Young adults' needs when seeking first-line healthcare: A grounded theory design.

BACKGROUND: Healthcare outpatient visits have increased in recent years, and young adults are often given as an explanatory factor for many avoidable visits. OBJECTIVE: The objective of this study was to explore how young adults perceive seeking first-line healthcare. DESIGN AND SETTING: The study utilized a grounded theory design with data collection at primary healthcare centres and emergency departments in southeast Sweden. METHOD: Data were collected during individual interviews and patient observations with subsequent interviews during the years 2017-2018. The analysis was performed using grounded theory. RESULTS: The main concern when young adults are seeking healthcare is that their worries are taken seriously. It is a four-part process: becoming aware of, verifying, communicating, and receiving an opinion about one's symptoms. The process includes external factors, clarity of symptoms, behavioural approaches, healthcare know-how, enabling self-management, and prior healthcare experience(s). When communicating symptoms, the clearer the symptoms, the less there needs to be communicated. When symptoms are unclear, the importance of different behavioural approaches and healthcare know-how increases. When receiving a medical opinion about symptoms, young adults want to learn how to self-manage their symptoms. Depending on previous healthcare experience, the healthcare visit can either harm or help the patient in their healthcare-seeking process. CONCLUSION: This study reflects several insights in the healthcare-seeking process from a young adult perspective. Based on the results, we suggest that healthcare providers focus on the final step in the healthcare-seeking process when giving their medical opinion about symptoms. Having extra minutes to give support for future self-care regardless of diagnosis could increase positive healthcare experiences and increase future self-care among young adults.

Young adults' healthcare utilisation and healthcare needs: Perceptions and experiences of healthcare providers.

BACKGROUND: Health care in many countries entails long waiting times. Avoidable healthcare visits by young adults have been identified as one probable cause. OBJECTIVE: The aim of this study was to explore healthcare providers' experiences and opinions about young adults' healthcare utilisation in the first line of care. METHOD: This study used latent qualitative conventional content analysis with focus groups. Four healthcare units participated: two primary healthcare centres and two emergency departments. This study included 36 participants, with 4-7 participants in each group, and a total of 21 registered nurses and 15 doctors. All interviews followed an interview guide. RESULTS: Data were divided into eight categories, which all contained the implicit theme of distribution of responsibility between the healthcare provider and the healthcare user. Young adult healthcare consumers were considered to be highly influenced by external resources, often greatly concerned with small/vague symptoms they had difficulty explaining and unable to wait with. The healthcare provider's role was much perceived as being part of a healthcare structure-a large organisation with multiple units-and having to meet different priorities while also considering ethical dilemmas, though feeling supported by experience. CONCLUSION: Healthcare personnel view young adults as transferring too much of the responsibility of staying healthy to the healthcare system. The results of this study show that the discussion of young adults unnecessarily seeking health care includes an underlying discussion of scarcity of resources. PATIENT OR PUBLIC CONTRIBUTION: The conduct of this study is based on interviews with young adult patients about their experiences of seeking healthcare.

Associations Between Sleep and Personality Factors Among Patients Living With Coronary Artery Disease.

BACKGROUND: Insomnia symptoms have become increasingly common in patients with coronary artery disease (CAD). Increasing evidence suggests comorbidity between personality traits and health status. Considering personality traits may act as a predisposition for future illness; this state may influence sleep quality and it appears to precipitate cardiac events in high-risk patients. OBJECTIVE: The aim of this study was to investigate self-reported sleep deficiency in relation to vicious cycle of sleeplessness (VCS) behavior, hyperarousal behavioral trait (H-personality), and type D personality traits in patients with CAD and in a population-based group. Furthermore, our aim was to explore the association of VCS behavior with H-personality trait and type D personality. Finally, we investigated to what extent type D personality can explain self-reported too little sleep in patients with CAD. METHODS: An observational case-control design was applied comprising 859 patients in cardiac outpatient care and 859 participants from a population-based group. Questionnaires assessing VCS behavior, H-personality, type D personality, and perceptions of too little sleep were used. RESULTS: Statistically significant higher scores of a hyperarousal and sleeplessness behavior were revealed for those with too little sleep compared with those with sufficient sleep in both the patient and the population-based group. Age, female gender, or sleeplessness behavior significantly predicted too little sleep (P < .001). CONCLUSIONS: The current study highlights the advantage of studying heterogeneity in patients with CAD from a person-centered perspective with focus to identify distressed individuals in order to prevent or treat sleep deficiency. A cluster of factors may be a more accurate predictor of patient-reported outcomes than a single psychosocial factor.

