strategies for recreating normal life: iranian coronary heart disease patients' perspectives on...

ORIGINAL ARTICLE

Strategies for recreating normal life: Iranian coronary heart disease

patients’ perspectives on coping strategies

Tahereh Najafi Ghezeljeh and Azita Emami

Aims and objectives. To identify coping strategies used by Iranian patients with

coronary heart disease.

Background. One of the most important nursing interventions is facilitating

adjustment for patients. A deeper understanding of patients’ coping strategies for

controlling illness and its consequences is needed.

Design. A qualitative design.

Methods. Participants were hospitalised patients diagnosed with coronary heart

disease, based on documented angiographic results. A qualitative study using

semi-structured interviews was conducted, and purposive sampling was per-

formed. The qualitative content analysis determined categories and subcategories

for describing and understanding coping strategies.

Results. The term ‘coping strategies’ refers to the strategies used by participants

living with coronary heart disease as they attempt to understand and control their

chronic condition and return to a social and physical state as similar to their pre-

disease condition as possible. During the data analysis, six strategies emerged:

searching for meaning and information; trying to achieve comfort and control;

resting more, doing less and slowing down; motivating, prioritising and caring for

self; turning to religion and spirituality; and expectations and receiving assistance

and support.

Conclusions. This qualitative study describes the coping strategies of Iranian

patients with coronary heart disease and the commonalities with strategies for

others dealing with chronic illnesses in Iran. The patients were found to use a

variety of coping strategies to deal with their illness and its impacts on their lives.

Relevance to clinical practice. This study contributes to the existing body of

knowledge about optimal nursing care strategies for patients with coronary heart

disease. Through increasing awareness of coping strategies, nurses can help their

patients employ the most effective tools and reinforce constructive successful

coping styles for patients who are dealing with coronary heart disease.

Key words: content analysis, coping strategies, coronary heart disease

What does this paper contribute

to the wider global clinical

community?

• An awareness of the need todevelop culturally sensitive andculturally appropriate copingstrategies.

• Identification of some of themajor elements of such strate-gies, which can become the basisfor defining appropriate strate-gies in other populations.

• Knowledge about the role ofboth cognitive and noncognitivemechanisms for coping with achronic illness.

Accepted for publication: 30 May 2013

Authors: Tahereh Najafi Ghezeljeh, BScN, MScN, PhD, Assistant

Professor and Lecturer, The Nursing & Midwifery Care Research

Center, Faculty of Nursing and Midwifery, Tehran University of

Medical Sciences, Tehran, Iran; Azita Emami, PhD, RN, RNT,

Professor, Dean of College of Nursing, Seattle University, Seattle,

WA, USA

Correspondence: Tahereh Najafi Ghezeljeh, Assistant Professor and

Lecturer, Faculty of Nursing and Midwifery, Tehran University of

Medical Sciences, Nosrat St., TohidSq., 1419733171 Tehran, Iran.

Telephone: +98-21-61054323, +98-935-9838447

E-mail: [email protected]

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.12428 1

Introduction

Coronary heart disease (CHD) is a major cause of morbid-

ity and mortality around the world, including Iran (Hatmi

et al. 2007). Three-fourths of CHD mortalities happen in

low-income and middle-income countries (Gaziano et al.

2010). In Iran, about 138,000 deaths (40% of total deaths)

annually occur as a result of CHD (Naghavi & Jafari

2007).

Patients with CHD experience a wide range of physical

and psychological issues, including uncertainty and fear

(Anyadubalu 2010), physical limitations, role changes, loss

of the active self and changes in lifestyle (Kristofferzon

et al. 2007, White et al. 2007). Coping strategies are ways

of controlling and reducing the consequences of illness and

its symptoms and directing patients towards adjustments

that improve their quality of life (Brannon & Feist 2010).

Consciously or not, patients adopt one or more strategies

for coping with their altered status. Many patients are will-

ing to consider explicit coping strategies to manage their

condition and reduce the impact of the illness if such strate-

gies are presented to them (Larsen & Lubkin 2009).

This study seeks to identify and explore the variety and

complexity of coping strategies used by patients with CHD.

Background

Some quantitative research has described coping strategies

among Iranian patients with CHD. One study found that

patients experienced stress and exercised insufficient coping

strategies (Heydaripahlavian et al. 2010). Others have

shown an association between perceived recovery and

negative, emotionally focused coping (Pourang & Besharat

2011), a relationship between problem-focused coping strat-

egies and reduction in stress and promotion of quality of life

(Nohi et al. 2011), and the effectiveness of education for

coping with CHD consequences (Seyam et al. 2011).

However, these studies did not describe in detail the dif-

ferent strategies patients with CHD used to cope with their

situations. To obtain a complete and detailed description of

CHD patients’ coping strategies, as well as to build a theo-

retical framework that could provide hypotheses to be fur-

ther tested through quantitative approaches (Klaassen et al.

2006), a qualitative study was conducted.

