan
State University’s Committee on Research Involving Human
Subjects for the present study (see Appendix D).

Results

In this section the results of the data analysis are
described for the sample and research questions.
Sample

The 46 women in this sample were from 40 to 87 years (M
= 65.5, SQ = 11.2). Half of the women were married (n =
23), and a third were widowed (n = 16).. Twenty-nine women
lived with a spouse or other family member and 17 lived
alone.

Thirty-five women were at least high school graduates
and almost half of those had advanced education. Prior to
their heart attack, 13 subjects worked full-time, two worked
part-time and one did volunteer work. Twenty-one women were
retired and 7 were unemployed. Thirty of the women

considered themselves full time homemakers and 12 stated

41
they were part time homemakers. Two subjects hired
assistants for homemaker services, one was cared for by her
family, and one relied on community resources for her
homemaker services (see Table 1).

In order to investigate the variable age, the women
were placed in cohorts by age (see Table 2). Most of the
women were in two cohorts, 60-69 and 70-79 years of age.

The most frequently reported risk factor for heart
disease was streSs (see Table 3). And the two most
frequently reported chronic health problems were
hypertension and arthritis (see Table 4). The most
frequently reported heart problem prior to the MI was

angina, but 20 women reported having had no prior heart

 

 

 

problems.
Table 1

_‘° '!C 11°. "_ ‘1t' ° ,".'-D’ll"_v'l ha C3 7‘ ‘3
IN = 46)
Characteristic Frequency Percent
Marital Status
Married 23 50.0
Widowed 16 35.0
Divorced 5 11.0
Single 1 2.0
Separated 1 2.0

Number of Children

none 5 10.9
one 2 4.3
two 11 23.9
three 11 23.9
four 4 8.7
five 6 13.0
>six 7 15.2

42

Table 1 (cont'd)

 

Characteristic Frequency Percent

 

Living Arrangements

Alone 17 37.0
With spouse 22 48.0
With adult child 4 9.0
With teen child 2 4.0
With grandchild < 6 1 2.0
Homemaker Status (pre-MI)

Full-time 30 65.0
Part-time 12 26.0
Cared for by family 1 2.0
Community assisted 1 2.0
Hired services 2 4.0

Highest Education

Grades 7-9 4 8.7
Grades 10-11 7 15.2
High school grad 18 39.1
Jr. or Business college 12 26.1
College grad 2 4.3
Post grad 3 6.5
Work Status (pre-MI)

Not employed 7 15.2
Full-time 13 28.3
Part-time 2 4.3
Retired 21 45.7
Disabled 2 4.3
Volunteer work 1 2.2
Main Occupation

Professional 5 10.9
Technical 6 13.0
Clerical/supervision 18 39.1
Laborer/domestic 7 15.2
homemaker/mother 5 10.9
homemaker/wife 4 8.7
homemaker/self 1 2.2
Financial Dependents

none 43 9

3.5
one 2 4.3
two 1 2.2

 

43

 

 

 

Table 2
WIN-46)
Age Frequency Percent
(in years)
40-49 4 8.7
50-59 9 19.6
60-69 17 37.0
70-79 10 21.7
80-89 6 13.0
46 100.0

 

Table 3

Egegneney of Self Renezted Risk Factors (N = 46)

 

 

 

Number 1 Frequency Number 2 Frequency
Stress 24 Stress 11
Obesity 7 High Blood Pressure 6
Diabetes 5 High Cholesterol 6
Family History 3 Diabetes 6
Cigarette Smoking 3 Cigarette Smoking 5
High Blood Pressure 2 Family History 5
None 1 Obesity 3
None 2
Table 4
,‘Ele! . e, :e-- - oi'c e: ! ' ob -n: ;ig
Ezeyious HQQEE Ezenlens (N =e461

 

 

Chronic health problems

Previous heart problems

 

Hypertension 30
Arthritis 28
Diabetes 15
COPD/Asthma 4
Ulcers 2
Cancer 1

None
Angina
Previous MI
CABG

CHF

RHF
Prolapse
PTCA

2O
14
11

PPM-50!

 

44

The women identified spouses and daughters or
daughters-in-law as the ones who were most frequently asked
to provide personal care and emotional support. It was
assumed that the women requested support from sources whom
they knew would help (see Table 5). Previous use of
community services for support was low in this sample.:
Sixty-seven percent of the women reported that they had
~never used community services. The most frequently used
community service was the visiting nurse, which is usually
prescribed and arranged for while still in the acute care

setting (see Table 6).

Table 5

Ezegnency and Peneent 9f Beguests fen Social Sunponn (N -
Aél

 

 

Social Support Frequency Percent
Personal care requests
Daughter/in-law 19 41.3
Spouse 14 30.4
Friends 4 8.7
Sister/Brother 3 6.5
Visiting Nurse 3 6.5
No one 2 4.3
Hired help 1 2.2
Emotional support requests
Daughter/in-law 11 23.9
Spouse 8 17.4
Friends 9' 19.6
- Clergy/Psychologist 7 15.2
Sister/Brother 4 8.7
No one 4 8.7
Parents 2 4.3
Visiting Nurse 1 2.2

 

45

 

 

 

 

Table 6

‘9l-'! 1!! " e! 'I ' e,°_- :1 ° '11.“..-1 'fi '-—‘
1N = 461
Community service Frequency Percent
none used 31 67.4
Visiting Nurse 7 15.2
Meals on Wheels 2 4.3
Sr. Citizens group 1 2.2
Social Services 1 2.2
Transportation 1 2.2
Church 2 4.3
Other 1 2.2
Weber};

In order to compare and contrast the cohorts,
cross-tabulations with chi-square statistic were done on the
variables marital status, living arrangements, self-reported
risk factors for heart disease and chronic diseases,
personal and emotional care sources, and use of community
services. Statistically significant results were obtained
for marital status only x2(4, N = 46) = 28.5, n < .05.
Proportionately more younger women were married, and more
older women were widowed. Risk factors for heart disease
came close to statistical significance. By cross-tabulation
the cohort with the most stress (most frequently named risk
factor) were the 70 to 79 year old group. It may be that
the small sample size and number of empty cells contributed

to the lack of significance for the other variables.

esu t e s u
t - , e - ., : , a. -. ., a _ ,
...,': . . . _ - 9.. ,. .- . .
We:

The first research question was analyzed by correlating
mean scores on the perceived social support scale with the
means of the total and subscale scores on the perceived
cardiac rehabilitation success scale. Mean scores on the
PCRS and P58 were between 2.6 and 2.9 respectively (see
Table 7). Indicating the women’s perceptions of cardiac
rehabilitation success and social support were in the
moderate range. The scores in the subscales, representing
components of cardiac rehabilitation were also in the
moderate range.

The positive correlations between PSS and PCRS total
scale and subscales were significant except for medication
management. The correlation coefficients ranged from a
moderately low .24 for the PSS and medication management to
a moderately high .53 for the PSS and PCRS. These scores
are within the normal range for variables of a psychosocial

nature (see Table 8).

