Racial differences in women's prodromal and acute symptoms of myocardial infarction.

BACKGROUND: Minority women, especially black and Hispanic women, have higher rates of coronary heart disease and resulting disability and death than do white women. A lack of knowledge of minority women's symptoms of coronary heart disease may contribute to these disparities. OBJECTIVE: To compare black, Hispanic, and white women's prodromal and acute symptoms of myocardial infarction. METHODS: In total, 545 black, 539 white, and 186 Hispanic women without cognitive impairment at 15 sites were retrospectively surveyed by telephone after myocardial infarction. With general linear models and controls for cardiovascular risk factors, symptom severity and frequency were compared among racial groups. Logistic regression models were used to examine individual prodromal or acute symptoms by race, with adjustments for cardiovascular risk factors. RESULTS: Among the women, 96% reported prodromal symptoms. Unusual fatigue (73%) and sleep disturbance (50%) were the most frequent. Eighteen symptoms differed significantly by race (P<.01); blacks reported higher frequencies of 10 symptoms than did Hispanics or whites. Thirty-six percent reported prodromal chest discomfort; Hispanics reported more pain/discomfort symptoms than did black or white women. Minority women reported more acute symptoms (P < .01). The most frequent symptom, regardless of race, was shortness of breath (63%); 22 symptoms differed by race (P <.01). In total, 28% of Hispanic, 38% of black, and 42% of white women reported no chest pain/discomfort. CONCLUSIONS: Prodromal and acute symptoms of myocardial infarction differed significantly according to race. Racial descriptions of women's prodromal and acute symptoms should assist providers in interpreting women's symptoms.

Comparison of anxiety between smokers and nonsmokers with acute myocardial infarction.

BACKGROUND: Increased anxiety correlates with increased complications after acute myocardial infarction. Anxiety levels and use of anxiolytic agents have not been compared between smokers and nonsmokers hospitalized because of acute myocardial infarction. OBJECTIVES: To compare anxiety level, sociodemographic factors, and clinical variables between smokers and nonsmokers hospitalized with acute myocardial infarction and to examine predictors of use of beta-blockers and anxiolytic agents among smokers and nonsmokers. METHODS: Secondary data analysis of a prospective multisite study on anxiety in 181 smokers and 351 nonsmokers with acute myocardial infarction. Anxiety was measured by using the State Trait Anxiety Inventory and the anxiety subscale of the Basic Symptom Inventory within 72 hours of admission. RESULTS: Smokers reported higher anxiety levels than nonsmokers reported on both anxiety scales. Female smokers reported the highest anxiety and peak pain levels of all, yet women were the least likely to receive anxiolytic agents. Smoking status was not a predictor for anxiety level when sex, peak pain, use of beta-blockers in the hospital, and age were controlled for. However, smokers were twice as likely as nonsmokers to receive an anxiolytic agent and 60% more likely to receive a beta-blocker in the emergency department, and smokers were 80% more likely than nonsmokers to receive an anxiolytic agent during hospitalization when these variables were controlled. CONCLUSIONS: Older female smokers are at risk for complications because they are older than their male counterparts and less likely to receive beta-blockers and antianxiety medications in the emergency department.

Social support, self-efficacy, and outcome expectations: impact on self-care behaviors and glycemic control in Caucasian and African American adults with type 2 diabetes.

PURPOSE: The purpose of this study was to examine the relationships of psychosocial variables (social support, self-efficacy, and outcome expectations) to diabetes self-care behaviors and glycemic control in Caucasian and African American adults with type 2 diabetes. METHODS: Study participants were scheduled for outpatient visits at 1 of 3 clinical sites in the southeastern United States. All 91 participants completed 4 self-report measures: Social Support Questionnaire (SSQ), Self-efficacy Questionnaire (SEQ), Outcome Expectancy Questionnaire (OEQ), and The Diabetes Activities Questionnaire (TDAQ) at the time of the clinic visit. Long-term glycemic control was assessed by glycosylated hemoglobin analyses at the time of the clinic visit. Pearson product-moment correlations were used to determine whether significant relationships existed between scores on the SSQ, SEQ, OEQ, and TDAQ and glycosylated hemoglobin values. Two-sample t tests were used to detect differences in scores on the self-report measures and glycosylated hemoglobin values between the 2 racial groups. RESULTS: In all participants, no significant relationships were found between (1) social support and self-care behaviors and (2) self-efficacy and self-care behaviors. Self-care behaviors were significantly, positively correlated with outcome expectancy scores for the total group and for African Americans. No significant relationships were found between (1) social support and glycemic control, (2) self-efficacy and glycemic control, and (3) outcome expectations and glycemic control. African Americans reported less social support satisfaction than Caucasians did. CONCLUSIONS: Psychosocial variables investigated in this study were not related to health outcomes of type 2 diabetes. Caucasians and African Americans were similar in these variables. It is important to investigate the relationships between other variables (eg, age, duration of diabetes, education) and self-care behaviors and glycemic control. Although African Americans experience higher rates of diabetes-related complications than Caucasians do, this may possibly be due to other factors (eg, heredity, financial barriers, inadequate health care). Additional investigations to study the relationships of these variables to diabetes control are warranted.