Coping strategies have been studied for many illnesses

and injuries in Iran, including spinal cord injury (Bab-

amohamadi et al. 2011), epilepsy (Hosseini et al. 2010),

leukaemia, for which hematopoietic stem cell transplanta-

tion is being undertaken (Farsi et al. 2010), and breast

cancer (Taleghani et al. 2006).

A review of the literature found limited studies on coping

strategies used by Iranian patients with CHD. In a study of

acute myocardial infarction (AMI), a healthy lifestyle,

appreciating life/health and improved social/interpersonal

relationships were identified as positive effects following ill-

ness (Afrasiabifar et al. 2011).

Studies in other countries have also explored coping pro-

cesses in patients who have experienced an AMI. Using

grounded theory studies, Brink et al. (2006) identified reori-

enting the active self as a core concept in patients’ readjust-

ment five months after a first-time AMI, and Sutherland

and Jensen (2000) described living with change in reconcili-

ation with AMI in older women.

One of the important nursing interventions is facilitating

a patient’s accommodation to his or her condition,

especially when it is a chronic disease or permanent injury.

This mandates that we develop a deeper understanding of

patients’ coping strategies for controlling illness and its con-

sequences. Such an understanding is essential if nurses are

to play a pivotal role in supporting patients as they seek,

find and implement the strategy or strategies that are opti-

mal for them. As coping is deeply embedded in cultural,

class and other contexts, we must identify and describe

those contexts as a necessary first step.

Methods and design

This study seeks to identify and explore the variety and

complexity of coping strategies used by patients with CHD.

A qualitative study using semi-structured interviews and

content analysis was conducted in Tehran, Iran, from

2009–2011. A qualitative approach provides deeper under-

standing of a phenomenon that cannot be investigated

through quantitative methods (Burns & Grove 2009). This

method is appropriate for understanding coping as a conse-

quence of social interactions within different contexts

(Sandelowski 2000), and it is useful for broad description

and providing knowledge about subjective and emotional

phenomena, including coping (Elo & Kyngas 2008).

Participants

Participants were patients hospitalised at a large, urban hos-

pital in Tehran. The patients’ demographics and reasons for

hospitalisation are summarised in Table 1. All participants

had been diagnosed with CHD (based on documented angio-

graphic results) and were experiencing angina pectoris (AP).

Purposive sampling was performed with maximum varia-

tion regarding age, sex, marital status and level of educa-

tion. Inclusion criteria were willingness to participate and


2 Journal of Clinical Nursing

T Najafi Ghezeljeh and A Emami

ability to speak Persian. Exclusion criteria were being too

ill to participate or having had AMI or coronary revascular-

isation in the previous six months (acute or recovery

phase).

Nurses in hospital cardiac units in Tehran helped recruit

a sample of 24 patients. The criterion for sample size was

data saturation, meaning that data collection ended when

no new data were obtained and no new category emerged

(Burns & Grove 2009).

Data collection and analysis

Data collection and analysis took place simultaneously. The

researcher first described the objectives of the study to each

potential participant. If he or she agreed to participate,

informed consent was obtained. Individual semi-structured

interviews were conducted in a private room on each unit.

Interviews were digitally audiotaped. One interview was

conducted with each informant, which lasted 80–120 min-

utes. Each interview started with a general question, such

as asking for information about the participant’s health.

Then, questions were asked regarding the patient’s experi-

ences and his or her understanding of coping strategies for

dealing with the illness and its effects. The participants

were encouraged to extend their answers (by being asked,

for example, ‘Would you mind explaining more about

this?’). This enhanced the information quality and deepened

our understanding of the patients’ coping strategies.

Each interview was transcribed and analysed before the

next one was conducted. The transcripts were read and

reviewed several times. A qualitative content analysis was

used to interpret the data and develop categories and subcate-

gories for describing the coping strategies (Sandelowski 2000,

Elo & Kyngas 2008). Figure 1 presents a flow diagram of the

analysis process. Analysis began with line-by-line open

coding. Through constant comparative methods, codes were

grouped and collapsed into subcategories according to their

differences and similarities. The subcategories related to and

belonging to a group were considered in categories, and

related categories were collapsed into a main one. At each

step, the authors reviewed the work to reach consensus. The

analysis continued until all the categories were integrated into

main categories that were then developed into thematic ele-

ments illustrating the CHD patients’ coping strategies. An

example of this data analysis is shown in Table 2.

To ensure the trustworthiness of the study, its credibility,

confirmability, transferability and dependability were taken

into consideration.

Credibility was established through peer checking (two

experts in qualitative analysis reviewed the analysis and

confirmed that 90% of codes and categories were accurate

and in line with their analysis of the data). A member

check was conducted by having six participants who were

accessible verify that the codes and categories were aligned

with their expressed experiences. In addition, the codes

and categories were checked with patients with CHD who

did not participate in the current study to ensure the

transferability of the analysis in similar situations. Maxi-

mum sampling variation and achieving saturation were

applied, which contributed to establishing confirmability.