47

 

 

 

Table 7
vTa - _ -nd. a I‘V : '01- and iaI°‘— - 0 a " a ‘9
ci ort 85 c d ce've Ca d'
Behahilitati2n_Sns2ess_1EQB§1_Totnl_and_§uhssales (N = 461
Scale H fin Range
P88 2.9 .53 3.7 - 1.6
PCRS 2.8 .57 3.6 - 1.6
Diet 2.9 .64 4.0 - 1.4
Med 2.9 .95 4.0 - 0.0
Phys 2.6 .74 3.7 - 0.9
Risk 2.7 .97 4.0 - 0.0
Life 2.9 .57 4.0 - 1.7

 

NQLQE Subscales represent components of cardiac
rehabilitation. Diet = diet management, Med = medication
management, Phys = physical activity, Risk = risk factor
modification, and Life = life style changes.

 

Table 8

gorzeiation Ceeffiicients between PCRS Iota; and Supecelee
end PSS Intel (n = 5g)

 

Correlation Coefficients

 

PCRS Diet Med Phys Life Risk
P88 .53*** .47*** .24 .48*** .43** .46***

 

*9 < .05. **p < .01. ***p < .001.

 

es arch u . s ssociat o t
woman's age and negceived cardiac rehabilitation succees?
The second research question was developed to
investigate the association between age and perceived
cardiac rehabilitation success (PCRS) and subscales. Five
cohorts were used to measure the variable age. The means on
the total PCRS and subscale scores were in the 2.3 to 3.1

range, indicating moderate to moderately high perceived

48
cardiac rehabilitation success (see Table 9). Variability
within and between the groups was examined for significance
(see Table 10). There were no significant differences in
mean cardiac rehabilitation success scores by cohort.
However, for the PCRS total and subscales, the means of each
cohort generally decreased with age, which was in the
expected direction. Perceptions of cardiac rehabilitation
success, for this sample of women, were generally not as

strong in the older as they were in the younger cohorts.

 

 

 

 

Table 9
ns t 'ons and es s e
'-Ic-' -: - die §‘!i!I,. 1 ion _ -ss . i, i!’ b:caI-:
We
Cohort No . M. SD Range
PCRS Total
40-49 4 3.09 0.76 1.97 3.64
50-59 9 2.87 0.70 1.85 ' 3.64
60-69 17 2.81 0.56 1.58 3.52
70-79 10 2.60 0.47 1.90 3.39
80-89 6 2.63 0.56 1.72 3.21
Diet management
40-49 4 3.40 0.16 3.20 3.60
50-59 9 3.11 0.72 2.00 4.00
60-69 17 2.87 0.69 1.40 4.00
70-79 10 2.78 0.58 1.80 3.60
80-89 6 2.87 0.70 1.80 -3.80
Medication management
40-49 4 3.00 1.50 0.83 4.00
50-59 9 2.81 0.88 1.66 4.00
60-69 17 3 . 18 0. 83 1. 50 4 . 00
70-79 10 2.58 1.13 0.00 4.00
80-89 6 2.72 0.74 1.83 3.83

 

49

Table 9 (cont’d)

 

 

 

 

 

 

 

 

Cohort No . M SD Range
Physical activity
40-49 4 3.21 0.72 2.15 - 3.69
50-59 9 2.81 0.72 1.62 - 3.69
60-69 17 2.59 0.74 0.92 - 3.77
70-79 10 2.33 0.59 1.31 - 3.31
80-89 6 2.28 0.85 1.00 - 3.38
Life style changes
40-49 4 3.96 0.63 2.17 - 3.67
50-59 9 2.80 0.83 1.67 - 3.83
60-69 17 2.91 0.60 1.67 - 4.00
70-79 10 2.92 0.36 2.17 - 3.33
80-89 6 2.92 0.43 2.50 - 3.67
Risk factor modification
40-40 4 2.75 1.19 1.00 - 3.50
50-59 9 2.94 0.92 1.50 - 4.00
60-69 17 2.72 1.03 0.00 - 4.00
70-79 10 2.60 0.61 2.00 - 3.50
80-89 6 2.50 1.41 0.00 - 4.00
Table 10
s of c e’ved Ca d'ac e a ’t t
Su cess To C S d Subsca s b Co ts
Source 9: M Square 2
Between Groups 4
PCRS 0.23 0.70
Diet Management 0.37 0.88
Medication 0.65 0.69
Physical Activity 0.81 1.57
Life Style 0.03 0.08
Risk Factor Modification 0.22 0.22
Within Groups 41
PCSR 0.33
Diet Management 0.42
Medication 0.93
Physical Activity 0.52
Life Style 0.36
Risk Factor Management 1.00

 

The third research question was developed to
investigate the association between age and perceived social
support. Like the second question, the variable age was
measured using cohorts. The means of the PSS scores were in
the 2.8 to 3.2 range indicating moderately high perceived
social support in all cohorts (see Table 11). The variance
within and between groups related to perceived social
support was tested for significance (see Table 12).

There were no significant differences in perceived
social support by age cohorts. However, similar to the
second research question, the means of each group generally

decreased with age, which was in the expected direction.

 

 

Table 11
Meens end Standeng Qeyietions of Scores on Perceived Sociel
c b 0
P88 Cohort No . M SD Range
40-49 4 3.17 0.36 2.81 - 3.67
50-59 9 3.04 0.69 1.62 - 3.71
60-69 17 2.87 0.59 1.71 - 3.71
70-79 10 2.76 0.38 2.33 - 3.43
80-89 6 2.79 0.38 2.14 - 3.19
Total 46 2.90 0.51 1.70 - 3.70

 

51

 

 

 

Table 12

Li'- 3 I ' ‘1 ,-! ’ 0 " ’, ’0. ,' I- “99' 3 '!°

Source e; M Square E

Between Groups 4 0.65 0.63

Within Groups 41 0.29

Total 45

{‘3‘: !.-‘3 'l‘ ' .!’-_ ‘4 ‘1 11'. l 1'. '.'.-.!!‘
'flt!,: '0' 1!! 9‘ ‘I '2 :OCI: :-99- ‘ 1 ‘2 -

peggeived eezgiec [enaniiigeeion eucceee?

The last research question was to determine the
relationship between age and perceived social support to
perceived cardiac rehabilitation success. Multiple linear
regression was used to determine the predictor value of the
independent variables, perceived social support and age, on
the criterion variable perceived cardiac rehabilitation
success. The results of the test indicated an R Square of
.30, meaning 30% of the variability in women's perceived
cardiac rehabilitation success scores can be explained by
their perceived social support and their age. Regression
weights by stepwise multiple regression were PSS = .55 and
age = - .01. The significant regression weight of PSS
indicate it was the best and only predictor of the two

variables under consideration (see Table 13).