Healthcare utilisation and health literacy among young adults seeking care in Sweden: findings from a cross-sectional and retrospective study with questionnaire and registry-based data.

AIM: The objective of this study was to examine young adults' healthcare utilisation and its possible association with health literacy. BACKGROUND: Many countries struggle with insufficient accessibility at emergency departments (EDs) and primary healthcare centres (PHCs). Young adults, aged 20-29 years old, account for a substantial number of unnecessary doctor visits where health literacy could be an explanatory factor. METHOD: This study incorporated a combined retrospective and cross-sectional study design with analysis of registry data, including all registered outpatient doctor visits between 2004 and 2014 (n = 1 086 432), and strategic sample questionnaire data (n = 207), focusing on socio-demographics, symptoms and information-seeking behaviour. Mean differences between first-year and last-year doctor visits for each age group were calculated using registry data. Fischer's exact test was applied to questionnaire data to analyse group differences between ED and PHC visitors as well as between patients with sufficient health literacy and insufficient health literacy. Binary logistic regression was used to investigate covariation. FINDINGS: Healthcare utilisation has increased among young adults during the past decade, however, not comparatively more than for other age groups. ED patients (n = 49) compared to PHC patients (n = 158) were more likely to seek treatment for gastrointestinal symptoms (P = 0.001), had shorter duration of symptoms (P = 0.001) and sought care more often on the recommendation of a healthcare professional (P = 0.001). Insufficient/problematic health literacy among young adults was associated with having lower reliance on the healthcare system (P = 0.03) and with a greater likelihood of seeking treatment for psychiatric symptoms (P = 0.002). CONCLUSION: Young adults do not account for the increase in healthcare utilisation during the last decade to a greater extent than other age groups. Young adults' reliance on the healthcare system is associated with health literacy, an indicator potentially important for consideration when studying health literacy and its relationship to more effective use of healthcare services.

Sleep Quality, Fatigue, and Health-Related Quality of Life in Patients on Initial Peritoneal Dialysis and Multiple Modalities after Two Years: A Prospective Study.

The purpose of this study was to investigate changes in sleep quality, fatigue, mental health, and health-related quality of life (HRQoL) over a two-year period among patients undergoing peritoneal dialysis treatment at home. We further explored the extent to which sleep quality, fatigue, and mental health predicted health-related quality of life outcomes. This prospective study included 55 patients. Sleep parameters changed over two years, independently of treatment. Sleep variables at baseline, to some extent, predicted sleep quality after two years. Daytime sleepiness can be a long-term problem. Findings indicate improvements in nocturnal sleep over a two-year time period, independently of dialysis treatment. In contrast, fatigue remained unchanged over the same time period. Transplantation seems to generally benefit the outcome of HRQoL. Strategies to improve sleep and HRQoL may include systematic risk factor modification and efforts to optimise symptomatic treatment.

Self-rated health, lifestyle habits and risk assessment in 75-year-old persons attending preventive clinic visits with a nurse in primary health care: a cross-sectional study.

AIM: To describe self-rated health in relation to lifestyle and illnesses and to identify risk factors for ill health such as pressure ulcers, falls and malnutrition among 75-year-old participants in a new clinical routine involving health assessment followed by tailored one-to-one health promotion at preventive clinic visits to a nurse at primary health care centres (PHCC). BACKGROUND: There is a rapidly growing ageing population worldwide. It is central to health policy to promote active and healthy ageing. Preventive clinic visits to a nurse in primary health care were introduced as a new clinical intervention in a region in Sweden to improve the quality of health for the older adults. DESIGN: A quantitative cross-sectional population-based study. METHODS: The sample consisted of 306 individuals in six primary health care centres in Sweden aged 75 years who attended preventive clinic visits to a nurse. Data were collected from March 2014 to May 2015 during structured conversations with a nurse based on self-administered questionnaires, clinical examinations, risk assessments and after the clinic visit existing register data were collected by the researcher. FINDINGS: Participants experienced good self-rated health despite being overweight and having chronic illnesses. Daily exercise such as walking and housework was more common than aerobic physical training. The majority had no problems with mobility but reported anxiety, pain and discomfort and had increased risk of falls. CONCLUSION: It is important to encourage the older adults to live actively and independently for as long as possible. The healthy older adults may benefit from the clinical intervention described here to support the individual's ability to maintain control over their health. Such supportive assessments might help the healthy older adult to achieve active ageing, reducing morbidity and preventing functional decline.