Direct quotes from study subjects were included in the

presentation of results to further establish dependability

and transferability.

Ethical considerations

Ethical approval for the study was granted by the research

ethics committee of the Ministry of Health and Education

in Iran. Informed consent was obtained, and the partici-

pants’ rights were further assured by the voluntary nature

of all participation, anonymity of the gathered information

and extensive efforts to maintain confidentiality.

Results

The study population was evenly divided between male and

female gender. The participants’ mean age (SD) was 53�33(8�24) years and mean disease duration (SD) was 4�38 (4�87)

Table 1 Characteristics of the participants

Demographic characteristics F (%) Mean � SD

Age 53�40 � 8�32Sex

Male 12 (50%)

Female 12 (50%)

Level of education

Little or no formal

education

5 (20�83)

Less than high school 10 (41�67)High school 2 (8�33)Diploma and university 7 (29�17)

Marital status

Married 19 (79�17)Widow 5 (20�83)

Disease duration

Less than 1 year 6 (25�00)1–4 years 10 (41�67)More than 5 years 8 (33�33)

Hospitalised for

An acute phase of illness 10 (41�67)Angiography 6 (25�00)Angioplasty 8 (33�33)


Journal of Clinical Nursing 3

Original article Coping strategies and CHD

years. About 80% were married and the remainder were wid-

owed. Of the participants, 62�5% had no education or less

than a high school education, about 8�5% had a high school

education, and the remaining 29% had some higher education.

‘Coping strategies’ in this study refers to the set of

actions and behaviours used by participants living with

CHD to overcome an illness and its consequences and live

as normally as possible. During the data analysis, six cop-

ing strategies in patients with CHD were identified: search-

ing for meaning and information; physical adjustments

(trying to achieve comfort and control; and resting more,

doing less and slowing down); motivating, prioritising and

caring for self; turning to religion and spirituality; and

altering expectations and receiving assistance and support.

Searching for meaning and information

Searching for causality

Participants tried to explain the ‘whys’ of suffering from

CHD. Through explaining cause of the illness, the partici-

pants attempted to understand their condition: ‘Why did I

get such a disease? What was the reason? I know I have

got a heart disease; however, I ask myself why I got it’

(P4, female, 57). Participants’ explanations about causality

classified into risk factors, stressors as cause of CHD and

divine punishment or cursed.

P15 (male, 45) explained, ‘Heart disease is a genetic

problem in our family. The fat level in my blood is so high

and I have got [high] blood pressure, as well’. Among par-

ticipants, stress was commonly mentioned as a cause of

their disease. ‘Stress was the main reason for my illness’

(P16, male, 45). Participants noted losing a loved one

(because symptoms started following that crisis) and inter-

personal relationships as sources of stress. P4 (female, 57)

said, ‘My son drowned in Karaj Dam Lake. My entire

problem started since I lost him. I hit my chest and cried a

lot’. P6 (female, 71) mentioned her disputes/conflicts with

her parents-in-law. ‘I used to live with my husband’s fam-

ily…in terms of culture we were so different…little by little

it affected me…and now I have heart disease’.

A few of the female participants believed that the disease

originated from ‘bad’ behaviours in relationships with oth-

ers and that the disease was a penalty from God for their

actions. ‘I always think perhaps I have done something

wrong that I have become sick. I have had a quarrel with

my mother-in-law; I think she has cursed me and as a result

I have got the disease. I believe if you bother others, you

will be punished. It was my own fault. I think she has

cursed me and I have become sick. I feel regret about

behaving like that’ (P6, female, 71).

Searching for information

Some participants sought information about their condition.

They explained that they used information from media,

books or other patients with CHD to assist them in address-

ing unanswered questions. P16 (male, 45) said, ‘I try to read

Line by line open coding

Interviewing and transcribing

Grouping codes intosubcategories

Constant comparison

Searching formeaning andinformation

Trying toachieve comfortand control

Resting more,doing less, andslowing down

Motivating,prioritising, andcaring for self

Turning to religion andspirituality

Receivingassistanceand support

Strategies for re-creating normal lifeFigure 1 Flow diagram of the analysis pro-

cess.




about what is happening to me, about illness and foods’. And

P15 (male, 45) said, ‘When one faces a problem, he tries to

get more information about it. When I faced the problem, I

tried to get more information about it to be used in case I

need to be cared for in emergency situations’.

Trying to achieve comfort and control

Participants pointed out their efforts to achieve comfort

and control by using cognitive methods, including distract-

ing themselves, comparing self with others for minimisation

and communicating with other patients. Distracting

themselves through involvement in activities such as house-

hold work, travelling and relationships with family or

friends were given as ways of diverting themselves from

their concerns and forgetting their worries. Some of the

participants compared themselves with others with worse

situations, in an attempt to minimise the suffering from

their illness. In addition, they compared their current condi-

tion with how they felt prior to initiating the treatment and

acknowledged that they felt much better now than they had

before diagnosis and treatment.

