Research and Theory for Nursing Practice: An ...

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Hashemite University, Zarqa, Jordan. Joy Kabasindi Kamanyire, MSN, RN. Sultan Qaboos University, Muscat, Oman. Ahmad H. Abu Raddaha, PhD, RN-BC.
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Research and Theory for

NURSING PRACTICE An International Journal

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Research and Theory for Nursing Practice: An International Journal, Vol. 31, No. 4, 2017

Another Chance at Life: Jordanian Patients’ Experience of Going Through a Myocardial Infarction Ali Ahmad Ammouri, PhD, RN Hashemite University, Zarqa, Jordan

Joy Kabasindi Kamanyire, MSN, RN Sultan Qaboos University, Muscat, Oman

Ahmad H. Abu Raddaha, PhD, RN-BC Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia

Susan Achora, MSN, RN Arwa Atef Obeidat, MSN, RN Sultan Qaboos University, Muscat, Oman

Background and Purpose: Myocardial infarction (MI) is a life-threatening health condition that has physical, spiritual, emotional, and social changes. Understanding feelings and thoughts of patients who suffered MI attacks is essential to recovery. Among Jordanian patients who suffered an acute attack of MI, the aim of the study was to describe the experiences and the varied meanings that they assign to their experiences. Methods: A qualitative hermeneutic phenomenological research design was used. Five participants were engaged in in-depth semistructured interviews. The participants were identified using a purposeful sampling technique, after being admitted at a coronary care unit in a university hospital located in Amman, the capital city of Jordan. The hospital provides a full range of cardiovascular medical and surgical care for patients admitted from different socioeconomic levels. Transcribed data were analyzed following inductive qualitative content analysis method. Results: The experience of MI was a traumatizing event characterized by life-threatening symptoms, and participants feared they would not come back home. However, cultural values and religiosity among the Jordanian patients played a major role in facilitating their positive coping during and after the MI attack. The participants’ recount of their

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http://dx.doi.org/10.1891/1541-6577.31.4.334

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Patients’ Experience of Myocardial Infarction335 experience was summed-up into 5 major themes: frightening experience, needed support, religiosity, experiencing changes, and lifestyle modifications. After the MI attack, most of the participants felt that they had given another chance to live, showing a pressing need to make healthier lifestyle modifications to avoid another MI attack. Implications for Practice: Health care workers should need not only pay attention on physical and physiological caring aspects but should also consider other patients’ needs, while supporting the patients and their family members.

Keywords: myocardial infarction; Jordan; experience; cultural; religious

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yocardial infarction (MI) continues to be a significant cause of mortality and morbidity in developed and developing countries. In 2012, an estimated 17.5 million worldwide deaths were because of cardiovascular diseases. Out of them, 7.4 million (42.3%) were attributable to coronary heart disease (World Health Organization [WHO], 2017). In Jordan, cardiovascular diseases ranked as leading cause of death (35%; WHO, 2014). Despite advancement in medical treatment for MI, progress in recovery after an MI attack remains an issue (Yan et al., 2011). Survivors of MI are at an increasing risk for recurrent infarctions, although nearly 75% of them may be prevented (WHO, 2017). Previous studies indicated that the time after MI is a susceptible period, both emotionally and physically (Andersson, Borglin, & Willman, 2013). If patients cannot cope with new situation, they may face various recovery problems (Yan et al., 2011). Understanding experiences of patients during and after an MI attack is essential. Nurses and health care providers need to understand their patients’ experiences to help them take control over the disease, cope with the changes in their lives, and plan for their treatment regimens.

BACKGROUND MI is a life-threatening health condition caused by blockage of coronary arteries, and it has physical, physiological, and psychosocial consequences (Grace et al., 2005). The period after MI is a vulnerable one, that is, if patients cannot adapt with this condition, they will face many recovery problems that may affect their functional abilities to return to normal life (Yan et al., 2011). Many patients after MI experience express that they have thoughts of been close to death (Junehag, Asplund, & Svedlund, 2014). The patients’ responses to this life-threatening condition are very dependent on their perceptions of the condition (Reges et al., 2011). When patients are unable to determine the implication of MI on them, they may end up with loss of sense of life (Baldacchino, 2011). Furthermore, MI experience is likely to add severe distress and can result in an uncertainty feeling (Coyle, 2009; Jensen & Petersson, 2003; Kristöfferzon, Lofmark, & Carlsson, 2007). The way patients deal with MI attacks differs with their different personalities. Some follow a positive coping experience such as being grateful for another opportunity in life and prefer the support of people around through sharing their burden,