Development of a self-care questionnaire for clinical assessment of self-care in patients with inflammatory bowel disease: A psychometric evaluation.

BACKGROUND: Patients with inflammatory bowel disease have lifelong needs to learn how to manage their symptoms and life situation. The range of actions that patients take in order to manage daily life and maintain health is referred to as self-care. Assessment of self-care in patients with inflammatory bowel disease could allow targeted support and education by health care professionals. There are no existing measures assessing self-care in patients with inflammatory bowel disease. OBJECTIVES: The aim was to develop and evaluate the self-care questionnaire for assessment of self-care among patients with inflammatory bowel disease. METHODS: Qualitative and quantitative methods were used to develop the inflammatory bowel disease self-care questionnaire. The development and evaluation process was performed in three phases: (1) item generation based on interviews with patients with inflammatory bowel disease (n = 20), (2) content validation in a panel of experts (n = 6) and patients (n = 100) assessed with the content validity index, cognitive interviews and quantifying and ranking the items to determine the usability of the questionnaire, and (3) final evaluation through a pilot study (n = 93) with test-retest evaluation (n = 50). An expert review group of three nurses and one physician continuously discussed the result during the development process. RESULTS: A total of 91 patients with Crohn's disease and 102 with ulcerative colitis participated. The final self-care questionnaire consists of 22 items. Assessment of content validity indicated that the items were adequate and easy to understand. Test-retest reliability was confirmed with intraclass correlations above 0.6 after a three week interval, for all items except one. CONCLUSION: An inflammatory bowel disease-specific self-care questionnaire was developed using structured methods. The evaluation indicated good validity and reliability. The questionnaire may be a useful tool to assess the ability of patients with inflammatory bowel disease to perform routine self-care.

Computer-Aided Evaluation of Blood Vessel Geometry From Acoustic Images.

A method for computer-aided assessment of blood vessel geometries based on shape-fitting algorithms from metric vision was evaluated. Acoustic images of cross sections of the radial artery and cephalic vein were acquired, and medical practitioners used a computer application to measure the wall thickness and nominal diameter of these blood vessels with a caliper method and the shape-fitting method. The methods performed equally well for wall thickness measurements. The shape-fitting method was preferable for measuring the diameter, since it reduced systematic errors by up to 63% in the case of the cephalic vein because of its eccentricity.

Patients requests and needs for culturally and individually adapted supportive care in type 2 diabetes patients: A comparative study between Nordic and non-Nordic patients in a social economical vulnerable area of Linköping, Sweden.

AIMS: This study sought to determine and compare the metabolic control of type 2 diabetes mellitus (T2DM) in non-Nordic immigrants and native Nordics. The aim was also to describe and compare the request of supportive care between these two groups. METHODS: One hundred and eighty-four patients (n=184) coming to a routine check-up in a primary healthcare setting (PHC), were consecutively enrolled to the study during a period of one year. Data on therapeutic interventions, clinical measurements, healthcare consumption, and adherence to standard diabetes healthcare program were extracted from the patients medical record. Structured interviews on supportive care were conducted by diabetes trained nurses. If needed, a qualified interpreter was used. Comparisons were made between Nordic patients (n=151) and non-Nordic patients (n=33). RESULTS: Among T2DM patients in a setting of PHC, there was a difference in meeting the metabolic target HbA1c, between native Nordics and non-Nordic immigrants. There was also a difference in request on supportive care. The non-Nordic group significantly requested more and different supportive care. They also attended the standard diabetes program to a lesser degree. CONCLUSIONS: Culturally/individually adapted prevention is not only medically warranted but also requested by the patients themselves.

'It's a matter of patient safety': understanding challenges in everyday clinical practice for achieving good care on the surgical ward - a qualitative study.