Table 2 Coping strategies used by patients with coronary heart disease: examples of codes and categories

Examples of codes Subcategories Categories

Appreciation of life

Hope for a cure

Adhering to treatment

because of children

Motivating Motivating, prioritising,

and caring for self

Coping strategies used by

patients with CHD

Health as top priority

Wanting to be alive

Prioritising self-health

Cooking separate meals

Quit smoking

Difficulties related to preparing food

Avoiding stressors

Managing comorbidities

Modifying risk factors and

changing lifestyle

Seeking why

Understanding reasons

Searching for cause Searching for cause

and information

Using information from media

Using information from books

Learning about illness

Searching for information

Distracting through travelling

Minimising negative emotions

Distracting through housework

Distracting Achieving comfort

and control

Comparing one’s self with other patients

with worse condition

Comparing one’s self with old and

disabled patients

Feeling relaxation through comparison

Minimising one’s condition through comparing

Comparing to minimise

Socialisation with colleagues

Communicating with family members

Visiting with family

Talking with family members

Communicating

Resting more and slowing down tempo

Resting and working intermittently

Reducing activities

Distributing tasks over several days

Resting more and

slowing down

Doing less

Resting more, doing less

and slowing down

Expectations from family members Expectations Expectations and

accepting assistanceDistributing tasks among family members

Accepting assistance from family members

Handing over responsibilities to colleagues

Taking assistance

Supplication

Relying on God

Religious activities Turning to religion

and spirituality

Beliefs about God’s will

Beliefs about God’s control over everything

Religious beliefs




Some found the research interview helpful as a way to

relieve their stress. P5 (male, 54) said, ‘I try to keep in

touch with others and talk with other people to recover my

spirits and manage to tolerate pain better than before’.

Talking with other patients gave them emotional support

and hope, and they felt that they were not alone. It helped

them to overcome the challenges, as P2 (male, 65)

suggested in saying:

Here in the hospital I have met some patients whose conditions

are worse than me. They are old patients…Thank God I can stand

on my own legs. There are some children here who suffer from

the disease and need to have surgery. When I was the same age as

they are, I didn’t have such a problem…Having met the other

patients, I feel more hopeful…I feel much more calm. I have

accepted it.

After communicating with others, which helped distract

them from their suffering, they felt hope and strength. P11

(female, 51) pointed out, ‘It is just through high spirits that

one can get along with his illness and in case you feel sor-

rowful, it won’t last long. If you keep thinking about your

illness, you will have a short life. If you want to lead a

good life, you should be happy and have high spirits. In

that case, you won’t feel pain on different occasions. Hap-

piness prolongs lifespan’.

Physical adjustments: resting more, doing less and

slowing down

Participants limited their activities or worked more slowly

than usual as a common coping strategy to prevent pain

from increasing or symptoms from starting. Participants

avoided exercise and everyday activities and rested more to

regain their abilities. ‘My speed has been lowered. If I plow

500 m and I feel pain in my heart, I reduce it to 200 m. I

lower my speed. If I see that carrying a load of 10 kg is dif-

ficult for me and causes pain, I will carry a load of 5 kg

instead’ (P16, male, 45). Instead of carrying out all the

tasks on the same day, patients might divide them up over

several days. P3 (female, 51) explained, I have divided my

activities to be done in different periods of the day so that I

don’t become tired. I work a little and after that I rest for a

while. Sometimes I pause to rest, then again continue work-

ing. Although individuals often continued to work, a num-

ber of the male participants reported switching to jobs that

were less challenging. P16 (male, 45) said, I am looking for

an alternative role. I am looking for a job which is less

challenging so that I can hide my weakness and illness.

I am thinking about this.

Motivating, prioritising and caring for self

Participants found their family an important motivator for

surviving. They wanted to be alive to help and support

their family members, especially nonmarried ones, until the

latter became independent and married. ‘Reviewing my

own conditions, I feel I have to keep myself alive to support

my youngest son who is single, and my mother. It is just

because of them that I am here in hospital’ (P6, female,

71). P7 (male, 45) expressed his desire to be alive and to

see his child grow up.

Participants prioritised self-care and survival. P16 (male,

45) explained, ‘At the moment the important issue is being

alive…living and being a patient is better than dying. P19

(female, 55) also said, I just think of my illness and don’t

care about anything else’. The participants wanted to care

for themselves: ‘I need to take care of myself, because no

one can take care of me. I know my condition better than

others’ (P2, male, 65).

Participants described their efforts to care for them-

selves by modifying risk factors and changing lifestyle.

Smoking cessation, managing stress and avoiding stressors,

consuming a healthy diet and controlling comorbidities

were all mentioned. P11 (female, 51) said, ‘I go hiking

regularly with my neighbors or my children. I try to

avoid going to crowded places and funeral ceremonies. I

am on a special diet. I cook something for the family and

special food for myself… I take good care of myself. I

take my pills’.