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whereas others follow a negative coping experience with protective-secretive strategies where they hide their symptoms and do not share their burden (SalminenTuomaala, Astedt-Kurki, Rekiaro, & Paavilainen, 2012). White and Verhoef (2006) suggested that when individuals manage to identify the implications of an illness and how it affects their lives, ultimately they might find means to cope with their illness and improve their quality of life by adopting healthier lifestyle. Many studies concentrated on different patterns and experiences following MI, such as information needs, symptoms, stress, fatigue, recovery process, lifestyle modifications, and relationship with others (Arenhall, Kristofferzon, Fridlund, Malm, & Nilsson, 2011; Sjöström-Strand & Fridlund, 2008). Despite the fact that several previous studies included people of many cultures, Arab and Muslim culture were not included. Subsequently, it is unclear how these results actually represent experiences of Arab and Muslims after MI attacks. In terms of religious beliefs, health values, as well as cultural norms, in Jordan and other Arab Muslim countries, religion and culture play significant role in illness interpretation, recovery, and coping (Nabolsi & Carson, 2011; Van Leeuwen, Tiesinga, Jochemsen, & Post, 2007). All Muslims express their faith by believing that when a Muslim is faced with a disease, it is expected of him or her to accept it as God’s [called Allah in the Arabic language] will, and his or her role is to ask God for forgiveness and lessen such calamity. Often in Arab Muslim culture, family members play major roles in decision-making activities regarding illness and recovery (Al-Zaru, Oweis, & Gharaibeh, 2013). Jordan is a predominantly Islamic country in the Middle East. In 2011, number of Jordan’s population was about 6 million. Arabs make up the vast majority (98%) of the population. Population density is concentrated in the capital city (Amman), which is located in the north of Jordan. The Muslims accounted for 94% (92% Sunni, 2% Druze). The Christians (6% of the population) follow the Orthodox Church. Jordanian people are decent and respectful to other cultures and norms (The Hashemite Kingdom of Jordan, 2016). Modern facilities for health services are available in Jordan. Many institutions gained international accreditations through several organizations such as The Joint Commission International, making Jordan among the top medical tourism destinations in the Middle East and North Africa. The health care system has public, educational, military, and private institutions, organizations, and agencies that provide all medical care services—primary, secondary, and tertiary (rehabilitation services). Furthermore, it has some international agencies (such as the United Nations Relief and Works Agency) and nongovernmental organizations that primarily deliver health services to refugees.

AIM OF THE STUDY The aim of this study was to describe the experiences of Jordanian patients when they suffered an MI attack and the varied meanings that they assigned to their experiences. Such understanding will illuminate thought processes, decision making, and

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Patients’ Experience of Myocardial Infarction337 future concerns that arise when patients experience an MI attack. This will enable nurses and other health care providers to offer individualized and specific care to meet needs of patients’ and families during and after the MI attack, while taking into consideration cultural and religious aspects surrounding this phenomenon. Furthermore, such understanding may benefit international health care providers to better serve Arab immigrants and refugees who tend to bring with them their religious and cultural values and beliefs.

METHOD Design A qualitative hermeneutic phenomenological research design was used to have a deeper insight for participants’ experiences when they get an MI attack. Hermeneutic phenomenological method focuses on thorough interpretation of human experiences (Andersson et al., 2013; Grove, Burns, & Gray, 2013; Holloway, Wheeler, & Holloway, 2010; Munhall, 2012; Polit & Beck, 2012).

Setting and Participants Before commencing data collection at a governmental university hospital, the study protocol was approved by an institutional review board committee. The hospital is located in the capital city of Jordan. It provides a full range of cardiovascular medical and surgical care, offering diagnosis, treatment, and rehabilitative services for patients admitted from different socioeconomic levels. The participants in this study were patients who admitted to the coronary care unit because of a primary diagnosis of MI, who were able to understand and speak the Arabic language well, and with no known psychiatric diagnosis. Those who had suffered from any MI attacks before this admission were excluded from the study.