Using a 0-10 scale for assessment of anxiety in patients with acute myocardial infarction.

Patients with acute myocardial infarction (AMI) often experience anxiety, an emotion that predicts adverse physiologic outcomes. The purpose of this study was to determine whether a single-item anxiety assessment instrument, the Anxiety Level Index (ALI), is a valid alternative to the State Anxiety Index (SAI) or the anxiety subscale of the Brief Symptom Inventory (BSI) for assessing state anxiety for patients with AMI. In this prospective multicenter study, 243 inpatients with AMI rated their anxiety using the SAI, the anxiety subscale of the BSI, and the ALI. Anxiety Level Index scores were compared to SAI and BSI anxiety subscale scores. There were moderate, positive correlations between the SAI and the ALI (rs = 0.52, P < .001), and between the ALI and the anxiety subscale of the BSI (rs = 0.45, P < .001). Although ALI scores were moderately and significantly correlated with scores on the SAI and the BSI anxiety subscales, the results of the Bland-Altman method indicate a lack of construct validity of the single-item measure. The quest continues to construct a simple self-report measure of anxiety that is appropriate for critically ill patients with AMI.

A cross-sectional examination of changes in anxiety early after acute myocardial infarction.

BACKGROUND: Anxiety is common after acute myocardial infarction (AMI). The assessment and treatment of anxiety early after AMI is important, because anxiety is associated with increased morbidity and mortality. Few data exist about anxiety early after AMI, the time when anxiety likely peaks. Furthermore, no researchers have evaluated potential gender differences in the evolution of anxiety after AMI. OBJECTIVES: The purpose of this study was to investigate the evolution of anxiety during the first 72 hours of hospitalization for AMI and to examine whether there is a gender difference in the pattern of anxiety early after AMI, from cross-sectional data. METHODS: In this cross-sectional study, 486 patients with AMI were recruited from 4 urban university medical centers and 2 private hospitals in the United States and 1 large university teaching hospital in Australia. The Spielberger State-Trait Anxiety Inventory was used to measure anxiety once in each patient within 72 hours of the patient's admission to the hospital. Patients were divided into 6 groups based on the time interval in which they were interviewed. RESULTS: The mean score of state anxiety was 39 +/- 13. Peak anxiety occurred within the first 12 hours after AMI (P<.05) and anxiety level differed among the time intervals (F [5, 474]=4.55, P<.001). There was a main effect of gender on anxiety (F [1, 474]=11.86, P<.001). Women reported higher anxiety than men at all time points except the time interval of 24.1 to 36 hours after AMI. CONCLUSION: Prospective, longitudinal, repeated measures research is needed to confirm the trajectory of anxiety in AMI patients, but data from this study suggest that anxiety should be assessed and treated in the early stages of AMI to prevent potential complications that may be exacerbated by anxiety and to provide comfort to AMI patients.

Women's early warning symptoms of acute myocardial infarction.

BACKGROUND: Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women. METHODS AND RESULTS: Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. CONCLUSIONS: Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events.

Effects of gender and preference for information and control on anxiety early after myocardial infarction.