BACKGROUND: Surgical care plays an important role in the acute hospital's delivery of safe, high-quality patient care. Although demands for effectiveness are high in surgical wards quality of care and patient safety must also be secured. It is therefore necessary to identify the challenges and barriers linked to quality of care and patient safety with a focus on this specific setting. AIM: To explore situations and processes that support or hinder good safe patient care on the surgical ward. METHOD: This qualitative study was based on a strategic sample of 10 department and ward leaders in three hospitals and six surgical wards in Sweden. Repeated reflective interviews were analysed using systematic text condensation. FINDINGS: Four themes described the leaders' view of a complex healthcare setting that demands effectiveness and efficiency in moving patients quickly through the healthcare system. Quality of care and patient safety were often hampered factors such as a shift of care level, with critically ill patients cared for without reorganisation of nurses' competencies on the surgical ward. CONCLUSIONS: There is a gap between what is described in written documents and what is or can be performed in clinical practice to achieve good care and safe care on the surgical ward. A shift in levels of care on the surgical ward without reallocation of the necessary competencies at the patient's bedside show consequences for quality of care and patient safety. This means that surgical wards should consider reviewing their organisation and implementing more advanced nursing roles in direct patient care on all shifts. The ethical issues and the moral stress on nurses who lack the resources and competence to deliver good care according to professional values need to be made more explicit as a part of the patient safety agenda in the surgical ward.

Between two roles - Experiences of newly trained nurse practitioners in surgical care in Sweden: A qualitative study using repeated interviews.

The position of Nurse Practitioner is a new role in Nordic countries. The transition from a registered nurse to the Nurse Practitioner role has been reported to be a personal challenge. This study, guided by the Nordic theoretical model for use in the education of advanced practice nurses, represents a unique opportunity to describe this transition for newly graduated Nurse Practitioners in an interprofessional surgical care team in Sweden. The aim was to explore how the first Nurse Practitioners in surgical care experienced the transition into a new role and what competences they used in the team. Eight new Nurse Practitioners with parallel work in clinical practice were interviewed twice around the time of their graduation. The qualitative analyses show that the participants integrated several central competences, but the focus in this early stage in their new role was on direct clinical praxis, consultation, cooperation, case management, and coaching. Transition from the role of clinical nurse specialist to nurse practitioner was a challenging process in which the positive response from patients was a driving force for the new Nurse Practitioners. The participants felt prepared for and determined to solve the challenging situations they approached working in the interprofessional team.

Life in standby: hemodialysis patients' experiences of waiting for kidney transplantation.

AIM AND OBJECTIVES: Our aim was to explore the experiences of hemodialysis patients who are waiting for a kidney transplant. BACKGROUND: Currently, more than 100,000 persons are waiting for kidney transplantation in the United States. In Sweden, the number is exceeding 600. The waiting period for a deceased donor can be one to three years or even longer in Sweden. This can be challenging, since the patients' situation, with chronic treatment and illness, is burdensome and requires advanced self-care. DESIGN: This study included a purposeful sample of eight patients (33-53 years old) who had been undergoing hemodialysis treatment for at least six months and were waiting for kidney transplantation. METHODS: The patients were interviewed, and descriptive content analysis was performed. RESULTS: Four categories emerged: (1) 'The waiting process,' what thoughts and expectations occur and what to do and how to be prepared for the transplant. (2) 'Awareness that time is running out,' patients felt tied up by treatment and by needing to be available for transplantation, and they had concerns about health. (3) 'Need for communication,' patients described needing support from others and continuous information from the staff. (4) 'Having relief and hope for the future,' patients described how to preserve the hope of being able to participate fully in life once again. CONCLUSIONS: This study reveals the need for extra attention paid to patients waiting for kidney transplantation. Patients' experiences during the waiting period indicate that pretransplant patients have an increased need to be prepared for the transition and for life post-transplantation. RELEVANCE TO CLINICAL PRACTICE: Dialysis patients on waiting lists must be prepared for the upcoming life change. This includes preserving hope during the waiting period and being mentally prepared for transplantation and a dialysis-free life. A pretransplant education program to prevent medical and psychosocial issues is highly recommended.

Self-Care Among Patients With Inflammatory Bowel Disease: An Interview Study.

Inflammatory bowel disease (IBD) is a chronic disease of unknown etiology. The disease occurs early in life and the burden of symptoms is significant. Patients need to perform self-care to handle their symptoms, but knowledge about what kind of self-care patients do is limited and these individuals need to learn how to manage the symptoms that arise. The aim of this study was to explore self-care among patients with IBD. Twenty adult patients with IBD, 25-66 years of age, were interviewed. Data were analyzed by performing a qualitative content analysis. Four categories with 10 subcategories emerged from the analysis of the interviews. The self-care patients perform consists of symptom recognition (subcategories: physiological sensations and psychological sensations), handling of symptoms (subcategories: adapting the diet, using medical treatment, stress management, and using complementary alternative medicine), planning life (subcategories: planning for when to do activities and when to refrain from activities), and seeking new options (subcategories: seeking knowledge and personal contacts). Self-care consists of symptom recognition, handling life through planning, and accommodating the existing situation with the ultimate goal of maintaining well-being. Being one step ahead facilitates living with IBD. A decision to actively participate in care of a chronic illness is a prerequisite for self-care. Healthcare professionals must consider patients' potential for and desire for self-care when giving advice on self-care activities. Doing so may help people better cope with IBD.

