ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Hope in elderly adults with chronic heart failure. Concept analysis

La esperanza en adultos mayores con insuficiencia cardíaca crónica. Análisis de concepto

A esperança em adultos maiores com insuficiência cardíaca crônica. Análise de conceito

Meriam F. Caboral¹; Lorraine S. Evangelista²; Martha V. Whetsell³

¹RN, MSN, NP-C, SUNY Downstate Medical Center Brooklyn –NY-, United States. meriam.caboral@downstate.edu.

²RN, Ph.D., FAHA, FAAN, University of California Irvine, United States. l.evangelista@uci.edu.

³RN, Ph.D., ARNP, Lehman College of the City University of New York, United States. martha.whetsell@lehman.cuny.edu.

Receipt date: January 14^th 2012. Approval date: September 19^th 2012.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Caboral MF, Evangelista LF, Whetsell MV. Hope in elderly adults with chronic heart failure. Concept analysis. Invest Educ Enferm. 2012;30(3):406-411

ABSTRACT

This topic review employed Walker and Avant's method of concept analysis to explore the construct of hope in elderly adults with chronic heart failure. The articles analyzed revealed that hope, as the belief of the occurrence of a positive result without any guarantee that it will be produced, is necessary for the survival and wellbeing of the elderly adults enduring this disease.

Key words: aged; heart failure.

RESUMEN

En este artículo se presenta una revisión del tema en el que se empleó el método de análisis de concepto de Walker y Avant para explorar el constructo de la esperanza en adultos mayores con insuficiencia cardíaca crónica. Los artículos analizados mostraron que la esperanza, como la creencia de la ocurrencia de un resultado positivo sin ninguna garantía de que se va a producir, es necesaria para la supervivencia y el bienestar de los adultos mayores que sufren esta enfermedad.

Palabras clave: anciano; insuficiencia cardíaca.

RESUMO

Apresenta-se neste artigo uma revisão de tema no que se empregou o método de análise de conceito de Walker e Avant para explorar o constructo da esperança em adultos maiores com insuficiência cardíaca crônica. Os artigos analisados mostraram que a esperança, como a crença da ocorrência de um resultado positivo sem nenhuma garantia de que vai produzir, é necessária para a sobrevivência e o bemestar dos adultos maiores que sofrem esta doença.

Palavras chaves: idoso; insuficiência cardíaca.

INTRODUCTION

Heart failure (HF) is a growing epidemic characterized by the progressive decline of cardiac performance and functional status.¹ Despite advances achieved in medical management, HF continues to present challenges in hospitalization, morbidity and mortality rates.² Varying with the severity of the disease and the underlying etiology of HF, the illness trajectory can be a rapid downward spiral with no hope of cure.³ Patients with HF usually present with substantial and progressive symptoms, such as breathlessness, fatigue, and angina that are debilitating,^4,5 marked psychological distress associated with reduced quality-of-life indices, and poor clinical outcomes.^6,7 To offset the downward trajectory and feelings of hopelessness associated with worsening HF nurses need to apply additional or alternative therapies which might better palliate the psychosocial distress that many patients experience. This can only begin when nurses make the effort to gain knowledge related to the concept or concepts of interest.

Evangelista and colleagues⁸ described the experiences of hope in women following heart transplant surgery, but less is known about hope in patients with HF. Although hope has been linked to health and has been shown to influence the way an individual adapts to a life-threatening condition,⁹ hope in the context of HF is poorly understood. Thus, the purpose of this paper is to explore the concept of hope in older adults with HF using Walker & Avant's¹⁰ method of concept analysis. Walker & Avant¹⁰ describe the systematic steps for concept analysis as follows: (1) identify construct; (2) determine the purpose(s) of the analysis; (3) identify the uses of the concept; (4) define attributes of the construct; (5) identify model case; (6) develop additional cases; (7) ascertain antecedents and consequences; and (8) define empirical referents.

Search methods

Experts agree that reviewing relevant literature is how to begin exploring a concept. For this analysis, a literature search was performed on the following electronic databases: PubMed, CINAHL, Embase, ProQuest, PsyInfo, Cochrane Library, and related websites using the main keywords of hope and heart failure. The search was limited to those citations published or translated in English and studies done in the U. S., except for articles related to HF. The search generated 751 results; 95 articles were isolated and 15 articles reviewed for the purpose of this paper.