52

 

Table 13
Q _ 0 Q- c e e ‘ e e ‘ eee e e
v c 't cc
Multiple R 0.54
R Square 0.30
Adjusted R Square 0.26
Standard Error 0.49

Analysis of Variance

 

 

 

 

 

df Sum of Squares Mean Square

Regression 2 4.305 2.148

Residual 43 10.245 .238

E = 9.02 Significance F = 0.0005

Variables b SE B 95% Confdnce Intrvl Beta
Age -0.01 0.01 -0.02 - 0.01 -0.12
PSS 0.55 0.14 0.27 - 0.83 0.51

Discussion

In this section the results of the analysis are
discussed for the sample and research questions in relation
to the conceptual framework and literature review.
mills

In this study, specific demographics related to social
support and self-reported risk factors for heartdisease and
chronic illness were evaluated to identify differences
between cohorts. Variables that gave a picture of the
women's support system included marital status, living
arrangements, who they asked for personal help, who they
asked for emotional support, and what community resources

they used.

53

Friedman (1993) and Primomo et al. (1990) identified
family, especially spouses as the most important providers
of tangible and emotional support during recovery from
chronic illness. Likewise, in this study, spouses and close
family members (daughters and daughters-in-law) were
reported as the people most often asked for support.

Similar to other studies, more younger women were married
than older, and more older women were widowed than younger
and therefore lacked spousal support for recovery.

Thompson and Heller (1990) studied the importance of
network embeddedness and perceptions of social support in
older women. They found that physical and mental well being
were significantly related to size of the network and
perceptions of social support. As in the Friedman and
Primomo et al. studies, family was identified as the most
important provider of social support. Moser (1994)
indicated that social support is positively correlated with
successful recovery, also that patients with social support
deficits are at risk for continuing cardiac problems and
decreased physical and mental well-being. In this study,
most women reported having a family member from whom they
could request assistance with personal care and emotional
support.

Ades et al. (1992) identified that women may not be
recommended by their physicians for formal rehabilitation
programs because of their age. Additionally,.both women and

physicians identified chronic health problems as limitations

54
to participation in rehabilitation. In this study, women
were asked to list their chronic health problems. Although
some women reported no chronic health problems; arthritis,
hypertension, and diabetes mellitus were reported most
frequently. These chronic health problems, especially
arthritis, are similar to those reported in the Ades et al.
study as one of the reasons women do not participate in
rehabilitation exercise programs. Women were asked to list
their first and second risk factor for heart disease.
Stress was the most frequently reported risk factor in all
cohorts. One woman in the study listed "my age" as a risk
factor.

Investigation of differences between cohorts in this
study showed that there were significant differences in
marital status and a trend toward significant differences in
self-reported risk factors for heart disease with increasing
age. Otherwise there were no significant differences. This
may be related to small sample size. Additionally, this
sample of women were similar in so many ways (education,
race, community, and living arrangements) that age
differences except with the youngest and oldest groups may
have been negated. Cohorts may not have been defined
appropriately. Ten year age intervals for cohort groups may
not span enough time to identify social-historical
differences. Similarities in the cohort groups, may explain

why there were few significant differences in this study.

55

The conceptual framework for this study, ”Women's Self-
Definition in Adulthood Model" (Peck, 1986), provided a
flexible structure for investigation of an issue important
to women. A flexible structure is suitable because it
represents the multiple roles, responsibilities, and
relationships of women's lives. For this study it provided
a framework to discuss the association of the variables age,
perceived social support, and perceived cardiac
rehabilitation success.

Endings

geeeaneh Questien i, 1e tnere an eesociation betneen e

nonan's nerceived soeiai support and nezeeived eagdiae
't ' c ?

The significant linear relationship between perceived
social support and perceived cardiac rehabilitation success
is supported both in the literature and by the conceptual
framework. Most literature on the subject of social support
and recovery from illness, identified that a strong social
support system enhances recovery, whereas lack of support
increases rates of mortality and morbidity. In this study
the sample had moderately high perceptions of their social
support (M = 2.9, fig .53) and cardiac rehabilitation success
(M = 2.8, fig .57). Possible scores on both scales ranged
from a high score of ”4" to a low score of ”0". Higher
scores in this study were given to answers of "most of the
time/excellent" and "usually/pretty good", moderate scores

given to "occasionally/fair" low scores to "seldom/poorly",

56
and "not at all". Moderately high total perceived cardiac
rehabilitation success scores of the women in this study may
be explained by their education level, occupational skills,
financial status, and perceptions of social support. These
factors may be related to good problem solving skills and
motivation to make the recommended changes for
rehabilitation success. Moderately high means were also
obtained for the subscales, identified as components of
cardiac rehabilitation; diet management, medication
management, physical activity, risk modification, and life
style changes. These scores may be explained by the same
reasons as the cardiac rehabilitation success score;
moderately high perceptions of social support, problem
solving skills and motivation.

The moderately high means on perceived social support
may be explained by the numbers of women who have spouses
and family support, as well as their responses related to
requests for social support. Also, the attention that women
received as part of a study can not be negated when
considering their perceptions of social support.

The linear relationships between PCRS total and.
subscales and P88 were statistically significant with the
. exception of medication management scores. This may be
explained statistically by the internal consistency of the
medication management scale. When compared to the other
subscales, the Cronbach's alpha was lower for medication

management than that of the other subscales. Another

57
possible explanation may be that the women did not see
medication management as a task requiring social support.

The direction and magnitude of the linear relationship
between perceived social support and perceived
rehabilitation success may be described as a moderate
positive correlation. A correlation of .53 means that 25%
of the variability of the variables can be explained by
knowing something about the other. For variables of a
psychosocial nature a correlation of .70 is considered quite
high. Correlations of .10 to .40 are more typical of
psychosocial variables (Polit & Hungler, 1991). Therefore a
correlation of .53 is within a range that may be considered
acceptable when explaining one variable in relationship to
the other.

The model explains the relationship between social
support and cardiac rehabilitation success by interaction
between the sphere of influence (perceived social support)
and self-definition which includes the achievement of
perceived cardiac rehabilitation success. With the support
of her significant relationships the woman can continue to
grow and feel confident in her ability to recover from a
myocardial infarction.

e ea es 0 s t e a e t ons b
'ial’: ..e a . .- e v-o ca 2 ac eras? tit’o :- :::

There were no significant differences between the five

cohorts on perceived cardiac rehabilitation success for

total and subscales. The means for each scale did, however,

58
generally decrease with increased age. The younger women
having higher cardiac rehabilitation success scores than the
older women.

Literature on the subject of women, age and cardiac
rehabilitation is limited. Ades et al. (1992) identified
that older women are not recommended for cardiac
rehabilitation programs by their physicians because of their
age. Older women may be subjected to ageism and therefore
it seemed important to identify differences between age
groups so that interventions related to cardiac
rehabilitation could be age appropriate.

In this study no statistical differences were found
between cohorts. This result could be related to several
factors; small sample size, sampling methods, small cohorts
of women with similar lifestyles grouped by ten year age
spans, and lack of specific age related questions.

The flexible outer wall of the conceptual model
identifies the importance of socio-historical time for
women. As women move through time, the social, political,
and cultural climate will have an effect on the
opportunities for women in all aspects of their lives.
Perhaps because the all of the women in this study were
affected by heart disease at the same point in time, their
individual ages may not have been as significant in their
perceptions of rehabilitation as the cardiac event itself

and resulting treatments.

59

There were no significant differences between age
cohorts on the variable perceived social support, although
the means for the PSS scale did generally decrease as age
increased, meaning the younger women had higher perceived
social support scores than did the older women. All the
women in this study regardless of age identified some source
of social support and had moderately high perceptions of
their social support systems.

