Miriam Gaston, BSc, MSc (Nursing), RN, RNT, RNCT, DipCounselling.
Lecturer in Nursing, University of SalfordThe link between depression and increased mortality (Jones and West, 1995; Thomas, 1995; Moser and Dracup, 1995; Crowe et al, 1996) has led to increased concern about a patient's psychological well-being in the aftermath of having a myocardial infarction (MI). Monitoring the psychological status of patients in cardiac rehabilitation is part of the role of the multidisciplinary team, yet there is limited evidence of the best methods of providing psychological support.
Having an MI is a frightening and unwelcome intrusion that disrupts any sense of control a patient may have over his or her life. Patients experience a 'biographical disruption' - an unavoidable and enforced alteration of their life (Holloway et al, 2000) and often recall a sense of numbness in the context of their hospital admission. This is similar to that experienced by people with post-traumatic stress (Owens et al, 2001).
Improving the way health-care staff relate to, and communicate with, patients is high on the health agenda. The NHS Plan: Personal action plans (DoH, 2003) suggests that nurses should not only encourage patients to tell their stories but also try to put themselves in the patient's shoes to inform and improve the quality of care they offer.
The main focus of psychological interventions is to assist the patient to adapt to change, become self-empowered and regain control of their life (Thomas et al, 2001). This involves helping them work through issues related to the concept of loss. Loss has been described as a central feature of our lives and an unavoidable and inextricable part of being human (Tschudin, 1997).
Loss is usually perceived as a negative experience that invokes varying degrees of fear, anxiety or depression in patients. However, by adapting to loss the patient may have an opportunity to re-evaluate personal values and beliefs, which in turn can lead to a sense of fulfilment.
For many clients the major fear is that of sustaining another heart attack - one that could be fatal. Worden (1991) used the term 'anticipatory grief' to describe the role reversal experienced by relatives of dying individuals. After an MI many patients undergo a similar process of anticipatory loss, fearing - wrongly or rightly - the risk of a fatal heart attack (Goble and Worcester, 1999).
To encourage the patient to tell their story of 'biographical disruption', it is necessary to foster a supportive relationship. This will provide the patient with a platform from which to describe the feelings that underpin their sense of having lost their life's destination. During this time the counsellor reflects any underlying feelings, enabling the patient to explore the issues.
There is limited evidence on how best to provide a comprehensive cardiac rehabilitation programme to address the psychosocial needs of patients and carers (Goble and Worcester, 1999). However, using the patient's journey during a period of ill health has become a part of a strategy to improve quality of care (DoH, 2002). This paper has drawn on the work of a counsellor working in a multidisciplinary team to highlight aspects of this patient journey in order to consider how those psychological processes affect a patient's perception of the care provided.
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