Coronary Health Care (1998) 2, 17-27 9 1998 Harcourt Brace & Co. Lid
ORIGINAL A R T I C L E
Quality of life in pacemaker patients from a nursing perspective D. Maim*, J.-E. Karlssont, B. Fridlund *Specialist Nurse, Department of Cardiology, County Hospital Ryhov, Jrnko'ping, and Department of Primary Health Care, Grteborg University, Grteborg, Sweden; tHead Physician, Department of Cardiology, County Hospital Ryhov, JOnkrping, Sweden; .~Associate Professor, Centrefor Health Promotion Research, Halmstad University, Halmstad, and Department of Primary Health Care, Grteborg University, Grteborg, Sweden SUMMARY. The aim of this study was to describe quality of life (QoL) in pacemaker patients based on a nursing perspective. The questions at issue were how these individuals assessed their QoL in general and also with respect to sex, age, civil status and occupation. A cross-sectional study was conducted in a health care area in southern Sweden with 310 000 inhabitants. A sample of pacemaker patients (n=182) entered into the study through a random selection of every fourth person. The results show that the total QoL for these pacemaker patients was acceptable. A poorer QoL was found with regard to physical health, the possibility of influencing one's own situation, lifestyle, health care resources and sociocultural orientation. Men, those who were cohabiting, white-collar workers, managers and those 64 years of age or younger assessed their QoL as higher. By using Orem's self-care theory, information, support and education can be carried out in such a way that nursing care affects the entire QoL in pacemaker patients. Measures should be taken on behalf of women, those living alone, those who are oldest and those who are blue-collar workers, all of whom have a lower QoL.
disease (SND) (25%) (Nordlander et al 1994). The modem pacemaker system, with a running time of up to 15 years, is checked one to two times a year at pacemaker clinics, while SSI systems can be checked via telephone modems (Furman 1993). It is felt that a pacemaker patient can live a normal life, although strong magnetic fields should be avoided since they can inhibit or stimulate the pacemaker (Sager 1987). Due to continuously more advanced pacemaker technology, staff involved in pacemaker care must provide continual education and information to these patients. An important aspect of the staff's supportive and educational functions also includes knowledge about the life situation of the pacemaker patient. No population study from a nursing perspective has been carried out in order to clarify how these patients assess their life situations. Therefore, the purpose of the study was to describe the quality of life (QoL) in pacemaker patients based on a nursing perspective. The questions at issue were how these individuals assessed their QoL in general as well as how QoL differed with respect to sex, age, civil status and occupation.
The first artificial pacemaker was implanted in a human being in 1958 by Elmqvist and Senning (Elmqvist 1978). From the beginning of the 1960s up until today, the pacemaker has become a very advanced electronic heart stimulator with thousands of transistors and microprocessors (HideO~ill 1996). In order to standardize pacemaker nomenclature, the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG) have developed terminology which explains the pacemaker's functions. As seen in Table 1, the code consists of five letters (Bernstein et al 1987). The trend in this area has led to an increase in sensor-directed SSI and DDD pacemakers (Table 1). There are about 19 000 persons with pacemakers in Sweden, and about 3200 implantations are carried out each year (Linde et al 1995; Nordlander et al 1994). The most common indications for pacemaker implantation are dizziness and fainting in association with atrioventricular (AV) block (55%) and sinus node
Correspondenceto: Dan MaimRN BNSc,SpecialistNurse, Department of Cardiology,CountyHospitalRyhovS-551 85 Jrnkrping, Sweden.Tel:+46 36 32 19 87; Fax: +46 36 32 20 55; E-mail:[email protected]
Quality of life is different for people depending on the circumstances in which they find themselves at a 17
Coronary Health Care
Table 1 The modified pacemaker code according to the N o r t h American Society of Pacing and Electrophysiology and British Pacing and Electrophysiology Group (Bernstein et al 1987) The identification code Letter position I
Stimulated heart chamber
Sensed heart chamber
Type of response
O = None V=Ventricle A = Atrium D = Dual S = Single
O = None V=Ventricle A = Atrium D = Dual S = Single
O = None I =Inhibited T = Triggered D = Dual
O = None R = R a t e adaptive M= Multiprogrammable C = Communicating P = N o telemetry
O= None B=Burst P = Pacing (anti-tachyarrhythmia) D= Dual
certain point in time (Nordenfelt 1989). It is difficult to define QoL, but Levine and Croog (1984) as well as Lawton (1991) believe that QoL should comprise physical capacity, mental health, social interaction, intellectual function, financial circumstances, and self-described state of health. Campbell (1976) describes QoL from an objective perspective, first of all comprising age, education, occupation, income, place of residence and type of dwelling, which are used with a view to exactness. This objective concept should be seen as a complement to subjective indications, which are inner experiences, such as the experience of pain, physical power and mental ability, which more closely elucidate the individual's QoL (Ferrans 1990). These subjective and objective approaches are of great importance when making comparisons between different cultures, sexes and ages (Campos & Johnson 1990). In most cases, both approaches are used to give a general value to QoL. The objective supportive model of health assumes that health care personnel know what is best for the individual. This is in contrast to the subjective selfdetermining model, which assumes that the individual himself knows what is best. The goal of both models is to provide balance between what is good and what is bad. Problems arise depending on who defines this goal and how the goal is to be measured and attained (McCullough 1984). According to Wenger et al (1984) the QoL in patients with cardiovascular diseases (CVDs) encompasses three areas. The first is functional ability, which has five subgroups: daily routines, social activity, intellectual function, emotional function, and finances. The second area, experienced capability, indicates those changes the patient experiences as being important in regard to health, well-being, and life satisfaction. These subjective perceptions are not entirely valid in regard to the patient's opinion of his QoL, but must be compared with something more objective, i.e. functional ability. The third area consists of symptoms, which comprise changes and impairment reflected by the recurrent disease events that the patient experiences such as hospitalizations,