Turning to religion and spirituality

All of the participants were Muslim, and all mentioned

how religion and spirituality are important in coping with

their illness and its symptoms. Through religious practices,

participants felt hope, strength and energy to tolerate and

cope with their situation. Participants pointed out that

God had control over their lives and everything that

happened to them such as health and illness. But religious

considerations did not prevent them from seeking medical

treatment. P16 (male, 45) said, ‘Whenever human beings

are in threat, they seek shelter, and that’s the Lord. Trust-

ing God leads to tranquility. When you trust the Lord, you

feel secure. P10 (male, 50) pointed out, Illness is given to

us by the Lord, and its cure is provided, as well. In my

opinion the doctor is provided with a cure to solve our

problems. All the things are in the control of God. But we

are responsible for taking care of ourselves’.

Religious practices involved praying, relying on God,

supplication and belief in a higher power. P4 (female, 57)




illustrated it this way: ‘It is through praying that people

become hopeful. We call on Prophet Mohammad’s holy

children (holy Imams) and recite some verses from Quran

to protect us from calamities…doing these things, I feel a

little bit calm. Afterwards, I beg the Lord to cure all the

patients and cure myself, as well’.

Altered expectations and receiving assistance and

support

Most of the participants said they had expectations that

family members and others would help them in dealing

with illness and its limitations. P14 (female, 71) said, ‘In

my opinion, patients expect their families to consider their

conditions and not to put them under pressure…As we try

not to make trouble for them, they are expected to under-

stand the circumstances and behave in a way to make

patients feel at ease’.

Women spoke about their expectation that family

members would support them emotionally and help them

with their tasks. Women reported receiving assistance from

their daughters in ‘housekeeping’ and from their sons in

‘lifting heavy things’. ‘I get help from others. My husband

and my children help me if they are at home’ (P19,

female, 55). Similarly, ‘I get help from my son. He helps

me with the housework. I shouldn’t lift heavy things;

because of this, he does them’ (P21, female, 54). Male

participants often reported transferring responsibilities in

the workplace to colleagues, and they expected their fam-

ily to support them emotionally. ‘At work, I get help for

heavy activities; they [workers] help me to do them. I do

light activities. I don’t put myself under pressure’ (P1,

male mechanic, 42).

In this coping strategy, the importance of family support

became apparent. Family supported the patients with sym-

pathy, increased attention and kind treatment, and by

assuming some of the patient’s responsibilities and assisting

in earning life expenses. ‘My children say, “Mom, you’ll

get better”. They persuade me to visit doctors and follow

up the treatment. They always ask me not to worry about

treatment expenditures and not to be unhappy. They call

me and they sometimes cry on the other end’ (P22, female,

57).

Many of the participants, particularly men, reported

overprotective tendencies in the family. ‘I used to be able to

do everything. Now my husband and my children do not

let me move even one glass…I was the one who did every-

thing but now I am not free to do whatever I want to…

they [family] are afraid of the time that I feel pain in my

heart’ (P19, female, 55).

Discussion

The results of this study illustrate the coping strategies of

Iranian patients with CHD. One strategy involved efforts to

identify the causes of the illness, which could enable

patients to respond effectively and modify risk factors, thus

promoting well-being and quality of life (see Leventhal

et al. 1992). Consistent with previous studies (White et al.

2007, Darr et al. 2008, Kristofferzon et al. 2007, Anyadub-

alu 2010, Farsi et al. 2010), participants attributed their ill-

ness to factors such as stress. In the present study, most

participants had experienced a crisis of loss and interper-

sonal relationships as sources of stress that were not under

their control. In a study of Iranian women, Good (1977)

noted that women attribute their illness to sadness and

grieving over the loss or death of relatives, and worry about

their life conditions and conflicts between family members

and relatives.

Some of the participants looked for information to

increase their knowledge about the disease as a coping

strategy. This is consistent with the findings of Babamoha-

madi et al. (2011) who reported that patients with spinal

cord injury tried to become independent and protect their

autonomy through gathering information about their condi-

tion. Providing information to facilitate this strategy is one

way that nurses can be productive facilitators (Bastable

2008).

One of the common coping strategies we observed was

achieving comfort and control through cognitive methods

(emotionally focused coping) (Folkman & Greer 2000).

This type of coping is used when individuals need to

increase their tolerance to the stressor (Folkman & Greer

2000). Iranian patients with leukaemia who were undergo-

ing stem cell transplantation used comparing, distracting

and similar techniques to manage the emotional effects of

their illness (Farsi et al. 2010). Hosseini et al. (2010) sug-

gested that Iranian patients with epilepsy tried to defend

themselves by downplaying the illness through comparison

of their conditions with those of other patients with more

severe situations.