Data Collection Using purposive sampling technique, participants were approached a research assistant, who was working as a registered nurse in a general medical-surgical unit in the same hospital but was not directly dealing with patients admitted with an MI attack. The research assistant was a graduate nursing program male student and had the knowledge of local area and traditional practices. The research assistant was trained on how to conduct in-depth semistructured interviews. After coordination with the coronary care unit charge nurse to consider only those who were stable and free of physiological dangers, the research assistant approached possible participants to explain the nature, importance and proceedings of the study. Given that length of stay for acute MI attacks in the study unit ranged from 3 to 6 days, the participants invited to take part of the study 4–5 days after their admission. The participants signed a written informed consent after been assured of confidentiality and voluntary nature to participate.

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Every effort was made to assure participants’ emotional and psychological stability during the interviews. The participants were informed that they might feel uncomfortable about discussing experiences they had during their MI attack. They were informed that they could decline answering any questions or stop the interview at any time if they feel too uncomfortable. Furthermore, the participants were notified that if they felt tired and would like to take a break, the interview could be completed at a time that is suitable for both the participant and the research assistant. To ensure privacy during interviews, they were conducted in participants’ rooms during nonvisiting hours and at a time that the participant agreed. After securing privacy, three open-ended questions were posed to each participant, they were as follows: “What was your experience like when you faced the heart attack (MI)?” “In your opinion, how do you think the heart attack (MI) has affected your whole life?” and “What are your plans for the future after having this heart attack (MI)?” Further probing questions were asked to encourage narration and clarification. Sampling continued until data saturation occurs (i.e., no new data mentioned). Data were collected between May and September 2011. We maintained confidentiality of collected data in our study. Each study participant was assigned a unique code, under which the patient health information (PHI) and study data been filed. All the PHI records were separated from other study data and kept in a locked file cabinet. Access to the file cabinet was solely permitted to the research team members. In this study, the semistructured interviews were audiotaped and lasted for an average of 45 min. The contents of interviews were transcribed word by word and then translated into English language by the same research assistant who is proficient in both Arabic and English languages. Some of our collaborative research team are expert bilinguals in Arabic and English languages. Thus, they validated the translated contents of conducted interviews.

Data Analysis Data were analyzed after each interview following inductive qualitative content analysis method described by Elo and Kyngas (2008), following the three steps of open coding, creating categories, and abstraction. Initially, two of the researchers independently immersed themselves into the data by reading and rereading the transcripts to obtain a nuance of what the participants were saying. Using open coding, relevant quotes were highlighted in the text. Notes and headings were written down in the margins, and codes were assigned to the significant phrases and sentences that conveyed an idea. These codes were generated from the data itself to avoid changing the original meaning of what the participants said (Elo & Kyngas, 2008; Holloway et al., 2010; Munhall, 2012; Sandelowski, 2000). Afterward, they were merged into broader categories based on shared concepts and comparisons made between those that did not belong to the same category. All categories were then reviewed to make sure no new categories could be merged or subcategorized. The two researchers then met to compare the coded texts for similarities and dissimilarities and made revisions until there was consensus on the codes and categories. A third researcher then went through the whole transcripts again Copyright © Springer Publishing Company, LLC

Patients’ Experience of Myocardial Infarction339 and compared the derived codes, categories, and themes to make sure all relevant data were included and appropriate themes were derived. All researchers agreed on final codes, categories, and themes.

Trustworthiness To achieve dependability and consistency in data collected, all interviews were conducted by one research assistant. Credibility was achieved using an interview guide that ensured each participant was asked the same questions; all the interviews were audiotaped and transcribed verbatim. Furthermore, credibility was ensured by long and deep engagement of researchers in data analysis. Two researchers performed data analysis independently and then they agreed on the final codes, categories, and themes ensured credible data were obtained. Furthermore, the two researchers refrained from entering their ideas into the study, ensuring dependability and confirmability (Holloway et al., 2010; Munhall, 2012). Content validation was also achieved when a third researcher who went through the whole coding process and when the entire researcher team agreed on the final labeling of the data (Graneheim & Lundman, 2004; Holloway et al., 2010; Munhall, 2012). The whole data analysis process had been described in detail so replication of the process can take place by other concerned researchers demonstrating reliability of findings (Elo & Kyngas, 2008; Grove et al., 2013; Polit & Beck, 2012). Transferability was maintained by diversifying participants and describing the data analyses approaches, findings along with the procedures in details.