Uses of the concept

Dictionary definition. The dictionary definition of hope is ''to want something to happen and to believe that this something will or might happen for a variety of reasons''.¹¹ Roget's Thesaurus¹² defines hope as ''to long for, and to dream about''. Hope is synonymous with anticipate, aspire, believe, cherish, foresee, pray, and trust. Fear, despair, disbelief, and hopelessness are the opposites of hope.

Hope from the perspectives of other disciplines. The concept of hope is universal and it has been explored from the perspectives of philosophy, theology, social sciences, psychiatry, and nursing. Hope is one of the theological virtues: faith, hope, and charity.¹³ In Greek mythology, hope was in the form of metaphors such as Pandora's box in which, after all the struggles that were brought into the world when it was opened, hope was the only good thing left in the box.¹⁴ Viktor Frankl¹⁵ described one of the human emotions in a Nazi concentration camp as being hopeful. In contrast, Nietzsche¹⁶ believed that ''in reality, hope is the worst of all evils, because it prolongs man's (sic) torment'' (p.71).

Definitions of hope. A myriad of definitions and descriptions of hope have appeared in the literature. Snyder and colleagues¹⁷ defined hope as a cognitive set that is comprised of agency, goal-directed determination and pathways, and planning of ways to achieve the desired goals. In psychiatry, hope is a dynamic, and future referenced variable that is concerned with the individuals' achievement of his/her positive goals, outcomes, or states judged as being at least potentially possible.¹⁸ In nursing, Parse's¹⁹ human becoming perspective defined hope as a universal lived experience of health propelled with the envisioned possibilities of everyday living; to hope is to ''recognize the limitations in situations, while believing that opportunities exist''. Hope according to Dufault and Martocchio²⁰ is a ''multidimensional dynamic life force characterized by a confident yet uncertain expectation of achieving future good which, to a hoping person, is realistically possible and personally significant'' (p. 380). It is a process of anticipation that acts as a way of thinking, feeling, acting and relating that is focused towards fulfilling what is personally meaningful.^21,22

Hope in people with heart failure. Substantive articles were found in the nursing literature examining the concept of hope with terminal and critical illness, cancer, HIV/AIDS, spinal cord injuries, and the homeless.^10,23-27 However, there is a paucity of data about the construct of hope in people with HF over the past two decades. Adherence, quality of life, and self-care are the most commonly explored themes in HF.^28,29 The most recently explored constructs in HF are spirituality, fatigue, pain, and coping.^7,8,30 Rideout and Montemuro³¹ were the first to examine hope in adults with HF who asserted that hopeful adults maintain life involvement despite physical limitations imposed by the disease. The four dimensions of hope and a hope model were used to develop nursing interventions to foster hope in patients with adults hospitalized with HF.^9,32 Phenomenological studies among men and women showed that one of men's life perceptions is feeling a belief in a future in which he does what he can to manage with hope of no further deterioration.^33,34 Hope was noted to be an independent predictor of mood states and quality of life among heart transplant recipients.^3,8 A study by Rustoen and colleagues3 described a ''response shift'' that occurs in patients hospitalized with HF as a way of adapting to a life-threatening illness. Davidson and colleagues^35,36 evaluated the relevance of HF illness trajectory and developed a ''maintaining hope in transition'' theoretical framework that was suggested to be used in developing nursing intervention.

Defining attributes

Future orientation. Heart failure is a disease that affects older adults. Future orientation varies across the age continuum and can be time specific or non-time specific.⁹ The future in older adults is the anticipation of a future in each day lived.³⁷ Older adults are more concerned about their past rather than their future.³ They look at their past successes as a way to nurture their hope. These individuals do not necessarily wish to return to their original functional state but rather hope that their condition will not worsen.³²

Sense of limitation. Treatment for HF sometimes requires multi-drug therapy that can be very complex. The HF illness trajectory can be unpredictable and range from being able to function without difficulties to severely limited functional capacity. Hopeful individuals with HF maintain their involvement in life despite the limitations imposed by the illness trajectory.^31,33 A study by Evangelista and colleagues⁸ asserted that having a better functional status does not necessarily translate to a better psychological adaptation.