The majority of the participants in this study, in

agreement with the findings of Brink et al. (2006), limited

their activities in an attempt to avoid exacerbation of their

illness and/or symptoms. Pihl et al. (2010) pointed out that

this is counterproductive because reducing or eliminating

activities can lead to underperformance, while reducing

physical fitness and angina pectoris thresholds. Smeltzer

et al. (2010) pointed out that such outcomes increase the

heart’s demand for oxygen. It is important that nurses

encourage patients to participate in physically tolerable




activities within their cardiac rehabilitation programmes.

Health education to explain the positive impact of physical

activity is very important and can improve the functional

status of patients (Balady et al. 2007).

One of the coping strategies identified in our study was

the participants’ strong motivation to prioritise their health

and self-care. Through motivation, they had recognised and

realised the value of behaviours and integrated them into

their lives (Deci & Ryan 2008). Afrasiabifar et al. (2011)

found that appreciating life and prioritising one’s health

were considered positive outcomes affecting AMI. Farsi

et al. (2010) pointed out that dealing with new circum-

stances makes some patients reconsider their priorities. It

seems that patients consider their health as a very impor-

tant issue in their life. This then directs them to manage ill-

ness and its consequences.

Another important coping strategy was the participants’

managing their illness and its consequences through

changes in lifestyle, and by modifying risk factors (prob-

lem-focused coping). Similar responses have been seen in

patients with epilepsy, who try to fight their illness by mak-

ing positive changes in their lifestyle (Hosseini et al. 2010).

Condon and McCarthy (2006) cited the importance of life-

style modifications to AMI patients. As Folkman and Greer

(2000) noted, patients try to alter the sources of illness

including habits, activities and behaviours to control the sit-

uation. These changes were considered positive in a study

by Afrasiabifar et al. (2011). A healthy lifestyle, such as

quitting smoking or eating low-fat foods with less salt, has

been shown to be a positive change after a cardiac event

(White et al. 2007, Afrasiabifar et al. 2011).

The most common coping strategy found in our study

was turning to religion and spiritual practices (meaning-

based coping) (Folkman & Greer 2000). This is in line with

previous findings (Hosseini et al. 2010, Taleghani et al.

2006, Farsi et al. 2010, Babamohamadi et al. 2011). Hos-

seini et al. (2010) reported that patients with epilepsy

confronted illness by using religion. Ebadi et al. (2009), in

a study of coping strategies in Iranian people affected by

mustard gas, found spirituality to be a major factor in

adjustment to chronic illness.

In a study of patients with breast cancer, religious faith

was the key factor to cope with illness (Taleghani et al.

2006). This demonstrates how religious beliefs (everything

is in God’s control) and practices facilitate the problem-

solving strategies and compliance and give patients a sense

of protection, safety and confidence. Through religious

belief, patients try to gain intimacy, comfort and control

over their condition and confront their illness (Klaassen

et al. 2006). This leads to accepting responsibility for

self-care and consideration of a healthy lifestyle (Cum-

mings & Pargament 2010) for achieving psychophysical

well-being and better social interactions (Bonet 2009). This

is why religious beliefs and participating in religious prac-

tices and group activities can be useful for patients with

CHD (Anyadubalu 2010). Healthcare providers and nurses

should increase their awareness of patients’ religious

beliefs and plan for the delivery of holistic and culturally

sensitive care (Galanti 2008) that incorporates these

beliefs.

One of the important coping strategies identified in our

study was expecting and receiving family support and

assistance. Patients expected and received emotional and

informational support as well as instrumental support

from their families. Patients with other diseases such as

epilepsy (Hosseini et al. 2010) and breast cancer (Tale-

ghani et al. 2006) have reported seeking support to pro-

mote successful adjustment. For the Iranian people, the

family is the main source of support when confronting

overwhelming life situations (Behjati-Sabet & Chamber

2005). Family support may improve the patient’s health

and restore positive emotions that are needed for dealing

with an illness (Lett et al. 2005). However, congruent with

the study of Condon and McCarthy (2006), some partici-

pants experienced excessive family support that seemed to

be grounded in the family members’ fears of losing the

patient.

This study was conducted on hospitalised patients with

an established diagnosis of illness. It would be useful to

undertake studies on newly diagnosed patients, whose

responses may differ in the acute phase, and patients in

other settings such as home and community, to help iden-

tify any relevant differences in the way behavioural coping

strategies are employed.

Conclusion

A variety of coping strategies were used by Iranian

patients with CHD to deal with their illness and its

impacts on life and to recreate (to the extent possible) nor-

mal life.

One of the important coping strategies was religious

practices. Further research is essential for exploring how

religious and cultural beliefs influence patients in coping

with illness and its effects. Another important coping strat-

egy was receiving assistance from family, but more investi-

gation is needed to fully understand the role of family

support for patients with CHD.

As many patients used cognitive methods for achieving

comfort and control, investigating the effectiveness of dif-




ferent cognitive-behavioural strategies on CHD patients’

physical and psychological well-being is recommended.