RESULTS The participants were five participants (one female and four males) who admitted with an acute MI diagnosis to the coronary care unit at a university hospital. The participants were aged from 50 to 66 years, with minimum education of elementary school and highest education being at diploma level. All participants were living in Amman (the capital city of Jordan). Three of the participants were retired, and two of them were employed. The participants’ recounts of their experience were summed up into five main themes: frightening experience, needed support, religiosity, experiencing changes, and lifestyle modifications.

Frightening Experience The participants recalled experiencing life-threatening symptoms and feared they would die. Symptoms.  Most of the participants recalled experiencing severe chest pain described as “being hit by a hammer” or heaviness, almost fainting, loss of consciousness that prompted them to seek medical treatment. I had a dinner with my family. I felt some exhaustion, when I went to bed I felt some chest pain like being hit by a hammer. When the pain became severe I started feeling [it like a] needle stick pain, I told them [meant family members nearby] this is different now. I lost my consciousness on my way to the hospital, and then in the Emergency Room I felt like a heavy thing [was] on my chest. (Participant 2, Male) Copyright © Springer Publishing Company, LLC

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I was going upstairs. I felt my heart and shoulders pressed hard by something heavy on them. It was very intolerable pain. I moved slowly to a chair to sit on. I sweated much. I thought the pain would go or subside. It did not. I felt sudden general weakness and dizziness so shouted for help because I lost the sense of control. It was a crisis for me. I never had this thing before. (Participant 1, Female)

However, one participant ignored the initial symptoms, considered it as a minor problem, and continued with his normal activities without seeking medical advice until later when the symptoms became so severe and intolerable. During the Friday pray I felt dizziness and sweating, I continued my prayer and I went home. (Participant 3, Male)

Most of our study participants linked these symptoms to some previous events, such as past medical diseases, a personality problem, or their lifestyle habits. Past experience of similar symptoms with their family members, relatives, and friends helped them to identify it as a cardiac problem and immediately seek care. Fear of Not Coming Back.  The participants experiencing the symptoms of MI flashed an image of eminent death in their minds. Thus, they were scared of not coming back to their loved ones and so bid them farewell: The only thing I was thinking of at the time of leaving my house is that am not coming back. And I said goodbye to my children while they are sleeping and asked forgiveness of my wife and my children . . . I told her I may not come back. Then she said “don’t say such words” . . . I wanted to leave the hospital and to tell everybody about my experience and that we should always say goodbye to family members because we don’t know if we are coming back or not . . . (Participant 2, Male)

Needed Support The participants needed and valued emotional and physical support from family members. However, in absence of family members, some participants sought support from friends and neighbors. Family Support.  Family was considered the most important resource of support for coping during the stressful experience and facilitated recovery. The participants valued the warmth, love, and care they received from their family members. When physically surrounded by their loved ones throughout the experience: My children and wife always with me in the hospital and the person will only know the value of his children in such situations, as they showed loving, caring attitudes towards me. And I feel loved by them. All my family, friends, and neighbor came to hospital when they knew about my condition so I thank them all. (Participant 2, Male)

Other Support.  The participants who lived alone longed for family support at that vulnerable time and when they could not obtain it, they sought it from their neighbors and friends. At the first moment when I had the symptoms I called my family my brother and my niece but nobody replied although their house is close to mine, so I called the neighbors then my family was told by the neighbors and they came to the hospital [She started to cry]. (Participant 1, Female) Copyright © Springer Publishing Company, LLC