Obstacles and opportunities for achieving good care on the surgical ward: nurse and surgeon perspective.

AIM: The purpose of this qualitative study was to explore and understand from the perspectives of nurses and surgeons the situations and processes that are important in the context of surgical care support or are obstacles to achieving good care. BACKGROUND: Medical advances and inpatients with multiple illnesses are on the increase. In addition, a high turnover of registered nurses has been identified. This contributes to an increasingly inexperienced nursing staff. Concurrently, studies have shown that patient safety and quality of care are linked to organisational structures and staffing education levels. METHOD: Eight nurses and six surgeons from three hospitals were interviewed and data were analysed by systematic text condensation. RESULTS: This identified three themes: shifting focus away from the patients, emphasising good communication, and using the competence of the team. CONCLUSION: This study contributes to a deeper understanding that many interruptions, insufficient communication and unused competence can be a threat to patient safety. Sweden has a high standard but this study elucidates that challenges remain to be resolved. IMPLICATIONS FOR NURSING MANAGEMENT: The focus on patients can increase by a balance between direct/indirect patient work and administration and by the support of clinicians using their full professional competence.

Optical Estimation of Beta 2 Microglobulin during Hemodiafiltration ­ Does It Work?

BACKGROUND: Currently, urea reduction seems to be the most widely used dialysis dose parameter. The aim of this study was to investigate the possibility to monitor beta 2-microglobulin (ß2-M) elimination by utilizing the ultraviolet (UV) absorbance of spent dialysate. METHODS: Blood and spent dialysate were collected during two week's sessions in 8 patients, one week in hemodialysis (HD) and one in hemodiafiltration (HDF). Correlation analysis between UV-wavelengths and concentrations of solutes in spent dialysate was performed. The reduction ratio (RR) of concentrations in blood, dialysate and UV-absorbance were compared. RESULTS: Differences between HD and HDF were discovered in wavelength correlation maxima for the solutes. Relative error in RR (%) was larger (p < 0.05) for ß2-M than for the other solutes. The most reasonable explanation is that ß2-M does not absorb UV-radiation; instead, the absorbance of surrogate substances is measured. CONCLUSION: A high correlation between UV-absorbance and ß2-M can be achieved for HDF but not for HD. Still, UV-absorbance could perhaps be used in solely HDF mode for estimation of ß2-M removal.

Evaluation of an individual sleep intervention programme in people undergoing peritoneal dialysis treatment.

AIMS AND OBJECTIVES: This study aimed to evaluate effects of a non-pharmacological intervention on sleep, activity and fatigue in patients receiving peritoneal dialysis by the use of both actigraphy registration and self-assessed questionnaires. BACKGROUND: Insomnia is estimated to affect up to 60% of haemo- and peritoneal dialysis patients. It is associated with two common uremic symptoms, pruritus and restless legs syndrome. To our knowledge, no interventions have been evaluated by actigraphy. DESIGN: A prospective multiple baseline single-case experimental design. METHODS: Two women and seven men with sleep problems, 48-77 years, treated with PD participated in a 17-week study from January 2009 to February 2011. Two interventions were separately implemented. First, a pressure-relieving mattress and second, a four week individual sleep hygiene and sleep scheduling intervention. The two interventions were evaluated both objectively by actigraphy and subjectively by questionnaires. RESULTS: A total of 315 sleep-wake cycles from nine individuals were evaluated. Three patients improved clinically significantly in five or more of the nine outcomes, i.e. sleep onset latency, nocturnal sleep duration, numbers and duration of napping, movement and fragmentation index, number of steps, metabolic equivalent unit, sleep efficiency and fatigue. The other six patients also showed improvements but to a lesser degree. Physical activity advice was the intervention that yielded most sleep improvements. CONCLUSIONS: This study illuminates the need for regular assessment of sleep and tiredness. It also demonstrates how a non-pharmacological treatment and self-management can be applied with renal supportive care to improve sleep quality. RELEVANCE TO CLINICAL PRACTICE: This study is a clinical example of a non-pharmacological intervention with supportive care and self-management. This model can improve health and reduce the pharmacological burden because hypnotics can be replaced by sleep hygiene self-care activities.