Thompson and Heller (1990) identified the importance of
perceived social support for psychological well-being and
functional health in a group of older women. The cohort
groups in this study all had moderately high scores on
perceived social support regardless of age and significant
differences were therefore not identified. It may be that
in this small homogenous group of women, with ages that
spanned forty years, that there were no true differences.

In a larger more randomly selected group perhaps differences
would be identified.

The conceptual framework for this study identifies the
importance of relationships for women. Therefore it seems
important to continue investigating the association of age
and social support. It may be, that as women age and their
social support system dwindles, that the remaining
relationships become even more important. This continuing

loss of relationships and social support may affect the

60
women's self-definition, which is where rehabilitation
success is found. Lack or loss of support may affect
rehabilitation efforts.

0
;es-- 1 0U‘- or ' 0 .9: a. ‘1 are 1 We: narr‘ : e

For this last question, the variables social support
and age were evaluated for their predictor value for
perceived rehabilitation success. The results were
statistically significant (n < .05) indicating that 30% of
the variance in perceived cardiac rehabilitation success can
be explained by perceived social support which was the one
significant predictor that supports the zero order
investigation of relationships of earlier questions and
confirms that age in this study even when using
chronological age does not help to explain variability in
rehabilitation success. Again, the homogenous sample may
better explain this result. This study adds to the body of
research on the importance 0f social support systems for
positive health outcomes. Both Fleury 1993) and Budd (1991)
found that social support was a significant variable in
cardiac rehabilitation success.

Age, however, did not add to the predictor value of
perceived cardiac rehabilitation success. The concept of
age related differences in evaluating health outcomes is not

statistically supported in this research although concept of

61
age and health care still seems conceptually important and
warrants further evaluation.
Implications

Implications for the Advanced Practice Nurse (APN) in
primary care are explored in the following section.

The finding of statistical significance in this study
was the positive correlation between perceived social
support and perceived cardiac rehabilitation success. The
findings that did not reach statistical significance, but
generally had results in the direction expected, were the
association of perceived cardiac rehabilitation success and
perceived social support with women's age. Keeping both of
these results in mind, the APN can use this information in a
number of different ways to improve outcomes for women
recovering from a myocardial infarction.

In clinical practice, the APN may see women who have
had a myocardial infarction. The women may be at any stage
in their recovery from the MI. Women may seek emergency
care or be hospitalized for cardiac events without knowledge
of their primary care provider, and may or may not be
enrolled in a cardiac rehabilitation program. The APN in
primary care has the opportunity to establish communication
with patients that will facilitate access to appropriate
post MI care by advising patients to notify their primary
care provider of hospitalizations or emergency care within
48 to 72 hours of admission and again at discharge, and

having an office protocol that flags these calls for follow-

62
up and possible case management. This information aids in
initiating treatments such as cardiac rehabilitation if
appropriate and not already ordered. Patients must be asked
if they have been referred for cardiac rehabilitation. If
not the APN may prescribe a rehabilitation program.

Establishing a rapport with patients encourages
communication and continuity of care. Ongoing assessment of
the patient's social support system is critical in
predicting recovery from any health problem including heart
disease. This study has identified that there is a
relationship between perceived social support and perceived
cardiac rehabilitation success. The perceived social
support scale could be used as a way of measuring the
woman’s perceptions of social support specific to cardiac
rehabilitation or may be modified as needed.

Some women may not have a support system that can meet
their needs. In this study assistance with personal care
was most frequently requested from daughters and daughters-
in-law (41.3%). Spouses (30.4%) were the next source most
frequently asked for assistance with personal care. Women
who are widows, who have no children (especially daughters
or daughters-in-law), or have children who live far away may
have difficulty finding ways to get help with personal care.
Women requested emotional support from several categories,
most frequent being daughters and daughters-in-law, other
sources of emotional support included spouses, friends,

clergy, siblings, parents, and visiting nurses. In addition

63
to personal care and emotional needs during recovery women
may need to request assistance with transportation for
grocery shopping, driving to appointments, and other
errands. They may also need to request financial assistance
for hospital and doctor bills, food, and medications.
These personal, emotional, and tangible needs may need to be
filled by community services. Continuing assessment would
help to identify women who have social support deficits so
the APN can intervene quickly if necessary. Assessment
includes identifying women who have social support deficits
because they have difficulty asking for help because they do
not like to bother others, do not want to be obligated to
others, or because no one has offered help.

During routine patient visits the APN has the
opportunity to education women regarding their risk factors
for coronary artery disease. This study identified that
women may not be able to correctly identify their risk
factors for heart disease. The literature indicates that
many women still believe that heart disease is not a major
health problem for women. Individual counseling in the
office and group programs for women's groups in churches,
senior centers, and the workplace are strategies the APN can
use inform women about heart disease.

I A supportive-educative telephone program similar to one
described by Beckie (1989) for post bypass patients is
another potential intervention to promote "positive,

potentially health promoting or stress-buffering" (House at

 

64
al., 1988, p. 294) supportive relationships. The Beckie
study demonstrated that an APN with a solid foundation in
the principles of teaching and learning for the adult
patient, knowledge and skills in dealing with the questions,
concerns and problems of patients after bypass surgery had
an important impact on the knowledge and anxiety of post
bypass patients. A similar program for women recovering
from an MI may help increase their perceptions of support
from health care providers during recovery, as well as
reinforcing the principles of rehabilitation. Women who are
recovering from a cardiac event may find this intervention
an important source of advice and encouragement. One of the
items on the PSS asks, "Have you sought answers to your
questions that have come up since discharge, from health
professions (i.e., doctor, nurse, rehab team etc.)?”
Moderately high scores on this item (M = 3.2, SD = 1.2)
indicated that women seek support from their health care
providers. Adaptation of the supportive-educative telephone
program is a way of providing easily accessible support from
health care providers for women recovering from a cardiac
event.

Part of the role of the APN is to help women understand
the etiology of their MI and the rationale for making
changes to reduce the risk of another MI. In this role as
educator/counselor the APN becomes part of the woman's
support system. The APN may work with women individually or

in groups depending on the needs of the women. Because of

 

65
the importance of relationships in women's lives, many women
like support groups. Important topics to be addressed in
groups include, expression of fears and concerns, the normal
psychological feelings of anxiety, depression, and guilt
that women experience after a MI, the importance of cardiac
rehabilitation regardless of age, resumption of sexual
activity, role changes and how they affect spouses and
families, how to negotiate and accept help from families,
friends and community support systems, distinguishing
between high energy housework activities and health
cardiovascular actives. Additionally the APN may develop
support groups for husbands, significant others, and
families of women heart patients, who may need guidance in
ways to support the woman through her cardiac
rehabilitation. Spouses and families need to know how
important their encouragement and support is for women's
successful rehabilitation.

