It has long been assumed that overprotection of a cardiac patient by family and friends would lead to a dependency that could inhibit full functional recovery. Researchers from Sharp Hospital in San Diego and the University of California at Los Angeles School of Nursing have indications that this may not be true.
"A lot of interest has been generated in finding what causes cardiac invalidism (CI). For 30 years people have been postulating that it's because those around the patient have been babying them too much," said Barbara J. Riegel, R.N., D.N.Sc., clinical researcher at the hospital. "In our study, patients who thought their family and friends were overprotective adapted better in the early months following a heart attack."
While working with out-patients in a cardiac setting, she noted differing levels of support from the patient's family. Some spouses would make major changes in routine while others would agree to far fewer disruptions. There was anecdotal evidence of differences in outcomes between the two groups.
"We set out test the statement that keeps coming up in the literature: `No one should cater to the patient, if they are on their feet and out of bed quickly they get better faster'," Riegel said. "As human beings we look at this and know intuitively it is stupid. I think that our study proves beyond a doubt that the literature is not correct."
She assembled a group of 120 first-time acute myocardial infarction (AMI) patients from nine hospitals in Southern California. The patients had to be unaware of pre-existing heart disease, could not have additional medical problems, and were without significant psychiatric illness.
Patients were admitted to the study regardless of what treatment was prescribed. However, those subsequently referred for coronary artery bypass surgery were excluded.
The group defined CI as a patient-centered perception of poor health, low-self esteem, emotional distress and feelings of dependency.
They measured overprotection by using a social support inventory. Patients were categorized by subtracting the "support desired" from the "support received" subscale. Those with a positive score were considered overprotected.
In addition, interpersonal dependency, self-esteem, and emotional distress were measured. A personality inventory was used to quantify character attributes.
Data on health status perceptions were gained using the General Health Perceptions Questionnaire. They obtained information on objective health status using the coronary prognostic index and peak creatine kinase and isoenzyme fractions.
They followed the group for four months using telephone and in-home visits for follow-up. Complete data was available on all but nine participants.
Initially the researchers assumed that it would be ideal to have a perfect match between the amount of support desired and the amount received. However, only two patients surveyed felt they got just the right amount.
At one-month after the AMI, the overprotected group reported less anxiety, depression, anger, and confusion. They also showed more vigor and a higher self-esteem than those inadequately supported by family and friends.
After four months, the two sets of responses were similar to each other in all categories except dependency. Those who felt inadequately supported were also the ones with higher degree of dependency.
"When I originally went to the literature, it predicted that people who got a lot support were going to do poorly," Riegel noted. "Instead what we found were those who reported they were getting more support than they wanted did significantly better over time. They exhibited less depression, anger, and dependency."
Although her data was not structured in a way that would measure it, Riegel feels it may be possible to give too much support. She makes an anecdotal distinction between mothering (getting more support than needed) and smothering (getting far more support than desired).
"During the early stages of the recovery, doing quite a bit for the patient may reassure them that their illness is not going to cause any emotional distancing or may allow them to use energy to become comfortable with their new reality," she said. "Although I cannot say from the data what level of protection is too much, clinically I feel that it may not be too much, but rather, too long."
Due to the short timeframe, there may be a limit on the positive effects of overprotection that was not found. Riegel and her colleagues are considering a longer-term study to address this possibility.
"I think that families should be told that it is okay and beneficial to be very caring and supportive immediately following a health crisis such as a heart attack," she continued. " As providers we need to communicate this to family members and others. When patients had more emotional and informational support than they wanted, they did better."
Riegel noted that supportive seems to the most important word. Her data show that family, friends and significant others need to be caring and good listeners. In addition, they should be involved in creative problem solving as needed.
"Logically we can say to ourselves that one is a cardiac invalid because they are physically an invalid," she noted. "However, our results show the people most psychologically disabled where not always those who were the most physically disabled."
Family teaching may be the most important intervention in the psychological recovery of a person with a recent infarct. Relatives are often afraid to get too close to the patient because they do not understand how they can safely interact with their friend or loved one. This is often threatening to those who should be closest to the patient.
"It falls on the nursing and medical staff to convince the family that it is all right to take an interest in the patient and to help when needed," said Riegel. "The caregivers should not be concerned when they see someone being what, in the past, would have called overprotective."
It also is important for healthcare providers to realize when support is not being given and take corrective actions. Riegel notes her research indicates this is a risk factor for a poor outcome,. The family has to be made aware of the importance of interacting with their relative or friend.
"This is part of the evolution of healthcare from doctors and nurses telling the patient what is best toward giving the patient back to the family," said Riegel. "We cannot do everything for the patient. We are unable to provide the love, caring and support that a family can."
Riegel is currently planning a longer term study in an attempt to discover what interventions by the family have an optimal impact on outcomes. She also plans to expand the number of women in the survey.
"The CI variable we can have an impact on as nurses and healthcare professionals is social support," Riegel stressed. "We can say that a given patient will do better if the family gets in there and loves him or helps her get through the crisis."
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