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Religiosity Participants had strong religious belief in a higher being. Faced with life-threatening condition such as MI, religion helped them make sense of their condition by realizing their mortality eventuality at a time in the future, thus helped them to cope better. In addition, religion provided a means for them to get closer to God through engaging in religious rituals as a way of recuperation. Life and Death Is in God’s [Allah’s] Hands.  The participants acknowledged drawing strength from their faith in God [Allah] whom they believed controlled their lives. Their focus on faith alleviated anxiety and brought reassurance and hence was a major resource in their coping. When the doctor told me that, I was not afraid from death because life and death are between our Allah’s [God’s] hands. (Participant 1, Female) . . . I did not think much of early death before. After this health problem I realized that death can be close enough and possible. Anyhow I believe that my soul is in Allah’s [God’s] hands. (Participant 4, Male) . . . I said I will depend on Allah [God] as usual even if am going to die, that’s my faith. (Participant 5, Male)

Fulfilling Religious Obligations.  Performance of different religious acts like praying and fasting reciting religious quotes provided a means to drawing closer to God, a sign of restitution and hope for better health. I think my belief in Allah [God] has increased, I prayed even when I was connected to the machines in the hospital. I think that belief in Allah [God] is there and always will be. I did 5 times Hajj [means Islamic pilgrimage], and last year one Omrah [means a religious Islamic visit to holy landmarks at Mecca in Saudi Arabia] and I had no health problems that time. (Participant 3, Male)

Experiencing Changes The aftermath of MI was marked by both physical and sexual changes. Physical Changes.  After the MI attack, some participants experienced physical changes, which were incapacitating their lives. Thus, they expressed worries over their inability to independently perform activities of daily living. After the heart attack, I lost my body strength . . . [silence] . . . I feel well tired most of the day. I would not be able to do my bodily care and daily living activities the way I used to have before hospital admission. (Participant 1, Female) Now after 2 days post the MI attack I do not feel chest pain but I do feel hotness and headache and exhausted and cannot walk to the bathroom and I feel blurred vision and difficulty in concentration. (Participant 2, Male)

Sexual Changes.  Some participants were scared about experiencing changes in their sexuality that would affect their marital obligations. I have no idea if this will affect my sexual relationship with my wife because it [meant the MI] was very difficult [meant hard acute illness experience] for me in this time, although it [meant the MI] is not affecting my wife. (Participant 5, Male) Copyright © Springer Publishing Company, LLC

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Lifestyle Modifications After the MI attack, participants felt it was another chance to live. Some conveyed that they need to make lifestyle modifications to avoid another attack but expressed uncertainty toward maintaining lifestyle modifications, whereas others felt they would just return to their usual lives before the attack. Avoiding Another Attack.  All the participants recognized importance of preventing risk factors that predisposed them to MI recurrence. After discharge, I will try to reduce my anger and being upset with the children and reduce weight lifting and not to think in this life too much, I will keep myself away from fatty meals and will avoid exhaustion . . . I take low salt & diabetic diet. Now I am on insulin for high blood sugar [meant diabetes mellitus]. (Participant 3, Male) For my health status in future God knows, but I will protect myself from complication and having another MI. (Participant 2, Male) I would take care of my health more. I should avoid any serious physical activities that may endanger my heart condition. I do not want this heart problem to come again. I am much weakened. (Participant 1, Female)

Returning to Routine.  Some of the participants felt they would actually return to their old life routines before the attack. The MI attack was viewed like any other momentary life occurrences with no significant impact on their future. For my health I will try to reduce the coffee and smoking in my life but I don’t know when I will go back to them again because I can’t resist them, and I will do more but sometimes I don’t follow this. (Participant 1, Female) In future I will go back to my usual life; I do not know if I will follow the treatment regimen of high blood pressure. (Participant 4, Male)

In conclusion, when participants experienced a MI, it changed their lives positively and negatively. All participants felt more drawn to God and their family members; they were also required to make lifestyles changes, which were challenging for some. Some of them decided to go back to their previous lifestyles before the MI attack. Others faced new challenges as an aftermath, which affect their daily life activities and sexuality, thus creating anxiety over their inability to meet their various obligations.

DISCUSSION Frightening Experiences MI is a stressful life-threatening event that leads to physical, spiritual, emotional, and social changes in patients (Momennasab, Moattari, Abbaszade, & Shamshiri, 2012). An MI attack is a shocking experience to some participants because of their perception of having seen themselves as healthy (Hutton & Perkins, 2008) or lack of knowledge of its manifestations (Cytryn, Yoskowitz, Cimino, & Patel, 2009).