BACKGROUND: Men and women differ in anxiety, which is one of the most stressful outcomes of an acute myocardial infarction (AMI). This anxiety may be moderated by coping styles of preference for information and control. OBJECTIVE: This study aimed to examine the relation of gender and preference for information and control to anxiety during the critical care period after AMI. METHODS: As part of a larger study on complications after AMI, a descriptive cross-sectional multicenter one-group investigation designed with a convenience sample of AMI patients admitted to acute care units was conducted. Within the first 48 hours after the patients were admitted to the hospital, anxiety was assessed using the State Anxiety Inventory, and preference for information and control was measured using the Krantz Health Opinion Survey. RESULTS: The sample of AMI patients (N = 410) was 68% male, 87% White, 68% married. The women were significantly older than the men (p <.05) and significantly more anxious (p <.05). Multiple stepwise regression analysis with a control for age demonstrated that neither preference for information nor preference for control moderated the relation of gender and anxiety. CONCLUSIONS: The women expressed greater anxiety than the men. However, the men and women were similar at all levels of anxiety in their preference for information and control. The search for other factors related to the stress of AMI will help healthcare providers design effective interventions to reduce anxiety among men and women.

Critical care nursing practice regarding patient anxiety assessment and management.

Anxiety is common in critically ill patients and can adversely affect recovery if not properly assessed and treated. The objectives of this study were to: (1) identify the clinical indicators that critical care nurses consider to be the defining attributes of anxiety in critically ill patients; and (2) delineate the interventions that critical care nurses use to alleviate anxiety in their patients. A total of 2500 nurses who worked in adult critical care areas were randomly selected from the membership of the American Association of Critical Care Nurses. Nurses selected were mailed a survey designed to determine what they considered to be the important attributes of anxiety in their patients and what interventions they commonly used to manage anxiety. The 593 nurses (31.6% response rate) who responded identified 70 individual anxiety indicators and 61 anxiety management strategies that were categorized into four and three major categories, respectively. The four major anxiety assessment categories were: (1) physical/physiological; (2) behavioral; (3) psychological/cognitive; and (4) social. The three major anxiety management strategies were: (1) care techniques; (2) improving knowledge and communication; and (3) support. Critical care nurses reported numerous and distinctive anxiety indicators and management strategies. Further research is needed to examine exactly how appropriate and effective these assessment indicators and management strategies are.

Critical care nurses' beliefs about and reported management of anxiety.

BACKGROUND: Anxiety is associated with increased morbidity and mortality. Critical care nurses are uniquely positioned to reduce anxiety in their patients. Critical care nurses' beliefs about and frequency of use of strategies to reduce anxiety have not been studied. OBJECTIVES: To explore critical care nurses' beliefs about the importance of anxiety management and to describe nurses' reported use of strategies to manage anxiety in their patients. METHODS: A random sample (N = 2500) of members of the American Association of Critical-Care Nurses was asked to complete the Critical Care Nurse Anxiety Identification and Management Survey. RESULTS: Respondents (n = 783) were primarily female (92%), white (88.5%) staff nurses (74.1%) who thought that anxiety is potentially harmful (mean, 4.1; SD, 0.8; range, 1 = no harm to 5 = life-threatening harm), that anxiety management is important (mean, 4.8; SD, 0.6; range, 1 = not important to 5 = very important), and that effective anxiety management is beneficial (mean, 4.6; SD, 0.6; range, 1 = no benefit to 5 = profound benefit). A majority commonly used pharmacological management; most also used information and communication interventions. Fewer subjects used the presence of patients' family members to alleviate patients' anxiety; few reported using stress-reduction techniques. CONCLUSION: Most respondents thought that treating anxiety is important and beneficial. Commonly used strategies included pharmacological relief of anxiety and pain and information and communication interventions. Although these strategies are useful, they may not effectively reduce anxiety in all patients.

Management of anxiety after acute myocardial infarction.