Cases

Model. Model cases clearly illustrate the attributes of the concept being examined. Hope is demonstrated in the following scenario:

Jeanie B. is a 65-year-old female recently diagnosed with HF who came to the clinic for a follow-up visit. She still complains of being short of breath and can walk only one block. Her history includes poorly controlled hypertension for 15 years, type 2 diabetes mellitus (DM) for 10 years, left leg amputation one year ago secondary to non-healing foot ulcers. During this visit, her nurse practitioner asked her to rate how she was feeling at the time, and Jeannie B. answered, ''I feel 100% fine.'' When asked what makes her feel perfect, she responded enthusiastically, ''I am still alive and not in the hospital today. I am looking forward to dancing at one of my granddaughter's wedding next week. She is getting married at the church where my husband and I were married.''

Borderline. Patrick who is a 39-year-old black male who was recently diagnosed with heart failure came to his clinic telling us that he stopped taking his medications. When the nurse asked why he stopped taking them, he responded, ''I'm having problem having sex since my doctor told me that I have a weak heart. Life has been so good today until this. I have a wonderful girlfriend and we had a highly sexual life, now I do not know what is going to happen next. Oh my God! What am I going to do when I can't have sex anymore?'' Borderline cases contain most of the characteristics of the concepts but not all of them.¹⁰ In this scenario, Patrick has only a vague idea of what his future holds for him after the diagnosis, so he has not adapted to the potential limitations that may be imposed by the illness. However, he has reflected on his past success.

Related. Mark F. is a 60-year-old Hispanic male admitted for placement of a left ventricular assist device secondary to end-stage HF. Mark F. was told that this will replace the functioning of his heart until he receives a new heart. When asked how he is feeling about his treatment he stated, ''I have faith in God that he will guide all of you to make me feel better.''

Hope and spirituality are related concepts that have close interaction between mind and body.³⁵ Spirituality is a way of adjusting to a new life situation by making sense of life priorities.³ Understanding a person's spiritual belief is important in discovering the source of that person's strength, hope, and future orientation.³⁶

Contrary. John S. is a 39-year-old black male who came to his primary physician complaining of chest discomfort. He went to the emergency room for evaluation of heart attack. An electrocardiogram was done with results that were consistent with a myocardial infarction and confirmed by elevated cardiac enzymes. He refused cardiac catheterization, saying he knew he is going to die soon, because heart disease runs in his family. From the initial interview, the nurse noted that his father died at the age of 45 from a massive heart attack. Likewise, his two other brothers died in their 40's from heart attacks. He also left his wife of 10 years and his son two months ago, saying he did not want them to suffer because he believes that he is going to have the same outcome as his father and siblings. This case is contrary to being hopeful because John had already lost hope by believing he will not live past his 40^th birthday.

Walker & Avant¹⁰ explained the contrary cases as ''the clear examples of not the concept.'' Hopelessness is the polar opposite of hope that represents the contrary case. John S. did not perceive any future past his 40^th birthday

Antecedents and consequences

Walker & Avant¹⁰ describes antecedents as events or situations that must occur prior to the concept. Suffering and despair brought by HF are considered antecedents of hope in this disease condition. The disease is chronic and can be debilitating. The HF illness trajectory can be unpredictable. Symptoms can range from mild to severe causing decreased functional capacity that can cause undue suffering and despair to someone with the disease.

Consequences are the events that can happen if hope occurs.¹⁰ The ability to achieve goals is the ultimate indicator of success in adults with HF.³² Goals in HF include being able to cope, and experiencing life satisfaction despite the limitations brought by the illness. These are the positive consequences of hope in HF.

Empirical referent

Empirical referent according to Walker & Avant¹⁰ represents categories of the actual phenomenon that by their mere existence demonstrate the occurrence of the concept itself. Adherence to therapy, a sense of well-being, having a positive attitude, and the ability to engage in self-management despite physical limitations could be empirical referents of hope. Several instruments that are valid and reliable are currently in use in research and practice.

Conclusion

Health is ever-changing. Health is a process that is inextricably woven with hope.¹⁹ Heart failure, like other chronic illnesses, can affect someone physically, mentally, and psychologically. People with HF try to find meaning in their everyday existence despite limitations imposed by their illness. Hope is an intangible concept that is difficult to observe, and is imbedded within someone's personal experience. It is a belief that something positive without any guaranteed expectation that it will occur.³⁸ Hope is necessary for survival and well-being.

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