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Patients’ Experience of Myocardial Infarction343 Congruent with our findings, Abed, Khalil, and Moser (2015) reported that greater anxiety and perceived seriousness along with importance of symptoms were highly correlated with shorter prehospital delay among Jordanians. Some participants experienced frightening and anxiety-inducing symptoms such as chest discomfort, fainting, or loss of consciousness, and they thought that these symptoms were fatal and made them seek health care promptly. Although others ignored less obvious symptoms such as dizziness and sweating, Kirchberger, Heier, Wende, von Scheidt, and Meisinger (2012) revealed that characteristic symptoms were often associated with heart problems, whereas ambiguous ones were often misinterpreted, resulting in delay in seeking care. In addition to chest discomfort, it is of note that the female participant reported more concerns about experiencing general weakness and sweating. This finding is congruent with the quantitative study conducted to explore differences between Jordanian men and women in signs and symptom presentation of MI (Omran & Al-Hassan, 2006). In a study conducted in Jordan to assess the discrepancy between the expectations and experiences of MI symptoms, Abed et al. (2015) reported that the patients expected a limited number of symptoms. They highlighted that female patients expected fewer MI symptoms than what men did. Assessing the public’s knowledge of MI warning signs and symptoms is important for designing interventions that may decrease time to treatment and improve patient outcomes (Pearlman, Affleck, & Goldman, 2011). Health education interventions should focus on teaching clusters of problems with varying levels of familiar and complex symptoms to increase flexibility in making decisions to both participants and their relatives (Cytryn et al., 2009).

Needed Support Participants acknowledged that their experience was enhanced when they received physical, emotional, and social support from family, friends, and neighbors. Support influences prognosis, decreases depression, and provides encouragement and direct assistance in making lifestyle changes (LeifheitLimson et al., 2010). Among Arab Muslims, family play a major and special role in any decisions concerning patient’s illness and recovery (Al-Zaru et al., 2013); hence, the two participants who were living alone at the time of MI expressed frustration with lack of family support at the index hospitalization. Therefore, health professionals need to assess social support systems and tailor interventions for patients with MI in vulnerable illness situations. Besides, community health services in following up the patients with MI after discharge should be encouraged. Home care professionals may reduce the risk of further heart problems. They can offer individualized care that aims at making positive lifestyle changes that target several cardiac disorders risk factors including tobacco exposure and smoking, diet, physical activity and exercise, weight, medications, and possible accompanying disorders such as high blood pressure and diabetes mellitus.

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Religiosity Because Jordan is a predominantly Islamic country with 94% of the population being Muslims, all participants were Muslims, believing that God (Allah) was in control of their illness and wellness. After facing this life-threatening MI attack, our participants’ religion provided a means to get closer to God by performing different religious acts such as praying. Such activities served to them as a sign of restitution, way of recuperation, and hoping for better health because they believe that God controls their lives and can help them to cope better. Enhancing connection with God through repentance, prayers, and devotions were found to be essential components of the participants’ religious experience (Momennasab et al., 2012). Religious beliefs give a sense of control and have the potential to influence the cognitive appraisal of negative life events such as illness, making them less distressing (Koenig, 2012). These bring peace and comfort in the middle of a life-threatening illness. Our study participants’ religion does not allow them to want death after illnesses, difficulties, calamities, and hassles. Thus, they maintained perseverance and faced this life-threating situation. When individuals are faced with crisis such as illness, suffering, uncertainty in life, and impending death, they reflect on their relationships with self, others, and God to make values of their lives (Frankl, 1985; Highfield & Cason, 1983). Seeking personal value to life enables patients to become more aware of their current holistic state of life and encourages necessary adjustments (Baldacchino, 2011). This experience offers zest for life and may encourage and improve coping during the recovery (Andersson et al., 2013).