Fragmented sleep: an unrevealed problem in peritoneal dialysis patients.

OBJECTIVE: The aim of this study was to describe the sleep-wake cycle, sleep quality, fatigue and Health Related Quality of Life (HRQoL) measured with questionnaires, actigraphy and a sleep diary during a one-week period in patients undergoing peritoneal dialysis (PD) treatment at home. A further aim was to explore differences compared with patients with coronary artery disease (CAD) and individuals from the general population. MATERIAL AND METHODS: In this study one-week actigraphy registration, four questionnaires (Uppsala Sleep Inventory, SF-36, FACIT-fatigue, International Restless Legs Study Groups' form) and a sleep diary were used. RESULTS: Data from 68 participants and 470 nights were collected. PD patients (n = 28) had more fragmented sleep (p < 0.001) and worse sleep efficiency (SE%) (p < 0.0001) than the CAD (n = 22) and the population (n = 18) groups. Pruritus (57%), restless legs (46%) and fatigue (89%) were prevalent in PD patients. Pruritus correlated with fragmented sleep (r = -0.45, p = 0.01) and SE (r = -0.49, p = 0.01). In HRQoL, the physical component score was decreased in the PD and CAD groups (p < 0.01) compared to the population group. CONCLUSIONS: To the authors' knowledge this study is the first to demonstrate that PD patients have deteriorated sleep, with serious fragmentation measured by a one-week actigraphy registration. Further, PD patients exhibit worse sleep quality than CAD patients and individuals in the population. Evaluation of sleep in clinical practice is highly recommended since PD patients are vulnerable individuals with extended self-care responsibilities and at risk for comorbidity secondary to insufficient sleep. Future research on whether PD patients' sleep problems and fatigue can be improved by an individual non-pharmacological intervention programme is required.

Circling around in tiredness: perspectives of patients on peritoneal dialysis.

The experience of tiredness linked to poor sleep in patients on peritoneal dialysis was explored using the qualitative method phenomenology. Eight women and six men in southeast Sweden were interviewed. The patients' descriptions were characterized by a circular structure "circling around in tiredness." This study illustrates the problems of tiredness and illuminates the need for healthcare professionals to assess the impact of tiredness and highlight the need for strategies to improve the patient's situation.

Self-reported subjective sleep quality and fatigue in patients with peritoneal dialysis treatment at home.

The aim of this study was to describe habitual sleep, daytime symptoms, sleep-disturbing factors, current sleep during 1 week and fatigue in patients with peritoneal dialysis treatment at home and also discover predictions for sleep quality outcome. The knowledge should increase possibilities for supportive nursing health care. Fifty-five patients answered two mailed questionnaires and filled in a sleep diary. Of these, 60% had moderate, persistent sleep problems combined with daytime symptoms. Nocturnal awakenings with difficulties falling asleep again and a sleep duration predicted as 57% of sleep quality. Nocturnal pruritus and 'difficulties finding a comfortable sleeping position' were significant sleep-disturbing factors. Sleep quality predictors means progress in knowledge about the complexity of the situation for peritoneal dialysis patients. Poor sleep, daytime symptoms, sleep-disturbing factors and chronic fatigue need to be enlightened, especially for the nephrology nurses who are in a unique position to give supportive nursing health care.

Effects of sleep loss in men and women with insufficient sleep suffering from chronic disease: a model for supportive nursing care.

This study evaluated self-reported subjective health and effects of sleep loss according to perceived interfering cognitive anxiety related to falling asleep in patients with and without insufficient sleep and gender differences in these aspects 5 years after coronary artery bypass graft and transluminal coronary angioplasty. A total of 145 patients, five years after intervention, responded to a mailed questionnaire. Nearly 60% had severe combined sleep disturbances; 35.9% of these had complained of insufficient sleep and 15% also perceived difficulty falling asleep related to cognitive anxiety. Measurable gender differences were small. A theoretical framework is presented which can increase understanding among nurses, patients and their relatives concerning the quality and quantity of sleep and sleep loss related to quality of life. These results suggest that there are significant relationships between sleep quality, resilience to stress and coping strategy in patients with a chronic disease, indicating the need for more individualised supportive nursing care.