In the case manager/patient advocate role the APN may
work in collaboration with other health care providers and
community services to assist the woman in her recovery.
Specific interventions based on this study would target
enhancing social support systems. Health care providers may
include the cardiologist, primary care physician, visiting
nurses, nurses aides, cardiac rehabilitation staff, and
discharge planners. Frequent communication with other
health care professionals involved with the patient's care

promotes continuity of care for the patient by reducing

66
replication of some activities and omission of others. The
APN in collaboration with discharge planning may prescribe
services in addition to the usual visiting nurses and
"Meals-on-Wheels", such as senior visitors, financial
counseling, legal aid, and specialty transportation.
Evaluation of all cardiac rehabilitation programs in the
community is essential to understanding where change is
needed. Multidisciplinary groups can be developed to
investigate the needs of women recovering from heart disease
and then compare the results to existing programs.

Community services such as support groups, Visiting
Nurses, special transportation, "Meals-on-Wheels", and
church groups may be needed to supplement the woman's social
support system. A working knowledge of these various
community resources may increase the APN's ability to "sell"
these services to women who appear unlikely at this time to
use them. In this study 67.4% of the women indicated that
they had never used community services as a source of
support. Women who have always cared for others may have
difficulty accepting assistance from others. Women may also
be embarrassed because they feel guilty for having had a
heart attack. Cohorts of older women may believe care
should be provided only by family, regardless of families
ability or willingness to do so. Helping women accept
community assistance may involve leading support groups,
attending and evaluating others, and volunteer work when

apprOpriate.

 

67

Inservices for staff at hospitals, community nursing
homes, extended care facilities, and visiting nurses are
important for disseminating current findings on the needs of
women recovering from a MI. Discussion about how to
evaluate support systems and actions to take based on those
evaluations is a topic appropriate in all levels of patient
care. In this study, 15.2% of the sample used visiting
nurse services, but only 6.5% reported asking for support in
terms of personal care and 2.2% in terms of emotional
support from the visiting nurse. These statistics indicate
that these women did not see Visiting Nurses as someone from
whom they would request personal or emotional support.
Although this may be surprising to a profession who prides
itself on caring, it is consistent with perceptions of
family care as most contributory to feelings well being and
satisfaction, but it does leave the door open to further
investigate the implications for nursing.

As a guest speaker for classes of nursing and medical
students, the APN can increase their awareness of the
special needs of women in cardiac rehabilitation. Programs
can be presented to physician groups to encourage them to
recommend cardiac rehabilitation to women. As indicated by
Ades et al. (1992) the strength of physician recommendation
was the most powerful predictor of patient's participation
in rehabilitation programs and physicians recommended
participation more strongly to older men than to older

women .

68

As a consultant the APN may review managed care systems
for evidence of appropriate treatments based on theory,
research and clinical knowledge of women's developmental
needs when recovering from an MI. Knowledge of stereotypes
related to age in the health care profession and general
public is essential to implement change in healthcare
policy. Change although necessary, is not always easy. In
the role as change agent/consultant, the APN may choose to
review charts to see if women are referred for cardiac
rehabilitation the same as men. More funding may be
requested for support services for women recovering from
myocardial infarctions to enable their ability to
participate in cardiac rehabilitation either in their homes
or in a formal program. Hopefully, the APN can help shift
the focus from rehabilitation programs developed for males,
to those that meet the needs of women too.

In this study all of the women indicated moderately
high to moderate levels of perceived social support and
cardiac rehabilitation success regardless of age. The
statistically significant correlation between social support
and cardiac rehabilitation success indicates the importance
of social support assessment and referral to cardiac
rehabilitation programs for all women. Although increased
chronologic age was not a significant factor in women's
perceptions of social support or cardiac rehabilitation
success, the results indicated that as age increased,

perceptions of social support and cardiac rehabilitation

 

69
success decreased. Therefor it seems important for the APN
to be cognizant of the potential effects of aging for women,
and their perceptions of social support and ability to
recover from illness.
WWW:

Based on this results of this study further
investigation of age, social support, and cardiac
rehabilitation related to women is recommended. Sample size
should be increased and composition (race, culture, economic
and educational level) should be more representative of all
women with heart disease.

Age, described as a biopsychosocial concept and
operationalized by chronolgic age and age cohorts did not
have a statistically significant association with social
support and cardiac rehabilitation success. The results
were however, in the expected direction, as age increased
perceptions of social support and cardiac rehabilitation
success decreased. Suggestions for future research using
this variable include a larger sample size and a greater age
range in each cohort. The age span of this sample (40 - 87
years) is a reasonable representation of the age when women
develop heart disease. Within this age span women could be
divided into cohorts by menopausal status. These three
cohorts, pre, peri, and post menopause would be symbolic
of the changes women go through biologically,
sociologically, and psychologically associated with

menopause which may generally be related to chronologic age.

70
Additionally the demographic data questionnaire could be
expanded to include questions about how women feel about
aging and its influence on their rehabilitation.

Perceived social support was significantly related to
women's perceptions of cardiac rehabilitation success.
Future studies should investigate the availability of formal
and informal social support systems for women with heart
disease. If informal (family support) is not an option for
women, then ways of supplementing social support with
community or formal sources needs to be investigated. The
results of this study indicated that women do not frequently
use community resources. Questions concerning barriers to
use of these services may include psychological, financial,
physical, and social components.

Cardiac rehabilitation, the third variable in this
study, has been identified in other research as an important
part of recovery from a coronary event. In this study women
had moderate to moderately high scores on cardiac
rehabilitation success subscales. Questions that describe
and measure women's response to the components of
rehabilitation will help increase understanding of how to
best develop rehabilitation programs for women and the
efficacy of rehabilitation for older women.

Generalizations of conclusions from this study is
limited related to sample size and diversity. Further
research is needed to focus on strategies to evaluate

subjective and objective affects of aging for women, improve

71
evaluation of support systems, supplement deficits in social
networks, and structure cardiac rehabilitation programs
specific to the needs of women of all ages.
E Summary

Cardiac rehabilitation is an important treatment
component for the person recovering from a cardiac event.
Current literature and research supports the development of
more client specific programs which lead to more successful
outcomes. I

This study focused on women’s perceptions of social
support and their age as variables that affect cardiac
rehabilitation success. It was found that social support
had a moderate to strong correlation on women's perceptions
of rehabilitation success. The effect of age on perceived
social support and perceived cardiac rehabilitation success,
although not significant was in the expected direction,
which was as age increased perceptions of social support and

rehabilitation success.decreased.

 

 

APPENDICES

APPENDIX A

'1

72

APPENDIX A

QUESTIONNAIRE - PART A

Before we begin, can you tell me a little about what
happened to you (your heart), starting when you first knew
something was wrong? The following questions ask general
things about you. Please answer all of the questions to the
best of your ability.

1. What is your age

2. What is your racial or ethnic background? (check one)

___ White ___ American Indian
____Black ___ Oriental
___ Mexican-American ___ Other (specify)
3. What is your marital status? (please check one)
___ Married ___ Divorced
___ Single, never married ___ Widowed
Separated

4. How many children do you have? (include number and ages)
5. lives in your household, besides yourself? (check
that apply)

No one else

Spouse/significant other

Children: number living at home ,

age range
Other relatives

Ill”
HO

 

 

 

 

Non-related persons

 

6. What is the highest grade you completed in school?
(please check one)

None or some grammar school (less than 7 grades)

Junior high school (9 grades)

Some high school (10 or 11 grades)

Graduated high school

Technical, business or trade school

Some college (less than 4 yrs.)