Experiencing Changes Experiences of fatigue, exhaustion, and worries of sexual dysfunctions after MI remained prevalent among some participants. Both fatigue (Alsén & Brink, 2013) and sexual dysfunction (Søderberg, Johansen, Herning, & Berg, 2013) following MI were found to affect health-related quality of life and well-being. Sexual dysfunction may result psychologically because of fear of dying, physically because of MI burden on the heart, or as a side effect of prospective medications (Bispo, de Lima Lopes, & de Barros, 2013; Byrne et al., 2016; Lange & Levine, 2014). Culturally, sexual abilities and performance play a role in shaping the Arab male’s personality and social image. Talking about possible sexual dysfunctions by some participants shows how important this matter is for them. In this study, when we used a male research assistant to collect the data, the participants expressed their concerns about sexual abilities. The concerns reported in this study may be uncovered easily should the interview be carried out by a female research assistant because of cultural perspectives. Given that sexual dysfunction affects both the individual and his or her partner (Arenhall et al., 2011), and that sexuality being an intimate subject many patients may not openly discuss (Yildiz & Pinar, 2004), the rehabilitation team members may actively probe the need for information and refer patient for appropriate counseling if necessary. Copyright © Springer Publishing Company, LLC

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Lifestyle Modifications Lifestyle factors were most commonly cited as having been significant in the development of MI. Patients after MI attacks have to make active lifestyle modifications such as dieting habits, increasing exercising, and promoting adherence to medication to prevent recurrences of MI (Hutton & Perkins, 2008). Patients often experience a constant struggle to comply with required healthy lifestyle changes (Andersson et al., 2013). Patients’ willingness to undertake secondary preventive strategies are likely to be affected by their understandings of their conditions (Astin, Horrocks, & Closs, 2014; Jensen & Petersson, 2003). Wiles and Kinmonth (2001) reported that MI was viewed as an acute event rather than a symptom of a chronic condition, thus not necessitating permanent change. Other reasons for noncompliance include lack of individualized lifestyle advice or the desire to reclaim a “familiar self” (Astin et al., 2014). To change patient behavior, it is crucial that health care professionals assess the patients’ understanding of their disease and tailor patient education to suit learning needs.

Study Limitations Participants in this study were purposively recruited to gain understanding of their experiences of acute MI. Because the narratives were the participants’ recall of the MI attack events, participants could not be able to remember all their experience in detail and fullness during the recovery phase after such an intense and lifethreatening health condition. Similar to previous quantitative studies among patients with MI in Jordan (Abed et al., 2015; Omran & Al-Hassan, 2006), limited data were reported about female patients. During the data collection period for this study, much of the admitted patients who had acute MI attacks were males and only one female participant met the other eligibility criteria to be invited for recruitment into the study (i.e., able to understand and speak the Arabic language well and free of known psychiatric diagnosis). Thus, the study findings should not be considered as abundantly addressing sex-specific experiences after acute MI attack among women.

CONCLUSION The experience of MI is traumatizing, and patients often think of death as an outcome. This qualitative study among Jordanian participants who admitted with an acute MI diagnosis to the coronary care unit at a university hospital showed that they recalled experiencing life-threatening symptoms, feared they would die, and flashed an image of eminent death in their minds. Participants felt it was another chance to live, and many conveyed they need to make lifestyle modifications to avoid another heart attack in the future. The participants highly valued emotional and physical support from their social support systems. Religion influenced interpretation of illness and helped our study participants cope positively during and after illness. Furthermore, concerns about physical changes including inability to independently performing activities of daily living, along with sexual changes that would affect their marital obligations were expressed. Copyright © Springer Publishing Company, LLC

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Implications Health care workers need not only focus on physical and physiological care aspects but also consider other patients’ needs, while supporting the patients and their family members. Moreover, sustained support for patients and families with lifestyle modifications during convalescence need to be addressed to minimize recurrences. This study can serve as a foundation for other researchers to build upon. Future work with more Jordanian women is needed to expand the knowledge regarding symptomatology and the psychosocial responses among females. Further research is suggested to highlight the symptoms and functional limitations experienced by patients with MI in the year following the MI attack. As an effort to minimize the risk of cardiovascular disorders, more educational programs in schools and other academic settings as well as health care centers should take place. Such programs may aim to shed the light on the cardiac risk factors such as hypertension, abnormal blood lipid levels, tobacco use, physical inactivity, Type 2 diabetes, and diets that are high in saturated fat. Moreover, this may aid in decreasing the high prevalence of cardiovascular disease in Jordan.

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