Empowered to gain a new foothold in life—A study of the meaning of participating in cardiac rehabilitation to patients afflicted by a minor heart attack

Figures & data

Figure 1.  Pathway in the standard treatment for patients with UAP or NSTEMI in Denmark.

The heart symbolizes a journey which the patients experience according to the findings of this study. The pathway is structured as a flowchart according to the guidelines from the National Heart Plan (Sundhedsstyrelsen, 2013). When CHD is suspected, acute admission to the hospital is initiated as the administration of medicine and a search for a diagnosis is started. Within 72 h after the onset of symptoms, the coronary arteries are examined by percutaneous coronary interventions (PCI), and angioplasty or stenting are performed if relevant and possible. Discharge from hospital often occurs 1–3 days after the invasive procedure. Subsequently, outpatient cardiac rehabilitation (CR) for approximately 12 weeks is offered at the hospital. In Region Zealand (where this project took place), CR consists of exercise-based cardiac rehabilitation (ECR) offered as a physiotherapist-guided joint physical training (8 weeks); individual consultations with doctors, nurses, physiotherapists and/or dieticians (based on individual needs); and a group-based psychosocial education session (a 1-day session of 6½ h). Produced by the primary author©.

Table I Demographic data of the participants.

Participant	P1	P2	P3	P4	P5	P6	P7	P8	P9	P10	P11
Participated in	FN1	FN1	FN2/FG1	FN2/FG1	FN2/FG1	FN2/FG1	FN2/FG1	FN3/FG2	FN3/FG2	FN3/FG2	FN3/FG2
Sex	♂	♂	♀	♂	♂	♂	♀	♂	♂	♂	♂
Married/cohabiting	+	+	+	+	−	+	+	+	+	+	+
Age	64	62	62	74	63	64	66	63	63	87	59
Diagnosis	NSTEMI	NSTEMI	UAP	NSTEMI	NSTEMI	NSTEMI	NSTEMI	NSTEMI	NSTEMI	UAP	UAP
Known CHD, month	1	2	5	1	1	2	2	1	14	1	8
Job status	R	SL	W	R	SL	PSL	R	PSL	SL	R	R

The patients who enrolled in the study were assigned codes, such as P1, P2, P3, up to P11. The table shows the demographic data of the patients and the field notes (FN) and focus group interviews (FG) in which they participated. All of the patients participated in individual interviews (I). Their job status is presented according to the following: retired (R), sick-listed (SL), partly sick-listed (PSL) or working (W). Produced by the primary author©.

Table II The set-up for the group-based cardiac rehabilitation.

Ten to fifteen patients with various ischemic diagnoses were enrolled in group-based CR, typically within 1–4 weeks after discharge from hospital. The programme took place in the hospital and consisted of shared physiotherapist-guided exercise-based training for 1½ h twice a week for 8 weeks and one 6½-h-long session of psychosocial education, which was held around midway in the programme. Most of the patients brought their closest relatives in the psychosocial education session.
The concept of the exercise-based sessions	The concept of the psychosocial education session
The training took place in a large training room. It consisted of:	In a meeting room lectures were held as follows:
Warm-up exercise for approximately 10–15 min followed by spinning, running, varied training with workout equipment, and games, like dodge ball or hockey; we finished by stretching out or deep breathing relaxation exercises. Well-known music	8:30 am–10:00 am	What is ischemic heart disease? - About arteriosclerosis, medicine and psychological reactions Performed by a nurse.
with quick stimulating rhythms was often used in the warm-up and the training. During stretch-out and relaxation, peaceful or pan flute music was played.	10:15 am–11:00 am	Stricken by heart disease Performed by a hospital priest.
	11:15 am–12:00 am	About the Heart Foundation and life with heart disease Presented by CHD representatives from the Heart Foundation.
	Lunch break
	0:30 pm–1:20 pm	Exercise Held by physiotherapists.
	1:30 pm–2:30 pm	The good heart diet Presented by a dietician.
	2:40 pm–3:00 pm	Social offers Held by a representative from the local society.

The participants in this study followed three different but similar group-based CR programmes, which took place in the hospital and consisted of exercise-based CR and a psychosocial education session. Produced by the primary author©.

Table III An example of the structural analysis.

A part of the structural analysis regarding the finding: Supported to find a new foothold in life during cardiac rehabilitation
Units of meaning: “What is said/what is observed”	Units of significance: “What is being talked about/what is the observation about”	Theme:
“It has been a truly positive event for me to participate in the training and to have that particular nurse that I spoke with in the hospital. It was really good because then I felt that I could see some light at the end of the tunnel” (I P11).	Patients were well supported to change habits and organize their everyday tasks in better ways.	Supported to find new values in life
“It was a good way to build up some mental sturdiness” (I P5). “I appreciated this rehabilitation. It made me look upon some things with different eyes” (I P 11). They stand in a cluster and talk about the two experienced patients from the heart foundation in the psychosocial education yesterday. The presentation had been very entertaining and with good points. In an admiring voice P3 says that it was really rewarding to listen to people that are suffering from heart disease themselves. Hearing about how they have experienced it all. The other consents by nodding or saying “Hmm.” P5 smiles and says that they had made him all high. They agree that it was good to hear how the more seasoned heart patients had tackled their problems with the disease. They talk about the fact that it was fine to hear a person who talked about the stages he had undergone. In addition, they agree that the best thing was to see that they were doing so well. That their everyday lives had become good again (FO2).	The heart specialists and more seasoned heart patients helped the patients to trust in their future and to find new meaningful ways to thrive in their everyday lives. The patients were guided to focus on their particular needs and to find out what was important and realistic to them. This made them prioritize more consciously. The patients considered the process of finding new values as a strengthening one.
“It made me get some thinking going. There is no doubt that if I had not participated down here, we would not have started doing exercise as we did. Moreover, we had probably not been able to change our eating habits. In this way, it has been a help.
In addition, one becomes more aware of some things and is trying to get a little more energy during the day. Changing work a little so that you get some breaks or what to call it. Finding time to do some other things. Say ‘this must also be done’ (with emphasis in his voice). Before it was perhaps more like that the job came first rather than some other things … now I am more aware of these things. … My family and I would like to spend our time differently than before and maybe do more of what we desire” (I P6).
“It went in and really touched you, so that you started thinking a little more about whether you actually took good enough care of yourself” (I P9).
“It was emphasised that you could build onto the experience with this particular disease and break unto the other side and really feel that things had become better” (FG2 P8).

Following the method described by Pedersen (2005) the text was structured and explained by units of meaning and units of significance. On the basis of these units themes were identified. The arrows indicate that the process of structuring units of meaning and units of significance and identifying themes can be characterized as dialectic, because this analysis moves forwards and backwards among these three stages to substantiate the basis and argument for the themes (Pedersen, 2005).

Sundhedsstyrelsen. [Pathway package for unstable angina pectoris (UAP) and acute myocardial infarction without ST elevation (NSTEMI)]. Pakkeforløb for ustabil angina Pectoris (UAP) og akut myokardieinfarkt uden st-elevation (NSTEMI). 2013. Author. Retrieved May 24, 2015, from: http://sundhedsstyrelsen.dk/publ/Publ2013/05maj/PkforlUAPogNSTEMIv2.pdf.

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Pedersen B. D. Sygeplejepraksis: Sprog & erkendelse [Nursing practice. Language and cognition] (3rd ed.). 2005; The Faculty of Health Science, University of Aarhus, Århus, Denmark: PhD thesis.

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