pain, respiratory problems, medication changes, and impairment in physical ability. Quality of life studies in the cardiovascular disease field
In general, most recent QoL studies of patients with CVD have used both objective and subjective assessments. A large number of studies have been performed using instruments validated for self-assessment such as: N H P (Sonja et al 1980), SIP (Bergner et al 1976), SF-36 (Garrat et al 1993), QLI (Ferrans & Powers 1985), PGC-MAI (Lawton et al 1982), QWB (Anderson et al 1989), and PGWB (Dupuy 1984). By means of these instruments it has been found that these patient groups experience limitations in practically all aspects of QoL, and that the development of additional instruments would be desirable. More specifically, patients with hypertension, angina pectoris, myocardial infarction (MI), and heart failure make up the largest group of patients with CVD. A clinical study done in Norway did not show any worsening of QoL in patients with newly discovered hypertension. On the other hand, patients with chronic hypertension were found to assess their QoL as subjectively, cognitively and affectively poorer (Mourn et al 1992). Wenger and Furberg (1990) called attention to a number of problems incurred by hypertensive patients such as depression, impaired memory, sleeping problems, nightmares, changes in temperament, and a lack of initiative. Patients who were only treated for hypertension assessed their QoL as better than those who had nervous disorders (Wiklund et al 1992). In order for patients with newly detected hypertension to retain their good QoL, the most important factors were shown to be that they were given support and care so that they did not feel a mental burden and assume the role of a hypertensive (Naess et al 1992). Patients with angina pectoris often had a symptomatically impaired capacity in everyday and leisure time activities, socializing and sexual relations. An improved QoL was obtained through surgical coronary artery bypass, but no difference was
Quality of life in pacemaker patients from a nursing perspective found in regard to return to work between the surgically and medically treated patients (Wiklund et al 1987). In order to obtain good treatment results, with reduction of ischemia and a decrease in chest pain, both QoL and the circumstances surrounding the disease had to be taken into account (Wenger & Furberg 1990). Studies of QoL and MI indicate a worsened QoL (Naess et al 1992; Wiklund et al 1987; Fridlund et al 1991; Conn et al 1991a,b; Wingate 1995). Differences have been found, however, which show that women experience poorer QoL than men, although older men run the risk of having fewer social contacts (Conn et al 1991a). On the other hand, women have been found to have an unexpectedly poor QoL after their MI if their social network works well and they have been able to return to their job (Wingate 1995). Studies have shown that early participation in individual cardiac rehabilitation programs (Fridlund et al 1991) and long-term follow-up after MI (Conn et al 1991b) facilitate recovery, and QoL is not experienced as worse. Furthermore, QoL in patients with heart failure is not the same as for those with other CVDs. Besides the fact that those with chronic heart failure had a high mortality rate, they also constitute the patient group with the highest frequency of hospitalization. The patients had impaired physical function but, if support was received from the family, the QoL in the home was judged as good (Hawthorne & Hixon 1994). If the patients were informed about the disease, the uncertainty at the prospect of treatment was experienced as decreasing. Good information provided the patients with positive expectations which could lead to improved results (Wenger & Furberg 1990). Those patients who underwent surgery because of CVD assessed their QoL as improved, in that chest pain as well as anxiety and nervousness decreased (Faris & Stotts 1990). A more rapid recovery was demonstrated when realistic goals were formulated preoperatively by health care personnel, as well as the patients and the relatives (Artinian & Hayes 1992). The patients were able to experience an improved QoL by means of postoperative psychological and social support (Raczynski & Oberman 1990). In general, it was found that patients with CVD perceived their QoL differently, depending on how they subjectively assessed their situation and the limitations they had because of their symptoms (Wiklund 1988). Using a medical approach, Hedback et al (1993) showed that those patients with CVD who received medical treatment and support through the hospital experienced a positive relationship between QoL and the assessed psychosocial situation. According to Aggernaes .(1994) psychological perspective, a good QoL is attained when a person has a meaningful occupation and feels valuable, has selfesteem, and is given the opportunity to experience social togetherness. From a sociological perspective, Starrin et al (1993) show a link between socio-economic structure and CVD. The structure of urban
and white-collar communities is clearer than for rual and blue-collar communities. If the structure is clear, a connection emerges which shows a good QoL and decrease in CVD. Selection of a theoretical nursing perspective means that additional QoL factors are attributed to the person in order to attain a comprehensive measure of his QoL. A study in which the person's health status, lifestyle, family situation, sociocultural and physical environment, the possibilities of independently influencing his situation, and health care resources, has not previously been conducted on pacemaker patients.