Graduated college

Postgraduate college or professional degree

10.

11.

12.

13.

73

Were you working at a regular job outside the home for
money prior to your heart attack?

yes, I was working full time, part time.
no, I an unemployed, retired, disabled,
housewife, other (if other,please specify)

 

What is/was your main occupation? Circle the one that
best describes your job: Professional, Technical,
Clerical Supervisory, Laborer, Full-time homemaker,
other (if other, write in the type of work you do or

 

 

did).
F
Is anyone in your household dependent upon you for:
a. Financial support . If yes, who?
(relationship).
b. Personal assistance? . If yes, who?

 

(relationship).
c. Emotional support, guidance, or supervision?
If yes, who? (relationshIp).

 

The following risk factors have been associated with
heart attacks. Please check all those risk factors that
you believe you have, and indicate with a number "1"
which risk you think is your biggest/worst risk factor:

___ High blood pressure ___ Physical inactivity
___ High blood cholesterol Obesity

Cigarette smoking Stress

My age Diabetes

Family history of
heart attacks

Post-menopause

Prior to this heart attack, what type of heart problems,
if any, did you have? Check all that apply. (If none at
all please check and go to 13)

none at all chest pain
previous heart attack heart surgery
congestive heart rheumatic heart disease

failure other
(please describe)

 

How many times have you been hospitalized in the past
year for heart problems?

Do you have any other chronic health problems?

____yes ___ no

If yes, please check if any apply:

___ arthritis ___ cancer
ulcer ___ lung disease
diabetes ___ hypertension

other?

 

14.

74

Do you have any financial worries related to your health
problems or your heart attack? No, Yes (If yes
please specify)

 

15. Who would you most likely ask if you needed help with each

16.

17.

18.

19.

of the following?
a) personal care (bathing, dressing, eating, etc)

 

b) cooking
c) cleaning
d) laundry
e) grocery shopping
f) driving to appointments
9) other errands

 

 

 

 

 

 

Who would you turn to for emotional support and under

standing, such as:

a) reassurance

b) sympathy

c) encouragement

d) assistance in following your prescribed plan (e.g.
medications, diet, activity)

 

 

 

 

Are there any problems or hassles about asking someone to
help you (e.g. perhaps you dislike having to ask others,
or you hate to bother them, or you don't want to be
obligated to anyone, or no one has offered)?

 

 

 

Have you ever used any community health services?
(If yes, which one?)
Were you satisfied with the service?

 

Please select the statement that most closely represents
how your body feels physically today. Select only one
response from the following four.

__Ordinary physical activity does not cause me any chest
pain or pressure, or shortness of breath or fatigue.
I am yezy comfortable at rest. If I get up and walk
around the hall I soon become tired, or short of
breath or feel chest pain or pressure.

I am comfortable gniy at rest. If I get up and walk a
short distance (such as walking to the bathroom) I
become yeny tired, or yeny short of breath or feel
chest pain or pressure.

Even at rest I usually feel some discomfort such as
chest pressure or pain, or short of breath or I feel
tired all the time.

 

20.

75

Regardless of what you have been told about your
activity level, what activity and restrictions do yen
believe should be prescribed for you? Select only ene
response from the following:

There should be no limitation on my ordinary
physical activity.

There should be only slight limitation on my
ordinary physical activity.

There should be moderate limitation on my ordinary
physical activity.

There should be extreme limitation on my ordinary
physical activity.

 

APPENDIX B

 

76

APPENDIX B

CRITERIA FOR REHABILITATION SUCCESS:
Post-discharge Telephone Interview - Part D

The questions you will be asked have to do with how you have
been able to manage during your rehabilitation at home and
what this experience ha been like for you There are no right
or wrong answers and there may be questions you prefer not
to answer. If you're ready, we'll begin.

0 = not at all

1 = seldom/poorly

2 - occasionally/fair

3 - usually/pretty good

NA = not applicable
ON VI 8 0

To what extent have you been able to manage in the following
areas, now that you've been home for a few weeks?

. ' t a e
TO WHAT EXTENT ARE YOU ABLE TO:
1. State the guidelines for your recommended 0 1 2 3 4 NA

diet (states low fat, low chol., low
calorie, no added salt) diet?

2. Stay on your healthy heart diet 0 1 2 3 4 NA
when eating at home?

3. Maintain your desired weight or 0 1 2 3 4 NA
lose weight, if advised?

4. Select the recommended foods at 0 1 2 3 4 NA
the grocery store?

5. Dine out and stay on your diet? 0 1 2 3 4 NA
(i.e., at a restaurant). _

6. Obtain more information on your diet 0 1 2 3 4 NA
if needed, from community resources
(i.e., hospital or Rehab team dietician)?

7. Get your family to help support your 0 1 2 3 4 NA
efforts to stay on your diet?

8. Go to a party and stay on your diet? 0 1 2 3 4 NA

 

 

77

9. Ask your friends or host/hostess 0 1 2 3 4 NA

to support your diet efforts?

What experience can you share about trying to stay on your
healthy heart diet?

Helpful (i.e. family support, self-determination)?

 

Non-helpful (i.e. family sabotage, cravings, taste,
etc. )?

 

S F- N T O '
Prototype - Medication related to nitroglycerine (NTG)

Have you had chest pain or pre-sure since you’ve been
home? (Y/N)
Have you taken nitroglycerine since you've been home?

(YIN)

If yes, how many times per day __ or times per week

TO WHAT EXTENT

10. Can you state the basic guidelines for 0 1 2 3 4
neking NTG? (identify chest pain or
pressure, time and/or sequence, placement
under tongue, and carrying NTG with her)

11. Can you identify the eeeien of NTG? 0 1 2 3 4
(vasodilates, relaxes arteries, etc.)

12. Can you identify the eige_efifegee of 0 1 2 3 4
NTG? (dizziness, headaches, etc.)

13. Can you manage the side effects of 0 1 2 3 4
NTG (or state how to do so)?
(sit down; take tylenol, etc.)

14. Can you evaluate if NTG is effective 0 1 2 3 4
(relief of chest pain, etc.)

15. Can you identify what to do if NTG is 0 1 2 3 4
nee effective? (call Dr. or E.R.)

16. Can you count on your family or friend 0 1 2 3 4
to give you NTG if you were unable?

17. Can you count on your family or friend 0 1 2 3 4
to recognize if you should need NTG?

Have any family members or friends given you NTG? (Y/N)
If yes, describe circumstances

?

NA

NA

NA

NA

NA

NA

NA

NA

 

 

Have you encountered any problems taking NTG? (Y/N) If

78

yes, please explain

 

PLEASE LIST THE HEART MEDS YOU ARE NOW TAKING AND WHAT EACH
IS FOR:

MED

FOR

 

 

 

 

 

 

 

 

 

 

ANY SIDE EFFECT __

 

 

 

 

IN YOUR EXPERIENCE WITH TAKING MEDICATIONS, WHAT HAS HELPED
you THE MOST? _i
WHAT HAS BEEN THE MOST DIFFICULT?