Relevance to clinical practice

This study contributes to the existing body of knowledge

about nursing care for patients with CHD to promote qual-

ity of care. Through increasing awareness of coping strate-

gies, nurses can use appropriate tools and reinforce

constructive coping styles that help these patients in dealing

with their condition.

It is essential that nurses recognise those patients who are

not adapting to their condition and direct them to resources

that will assist in developing effective and constructive cop-

ing strategies. There are a variety of strategies that can be

used in varying proportions, based on factors such as a

patient’s religious beliefs, cultural and educational back-

ground, family circumstances and other personal factors.

The goal is to develop a holistic care plan that uses knowl-

edge of the patient as the basis for referring patients to

rehabilitation programmes (focusing on risk factor modifi-

cation, healthy diet, and exercise and activity) and for plan-

ning educational sessions, including informational sessions

about how to better use family, religious/spiritual and other

resources available to them.

Acknowledgements

The authors would like to thank the Swedish Institute,

AMF Pension, Department of Neurobiology, Care Sciences

and Society, Division of Nursing at Karolinska Institutet,

Sweden, the College of Nursing at Seattle University, USA,

and Faculty of Nursing and Midwifery at Tehran University

of Medical Sciences, Iran, for their support. The authors

would like to thank Dr. Brian Weiss for the English editing

and finalising efforts.

Disclosure

The authors have confirmed that all authors meet the IC-

MJE criteria for authorship credit (www.icmje.org/ethi-

cal_1author.html), as follows: (1) substantial contributions

to conception and design of, or acquisition of data or

analysis and interpretation of data, (2) drafting the article

or revising it critically for important intellectual content,

and (3) final approval of the version to be published.

Conflict of interest

The author(s) declare that they have no conflict of

interest.

References

Afrasiabifar A, Hassani P, Fallahi Khoshk-

nab M & Yaghmaei F (2011) Positive

effects of illness following acute myo-

cardial infarction. Iran Journal of

Nursing 24, 30–38.

Anyadubalu C (2010) The experiences of

coronary heart disease patients: bio-

psychosocial perspective. International

Journal of Human and Social Sciences

5, 614–621.

Babamohamadi H, Negarandeh R &

Dehghan-Nayeri N (2011) Coping

strategies used by people with spinal

cord injury: A qualitative study. Spinal

Cord 49, 832–837.

Balady GJ, Williams MA, Ades PA, Bittner

V, Comoss P, Foody JM, Franklin B,

Sanderson B& Southard D (2007) Core

components of cardiac rehabilitation/

secondary prevention programs: 2007

update.Circulation 115, 2675–2682.

Bastable S (2008) Nurse as Educator: Prin-

ciples of Teaching and Learning for

Nursing Practice, 3rd edn. Jones and

Bartlett, Sudbury, MA.

Behjati-Sabet A & Chamber N (2005) Peo-

ple of Iranian descent. In Cross-Cultural

Caring: A Handbook for Health Profes-

sionals (Waxler-Morrison N, Anderson

JM & Chambers N eds). 2nd edn. UBC

Press, Vancouver, BC, pp. 127–162

Bonet N (2009) The Impact of Spiritual

Well-Being and Stressful life Experi-

ences on Traumatic Stress. Seton Hall

University, South Orange, NA.

Brannon L & Feist J (2010) Health Psy-

chology: An Introduction to Behavior

and Health, 7th edn. Wadsworth Cen-

gage Learning, Belmont, CA.

Brink E, Karlson B & Hallberg L (2006)

Readjustment 5 months after a first-

time myocardial infarction: reorienting

the active self. Journal of Advanced

Nursing 53, 403–411.

Burns N & Grove S (2009) The Practice

of Nursing Research: Appraisal,

Synthesis, and Generation of Evidence,

6th edn. Saunders, Philadelphia, PA.

Condon C & McCarthy G (2006) Lifestyle

changes following acute myocardial

infarction, patients perspectives.

European Journal of Cardiovascular

Nursing 5, 37–44.

Cummings JP & Pargament KI (2010)

Medicine for the spirit: religious

coping in individuals with medical

conditions. Religions 1, 28–53.

Darr A, Astin F & Atkin K (2008) Causal

attributions, lifestyle change, and cor-

onary heart disease: illness beliefs of

patients of South Asian and European

origin living in the United Kingdom.

Heart & Lung: The Journal of Acute

and Critical Care 37, 91–104.

Deci E & Ryan M (2008) Self-determina-

tion theory: a macrotheory of human

motivation, development, and health.

Canadian Psychology 49, 182–

185.

Ebadi A, Ahmadi F, Ghanei M & Kaze-

mnejad A (2009) Spirituality: A key

factor in coping among Iranians

chronically affected by mustard gas in

the disaster of war. Nursing and

Health Sciences 11, 344–350.




Elo S & Kyngas H (2008) The qualitative

content analysis process. Journal of

Advanced Nursing 62, 107–115.

Farsi Z, Dehghan Nayeri N & Negarandeh

R (2010) Coping strategies of adults

with leukemia undergoing hematopoi-

etic stem cell transplantation in Iran: a

qualitative study. Nursing & Health

Sciences 12, 485–492.