Orem's self-care theory applied to pacemaker patients Orem's nursing model (1991) might be able to be used for pacemaker patients, since it is possible to apply the self-care view to their assessment of their QoL. There must be balance between the requirement to understand and the possibility of feeling secure about the function of the pacemaker if the pacemaker patient is to practise self-care. If this security does not exist, and if instead the person is fearful about having a pacemaker, anxiety and nervousness can lead to depression and loneliness with loss of the feeling of social togetherness. The basis of the nursing theory is the individual's ability to choose, and to take responsibility for his own survival and well-being. In order to be able to use this capability the individual needs continuous stimulation, both for himself and his environment, in order to function according to his requisites. Those activities which the individual carries out have as their goal to maintain health and QoL. Orem (1991) shows that, if the demands are too great in relationship to the individual's capacity, a self-care deficit arises which is caused by the individual himself or society. In addition to gender and age, the ability to engage in self-care is dependent on the individual's developmental status, health status, sociocultural orientation, available health care resources, family factors, patterns of living, environmental factors, and the possibilities the individual has to affect his own situation. In order to preserve the pacemaker patient's QoL, the nurse's support and information based on the patient's needs are important, since emphasis is directed toward his questions about limitations and prospects. By using Orem's self-care theory (1991) and utilizing the ten stipulated self-care factors as a measure of QoL, the pacemaker patient can be studied from a nursing perspective.
METHOD Design and setting During the spring of 1994, a cross-sectional study of persons with pacemakers was conducted in a health care area in southern Sweden with 310 000 inhabitants. The study had been approved by the Committee
Coronary Health Care Table 2 ECG-rhythm, reason for implantation, and pacemaker function in pacemaker patients (n= 182) ECG rhythm at implantation
Reason for implantation
Sinus node disease Atrioventricular block Atrial fibrillation
Fainting Dizziness Bradycardia Tachycardia Prophylactic
Ventricularinhibited pacing Dual-chamber pacing Atrial inhibited pacing
n = 91 n = 66 n = 25
n = 86 n = 70 n = 21 n=3 n=2
n = 166 n = 14 n=2
Table 3 Orem's theory (1991) of self-carerelated to the entire questionnaire QLPMQ comprising PGC-MAI
(Lawton et a11982), the QLI (Ferrans & Powers 1992) and the LPQ Self-care factors
Developmentalstatus Health status physical mental Sociocultural orientation
25, 26, 27, 28, 29b, 30 16, 17, 18, 32 41, 43, 44, 45, 59, 60 7, 1lb, 34a,b,c
Health care system factors Family system factors Patterns of living Environmental factors
19, 20, 21 6b, 38b,c, 39a,b, 40 14, 34d,e, 66 46, 47, 49, 51, 52 54, 55 10a, 31, 42, 62, 64
17,26,27,28,31 1, 3,4,5,6 18, 29,32 14, 15,22,23, 24,30 2,36 9,10,11,12,13 33,34,35 19,20,21
Availability and adequacy
for Ethics in Medical University.