 

 

 

us iGHL __ 0 ‘2 i .‘ V I i- D .

Please state what guidelines you were given for activity and

exercise at discharge (Subject’s Comments)

‘7

 

 

 

TO WHAT EXTENT:

18.

19.

20.

21.

22.

Have you followed your prescribed
activity level since discharge?
(Subject’s CommentS)

 

Do you monitor your own activity
(i.e. take pulse, note s.o.b.)?

Can you state the symptoms that would
alert you to stop an activity so as
to prevent over stressing your heart
(Ht rate no > 20 bpm higher than

at rest, stop and rest if short of
breath, or feel chest pain, fatigued,
faint, dizzy, or ht palpitations.)

Do you follow the guidelines for safe
activity (i.e. paced activity)?

Have you increased your activity
level since You've been home

79

PLEASE STATE WHICH OF THE FOLLOWING ACTIVITIES YOU NOW DO ON
YOUR OWN
Personal care (bathing, grooming, dressing)?

 

___ Meal preparation for self? ___ For family? ___ Kitchen
clean up? -
'Bedmaking? ___ Bed changing? ___ Dusting? ___ Laundry?

___ Ironing? Scrubbing kitchen/bathroom fixtures and
appliance§?—

___ Vacuuming/mOpping floor? other?

___ Grocery shopping? ___ DriVIfig car? ___ Child/grandchild

care?

Working on a hobby? Volunteer work?

23. Do you engage in cardiac exercises 0 1 2 3 4 NA
If not, why?

 

PLEASE INDICATE WHICH OF THE FOLLOWING EXERCISES YOU ENGAGE
IN NOW:

Walking inside your home? Walking outside around
your home?
Walking less than 1 mile? 1 to 2 miles? more

 

than 2 miles?
Indicate how many times per week you usually walk
Bicycling (stationary or mobile)? How much time or

 

miles ___? and how many times ___ per/week?

___ Swimming? How much time ___ (hr.) and how many
times/wk ?

___ Other exefEIse? ( ) Amount of time? ___
Frequency? _

24. Do you follow the basic guidelines 0 1 2 3 4 NA

for exercise, (warm up, cool down)?

25. Are you exercising more now then 0 1 2 3 4 NA
prior to your hospitalization?
(rate 0 if less, 1=lek, 2=2ka 3=3ka,
4=4ka plus, NA if ordered not to).

T0 WHAT EXTENT:
If you WORK FOR PAY?

26. Have you returned to work, if you 0 1 2 3 4 NA
work. (1=25%, asset, 3=7s%,4=100:)

27. Do you follow the guidelines for work, 0 1 2 3 4 NA
if you work? (i.e. gradually work up
to previous level/time. Comments)

 

If you work for pay but have not yet returned to work, what
plans do you have? ie Return to same job? Change to
new job? Retire? . Have you discussed this
with your Dr.? Indicate type of job planned:

80

 

 

28. Are you able to follow the guidelines 0 1 2 3 4 NA
for sexual activity, if sexually active?

29. Have you negotiated any household 0 1 2 3 4 NA
responsibilities with family/friends?
Explain:

30. Does your family/friends participate 0 1 2 3 4 NA

in your exercise program with you? ~

31. Have you considered attending a Heart 0 1 2 3 4 NA
Rehab class or program?

32. Have you sought answers to your 0 1 2 3 4 NA
questions that have come up since
discharge, from Health Professional
(i.e., Dr., Nurse, Rehab team, etc.)?
Please explain

 

33. Are you pursuing follow-up health care? 0 1 2 3 4 NA
(i.e., have you returned for doctor's
appointment, checked into an exercise
program, know when allowed to drive, etc.)

34. Have you begun to participate in 0 1 2 3 4 NA
family or friend social functions?
(within activity limits?)

 

What has helped you the most in carrying out recommended
activities and exercises? Please explain:

 

 

 

What has been your biggest activity/exercise barrier or
hassle?

 

 

RATE YOUR CURRENT PHYSICAL Activity LEVEL
LOW = 1- -2- -3- -4 8 HIGH

. ISK FACTOR ODIF T
In the hospital, you were asked to identify your risk

factors that are associated with heart disease. Please list
them again.

 

What is your priority risk factor, i.e., the one you are
willing to work on, or feel you should work on?

 

 

81

TO WHAT EXTENT

35. Have you been working on controlling 0 1 2 3 4 NA
your risk factors (effort)?

36. Have you been successful? 0 1 2 3 4 NA

37. Have you made others aware of your 0 1 2 3 4 NA

efforts to modify your risk factors?

38. Have you sought assistance from family/ 0 1 2 3 4 NA
friends to help you control your risk
factors?

39. Have others encouraged you to modify 0 1 2 3 4 NA
your risk factors?

40. Have others given you the kind of 0 1 2 3 4 NA

support you need to reduce your risks?

What has enhanced your efforts to modify your risk factors?

 

What has been the most difficult part in modifying your risk
factors?

 

RATE YOUR PROGRESS IN CONTROLLING YOUR RISK FACTOR:

LOW - 1- -2- -3- -4 = HIGH
e, LIFE-STYLE ne-enJusznenme

TO WHAT EXTENT:

43. Have you been able to deal with the 0 1 2 3 4 NA
changes in your life since your heart
attack? (Subject's Comments)

 

44. Have others in your family helped you in 0 1 2 3 4 NA
the process of dealing with changes? How?
(i.e., emotionally, informationlly, physically)?

45. Have you been satisfied with this 0 1 2 3 4 NA
help or support? Explain.

 

HAS YOUR MAJOR ROLE (homemaker? (spouse? job?
child care? financial manager? other? ) CHANGED?
(Ck Y/N if apply) Subject’s Comments)

46. Have you been able to negotiate or 0 1 2 3 4 NA
ask for support when needed at home?

 

82

47. Have you been able to negotiate or 0 1 2 3 4 NA
ask for support when at work?

DO YOU BELIEVE THAT YOU (OR YOUR MAJOR ROLES) ARE INFLUENCED
BY SOCIAL OR CULTURAL ASPECTS (i.e., Man's work vs. Woman's
work)? Y/N If SO, DO YOU THINK THIS HAS INFLUENCED YOUR
EFFORTS TO DO THE THINGS YOU NEED TO DO FOR YOURSELF FOR
REHABILITATION? Subject's comments:

 

48. Do you utilize spiritual support? 0 1 2 3 4 NA

49. Has your spiritual support been 0 1 2 3 4 NA
helpful during your rehabilitation?

50. Have you started to become socially 0 1 2 3 4 NA
active again (attending community
functions and/or entertaining at home)?

51. Have you been able to keep your 0 1 2 3 4 NA
morale up?

52. Have you been able to successfully 0 1 2 3 4 NA
deal with "STRESS"? Explain type of stress

 

 

53. Have you used stress management 0 1 2 3 4 NA
techniques? If so, helpful?
If not, why?

 

 

54. Do you believe you have enough 0 1 2 3 4 NA
information about your therapy to
make decisions about life-style changes?