BACKGROUND: Anxiety is common after acute myocardial infarction (AMI) and may induce complications and poorer outcome because of activation of the sympathetic nervous system and the hypothalamic pituitary adrenal axis. Little is known about critical care nurses' management of anxiety in the initial days after AMI. OBJECTIVE: The purpose of this study was to describe pharmacological and nonpharmacological anxiety management practices in a sample of patients with AMI and to determine the association between patient self-reported anxiety level, clinician anxiety assessment, and subsequent anxiety management by clinicians. METHODS: In this descriptive, correlational investigation, subjects (n = 101) were requested to complete the Spielberger State Anxiety Inventory (SAI) within 48 hours of hospital admission for AMI. After hospital discharge, the investigators performed a thorough medical records review to evaluate the use of pharmacological and nonpharmacological anxiety management strategies for the period that encompassed 12 hours before and 12 hours after administration of the SAI. RESULTS: Subjects were primarily white (93%), married (72%) individuals with a hospital admission Killip classification of I (71%). Documentation of subjective anxiety assessment was found for only 45 subjects (44.6%). Subject rating of anxiety with SAI ranged from 20 (no anxiety) to 77 (extreme anxiety; mean, 37.2 +/- 12.4). Seventy-two subjects had documentation of anxiety management (pharmacological, 25.7%; nonpharmacological, 45.6%). No significant relationship was seen between the subject SAI score and the clinician assessment of anxiety (lambda = 0.03; P < .05). Although documentation was seen that 72 subjects received anxiety management, no association was found between the clinician evaluation of anxiety and the use of anxiety management strategies (pharmacological: lambda = 0.11; P = .65; nonpharmacological: lambda = 0.07; P = .08). A small but significant relationship was found between the subject SAI score and the use of pharmacological anxiety management (lambda = 0.10; P = .03) but no association was found between SAI score and the use of nonpharmacological anxiety management (lambda = 0.6; P = .50). Evaluation of efficacy was not routinely documented (pharmacological, 58%; nonpharmacological, 2%). Only 2 subjects (2%) received consultation to social work for management of anxiety. CONCLUSION: Anxiety was not systematically and accurately assessed or logically managed in this sample of patients with AMI. Critical care clinicians need a comprehensive understanding about the importance of anxiety to patient outcome in addition to objective, reliable, and valid anxiety measures and a useful repertoire of evidence-based management strategies to effectively manage anxiety. Effective management of anxiety positively influences patient outcome and should be a goal for all critical care patients.

Infant feeding responsiveness: a conceptual analysis.

BACKGROUND: The phenomenon of infant responsiveness to the caregiver during feeding interactions has been of interest to researchers for many years, because of its associated implications for child growth and development. Although many studies have examined feeding responsiveness in caregiver-infant dyads, it is infrequently and inconsistently defined in the literature. SPECIFIC AIMS: The purpose of this paper is to clarify the concept of infant feeding responsiveness through the provision of a working definition of the concept for further study and usage. METHODS: Medline, CINAHL, and PschInfo databases from the year 1970 to the present were searched for English articles containing the keywords 'infant', 'feeding', 'responsiveness', 'synchrony', and/or 'interaction'. Articles were selected for inclusion according to whether or not the phenomenon of infant feeding responsiveness was defined or assessed. Walker and Avant's (1995) method for concept analysis was employed for the development of defining attributes, case examples, antecedents, and consequences for further clarification of the concept of infant feeding responsiveness. FINDINGS: Infant feeding responsiveness was defined as the manifestation of physiologically influenced visual, expressive, vocal and motor reactive behaviours expressed by an infant in reaction to a caregiver's feeding attempts, indicating a readiness to feed. CONCLUSIONS: Implications for nursing are explored as well as the need for refinement of measures of this concept.

Critical care nurses' assessment of patients' anxiety: reliance on physiological and behavioral parameters.

BACKGROUND: Anxiety activates the sympathetic nervous system and hypothalamic-pituitary-adrenal axis and may increase morbidity and mortality in vulnerable critical care patients. Despite the adverse effects of anxiety, little is known about critical care nurses 'practices for assessing anxiety. OBJECTIVE: To determine the importance that critical care nurses place on evaluating anxiety and to describe clinical indicators used to assess anxiety. METHODS: Twenty-five hundred members of the American Association of Critical-Care Nurses received the Critical Care Nurse Anxiety Identification and Management Survey and were asked to rate the importance of anxiety assessment, to rate the importance of 61 anxiety indicators, and to select and rank the 5 most important anxiety indicators. RESULTS: Seven hundred eighty-three completed surveys (31.6%) were returned by female (92.0%), white (88.6%) staff nurses (74.2%) who practiced critical care nursing 32.5 hours (SD, 12.3 hours) weekly. Nearly three quarters (71.3%) of respondents thought that anxiety assessment is very important. Only 2 indicators, agitation and patients' verbalization of anxiety, were rated as very important to anxiety assessment. Thirty-nine indicators rated as important primarily included measurable physiological changes and observable behaviors. The top 5 anxiety indicators were agitation, increased blood pressure, increased heart rate, patients' verbalization of anxiety, and restlessness. CONCLUSION: Important indicators of anxiety included observable behaviors and measurable physiological changes. Reliance on these criteria may produce an inaccurate and incomplete anxiety evaluation in vulnerable patients and lead to poorer outcomes. A comprehensive, systematic anxiety assessment tool for valid and reproducible evaluation of patients' anxiety is needed.