Folkman S & Greer S (2000) Promoting

psychological well-being in the face of

serious illness: when theory, research

and practice inform each other.

Psycho-oncology 9, 11–19.

Galanti GA (2008) Caring for Patients

from Different Cultures, 4th edn. Uni-

versity of Pennsylvania Press, Philadel-

phia, PA.

Gaziano TA, Bitton A, Anand S, Abrahams-

Gessel S & Murphy A (2010) Growing

epidemic of coronary heart disease in

low- and middle-income countries. Cur-

rent Problems in Cardiology 35, 72–115.

Good B (1977) The heart of what’s the

matter: the semantics of illness in Iran.

Culture, Medicine and Psychiatry 1,

25–58.

Hatmi Z, Tahvildari S, Motlag AG &

Kashani AS (2007) Prevalence of coro-

nary artery disease risk factors in Iran: a

population based survey [Electronic

Version]. BMC Cardiovascular Disor-

ders 7. Available at: http://www.ncbi.

nlm.nih.gov/pmc/articles/PMC2200651/

pdf/1471-2261-7-32.pdf (accessed March

2011).

Heydaripahlavian A, Gharakhani M &

Mahjoub H (2010) A comparative

study of stressful life events and stress

coping strategies in coronary heart dis-

ease patients and non-patients. Scien-

tific Journal of Hamadan University of

Medical Sciences and Health Services

17, 33–38.

Hosseini N, Sharif F, Ahmadi F & Zare M

(2010) Striving for balance: coping

with epilepsy in Iranian patients.

Epilepsy & Behavior 18, 466–471.

Klaassen DW, McDonald MJ & James S

(2006) Advances in the study of reli-

gious and spiritual coping. In Hand-

book of Multicultural Perspectives on

Stress and Coping (Wong L ed.).

Springer, New York, NY, pp. 105–

132.

Kristofferzon M, L€ofmark R & Carlsson

M (2007) Striving for balance in daily

life: experiences of Swedish women

and men shortly after a myocardial

infarction. Journal of Clinical Nursing

16, 391–401.

Larsen P & Lubkin I (2009) Chronic Illness:

Impact and Intervention, 7th edn.

Jones and Bartlett Publishers, Sudbury.

Lett H, Blumenthal J, Babyak M, Strau-

man T, Robins C & Sherwood A

(2005) Social support and coronary

heart disease: epidemiologic evidence

and implications for treatment. Psy-

chosomatic Medicine 67, 869–878.

Leventhal H, Diefenbach M & Leventhal

E (1992) Illness cognition: using com-

mon sense to understand treatment

adherence and affect cognition interac-

tions. Cognition Therapy Research 16,

143–163.

Naghavi M & Jafari N (2007) Death Pro-

file in Iran, 2005. Iranian Ministry of

Health, Tehran.

Nohi E, Abdolkarimi M & Rezaeian M

(2011) Quality of life and its relation-

ship with stress and coping strategies

in coronary heart disease patients.

Journal of Rafsanjan University of

Medical Sciences and Health Services

10, 127–137.

Pihl E, Fridlund B & M�artensson J (2010)

Patients’ experiences of physical limi-

tations in daily life activities when suf-

fering from chronic heart failure: a

phenomenographic analysis. Scandina-

vian Journal of Caring Sciences 9.

Available at: http://onlinelibrary.wiley.

com.proxy.kib.ki.se/doi/10.1111/j.1471-

712.2010.00780.x/pdf (accessed 12

May 2011).

Pourang P & Besharat MA (2011) An

investigation of the relationship

between coping styles and psychologi-

cal adaptation with recovery process

in a sample of coronary heart disease

patients. Social and Behavioral Sci-

ences 30, 171–175.

Sandelowski M (2000) Whatever happened

to qualitative description? Research in

Nursing and Health 23, 334–340.

Seyam S, Hidarnia AR & Tavafian S

(2011) Self-care education through

coping style for patients after heart

surgery. Journal of Isfahan Medical

School 29, 433–444.

Smeltzer S, Bare B, Hinkle J & Cheever K

(2010) Brunner and Suddarth’s Text-

book of Medical Surgical Nursing,

12th edn. Lippincott Williams &

Wilkins, Philadelphia, PA.

Sutherland B & Jensen L (2000) Living

with change: elderly women’s percep-

tions of having a myocardial infarc-

tion. Qualitative Health Research 10,

661–676.

Taleghani F, ParsaYekta Z & Nikbakht

Nasrabadi AR (2006) Coping with

breast cancer in newly diagnosed

Iranian women. Journal of Advanced

Nursing 54, 1–9.

White J, Hunter M & Holttum S (2007)

How do women experience myocar-

dial infarction? a qualitative explora-

tion of illness perceptions, adjustment

and coping. Psychology, Health and

Medicine 12, 278–288.




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