 

55. Do you believe you have enough support 0 1 2 3 4 NA
(family, friends, or community) to make
the necessary changes? (Areas lacking)?

 

 

56. Do you believe you are motivated 0 1 2 3 4 NA
to make life style changes?

RATE YOURSELF IN TERMS OF OVERALL SUCCESS 0 1 2 3 4 NA
IN THE REHABILITATION PROCESS

WHAT HAVE BEEN THE MAJOR BARRIERS TO REHABILITATION?

 

WHAT HAS BEEN THE GREATEST HELP TO YOU IN THE REHABILITATION
PROCESS?

 

DO YOU THINK MEN OR WOMEN HAVE A MORE DIFFICULT TIME AFTER A
HEART ATTACK? Why?

 

 

83

WHAT ADVICE WOULD YOU GIVE OTHER WOMEN WHO HAVE HAD A HEART
ATTACK?

 

WHAT ADVICE WOULD YOU GIVE CARDIAC REHAB NURSES AND
EDUCATORS?

 

HOW MANY HOURS DID YOU WAIT BEFORE YOU CAME TO THE HOSPITAL?

 

 

 

 

APPENDIX C

84

APPENDIX C

2erceixed_fiocial_§upport_was measured using 21 items
extracted from the Behabilitation_§ncses§_ficale. to create a

subscale related to social support.

Items:

6. Obtain more information on your diet in needed, from
community resources (i.e., hospital or Rehab team
dietician)? .

7. Get your family to help support your efforts to stay on
your diet?

9. Ask your friends or host/hostess to support your diet
efforts?

16. Can you count on your family of friend to give you NTG
if you are unable?

17. Can you count on your family or friend to recognize if
you should need NTG?

29. Have you negotiated any household reSponsibilities with
family/friends?

30. Does your family/friend participate in your exercise
program with you?

32. Have you sought answers to your questions that have
come up since discharge, from Health Professionals
(i.e., Dr., Nurse, Rehab team, etc.)?

34. Have you begun to participate in family or friend

social functions?

 

37.

38.

39.

40.

44.

45.

46.

47.

48.

49.

50.

55.

85

Have you made others aware of your efforts to modify
your risk factors?

Have you sought assistance from family/friends to help
you control your risk factors?

Have others encouraged you to modify your risk factors?
Have others given you the kind of support you need to
reduce your risks?

Have others in your family helped you in the process of
dealing with changes?
Have you been satisfied with this help or support?

Have you been able to negotiate or ask for support when
needed at home? I

Have you been able to negotiate or ask for support when
at work?

Do you utilize spiritual support?

Has your spiritual support been helpful during your
rehabilitation?
Have you started to become socially active again
(attending community functions and/or entertaining at
home)?

Do you believe you have enough support (family,

friends, or community) to make the necessary changes?

 

 

 

 

 

it:

APPENDIX D

 

86

APPENDIX D

MICHIGAN STATE
U N I v E R s I T Y

October 23, 1995

 

TO: Kristin L. Forester
2542 Sundance Lane
Okemos, MI 48864-5210

RE: IRBW: 95-536
TITLE: THE RELATIONSHIP OF AGE AND PERCEIVED SOCIAL
SUPPORT TO PERCEIVED CARDIAC REHABILITATION
SUCCESS OF WOMEN
REVISION REQUESTED: N/A
CATEGORY: Z-H
APPROVAL DATE: 10/20/95

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this pro3ect 13 complete.. I am pleased to adv15e that the
rights and welfare of the human subjects appear to be adequately

protected and methods to obtain informed consent are appropriate.
gerefore, the UCRIHS approved this pro3ect and any reVIsion listed

a ove.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a prOJect beyond one year must use the green renewal
form (enclosed with t e or1gInal agproval letter or when a
pro3ect is renewed) to seek u date cert1ficat1on. There is a
maXImum of four such expedite renewals ssible. Investigators
wishing to contInue a progect beyond the time need to submit it
again or complete rev1ew.

REVISIONS: UCRIHS must review eny changes in Brocedures involving human
subjects, rior to 1n1t1at1on of t e change. If this is done at
the time o renewal, please use the green renewal_form. To
rev15e an approved protocol at any o her time during the year,
send your wr1tten request to the. CRIHS Chair, requesting revised
approval and referenCIng the prOJect's IRB # and title. Include
In our request a description of the change and any revised
Ins ruments, consent forms or advert1sements that are applicable.

 

meEm:

PRODLIMS/ , , , .
RESEARCH CHANGES: Should either of the follow1n arise during the course of the
AND work. investigators must not1 UCRIHS promptly: (1) roblems
(unexpected side effects, comp aints, e c )_1nvo1ving uman
GRADU‘JE subjects or (2) changes In the research env1ronment or new
information indicating greater risk to the human sub'ects than
STUDIES ex13ted when the protocol was prev10usly rev1ewed an approved.
Ibhmflhtammflmnm

Winkle. If we can be of any future hel , lease do not hesitate to contact us
mm at (517)355-2180 or FAX (517)4 2- 171.

. Lia

avid E. Wright, Ph.D
UCRIHS Chair

DEW : bed
cc: Rachel F. Schiffman

Michigan State Unmiiy S into re 1y ,
ZRAemmwamnamm
hfiUmwaMfimm
“Bfi4M6

flUESMKl
FAXLS17/432-1171

 
  
  

nanpmflmMWHnw
095mmmeammm
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MWsanflmmeaun
WWW

 

 

 

 

87

MICHIGAN STATE UNIVERSITY

 

mmwmalmm MW‘MAN'WIIII

HUKAN SUBJECTS m
I“ m HAD.
(5!” 335-97”

July l0. l990 meat 89-322

Suzanne P. Budd
2I5 Mark Street
Mason. Ml 48854

Dear Ms. Budd:

RE: 'POST-MYOCARDIO INFARCTION WOMEN: FACTORS INFLUENCING
REHABILITATION IRB# 89-322'

UCRIHS'reviewofmeabovereferenoedprojecthasnowbeenoompleted. lampleased
madvisematmenghtsammeofmehumansubleasappea'mbeadequately
protectedandmeCommittee,merefore.apr0VedthisprojeaatitsmeeflngonJulys.
l990.

You are reminded that UCRIHS approval is valid for one calendar year. If you plan to
mnfinueWsproledbeymdmeyempbasemakeproWsionsbrobmirfingappmpnate
UCRll-ls approval one month prior to July 9, l99l.

Any changes in procedures Involving human subjects must be reviewed bythe UCRIHS

priortoinitlatlonoftl'leohange. UCRIHSnmstalsobenotifiedpromptlyofanyproblems
(mexpeaedsweeflects,mmplahts.em.)hvdvhghwnmsubledsdunngmmurseol
thework.

Thankyoulorbrhghgflisproleotloouatterfion. Ifweoarlbeolanymehelp,
pleasedonothesitatetoletuskmw.

Sincerely.

l
Igfijé? lewd ,.

Kenneth 0. Marvin, Jr.
Acting Co-Chalr, UCRIHS

KOM/sar

 

cc: 8. Yelon

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88

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