Patients and selection
A total of 216 Swedish pacemaker patients were entered into the study through a r a n d o m selection of every fourth person with a pacemaker from the catchment area. After exclusion due to moving (n = 2), no interest in participating (n = 4), inability to communicate (n = 9), and death during the course of the study (n = 19), 182 persons participated. There were 93 men (51%) and 89 women, with mean ages of 75 years (range 26-93, standard deviation (SD) 11) and 79 years (range 45-95, SD 10), respectively. Fifty-nine per cent were married or co-habiting, and 69% had blue-collar jobs. Table 2 shows that the most c o m m o n reason for pacemaker implantation was fainting due to SND, resulting in the selection of a V V I / R pacemaker (see Table 1). Instruments
An instrument, the Quality of Life Pacemaker Questionnaire (QLPMQ), was developed which contained a three-part questionnaire with questions about quality of life. A total of 133 items were used, allocated to the ten self-care factors, in addition to the background factors of gender and age, see Table 3. Information about symptoms, ECGs and reasons for pacemaker implantation was obtained from patient charts and a database where all pacemaker patients were registered. The Q L P M Q instrument, was comprised of items from P G C - M A I (Philadelphia Geriatric Center Multilevel Assessment Instrument) (Lawton et al 1982), Q L I (Quality of Life Index-Cardiac III
7, 8, 16, 25
LPQ 4bl,4ab2 3cl,2 3c3,5,10a,b,c 3b2,3,8 3bl 3d, 9
Version) (Ferrans & Powers 1992) and LPQ (Living with a Pacemaker Questionnaire), and the level of reliability for the entire Q L P M Q instrument used in this study was 0.87 according to Cronbach's ct (Altman 1991).
Part I Forty-six questions of a total of 68 were selected from the P G C - M A I (Lawton et al 1982) for use in this study. There are questions conceming physical health, comprehension capability, self-care and activities of daily living, participation in activities, living conditions, ability to transport oneself, spirits/mood, social relationships and financial situation. The P G C - M A I assesses the individual's own understanding, and each area is divided into subgroups which can be used separately or combined into an overall index. The answers are primarily of an ordinal type (Altman 1991) with the exception of some background questions. The level of reliability for this instrument according to Cronbach's c~ was 0.80 in this study.
Part 2 Seventy-two questions of a total of 72 from Ferrans and Powers instrument, the Q L I (Ferrans & Powers 1992) were used in this study. The Q L I consists of two sections: the first 36 questions measure life satisfaction in different areas, while the remaining 36 questions measure the importance of these areas. There are four domains of questions: family, health/physical activity, psychology experiences and financial situation (Ferrans & Powers 1992; Bliley & Ferrans 1993). Each question has answers on a six-point ordinal scale ranging from 'very unsatisfactory/unimportant' <1> to
Quality of life in pacemaker patients from a nursing perspective 'very satisfactory/important' <6>. The level of reliability for this instrument according to Cronbach's ot was 0.85 in this study.
Part 3 Fifteen questions of a total of 18 specific items associated with pacemaker treatment, LPQ, developed by one of the authors (DM) were used. The LPQ focused on the patient's experiences as a result of having a pacemaker. The responses to each item were primarily of an ordinal type, with the exception of an open question about the patient's medications. Validation of the instrument was done in three steps. The first step was carried out by six cardiac nurses and four cardiologists who assessed the content validity, i.e. judged whether the questions were relevant in regard to content and construct. After adjustments, the content validity was assessed by ten pacemaker patients, after which further changes were made in the instrument. Finally seven factors in the instrument were identified by means of a rotated varimax factor analysis (Altman 1991). The seven dimensions can be described as: Mental stability contained two questions: Has the pacemaker caused a change in activities outside the house? and, Has there been a change in activities because of the pacemaker? Cardiac function contained three items: Pacemaker function, ECG rhythm preoperatively, and, heart rhythm as recorded on the ECG at the time of the interview. Physicalfunction had two questions: Mobilization capability inside and outdoors? Need for information contained two questions: Is there anything the patient wonders about? and, Any problems with the pacemaker during the past twelve months? The giving of information contained four questions: What did you think of the information you received prior to pacemaker implantation?, How should information be improved today?, Who gave you information and how was it given? and, Sleep disturbances, fatigue or other problems from the pacemaker? Complications contained three questions: When did the patient get a clot?, Where do the patient's problems occur? and, When do these problems arise? Clinical picture had two questions: Generally satisfied/dissatisfied with the pacemaker? and, Where was the blood clot? The level of reliability for this instrument according to Cronbach's ct was 0.57 in this study. Data collection
Just prior to a pacemaker check-up, which occurred regularly every 6-8 months, the patients were informed in writing about the purpose of the study and a request was made that they undergo a structured interview concerning their QoL at the same time as the check-up. One of the authors (DM), who was the pacemaker nurse, conducted both the pacemaker
check-up and the interview during a period of about 90 rain. The interview was done after the check-up. In both the written information and at the time of the interview, these patients were told that participation was voluntary, that information obtained in the interviews would be handled confidentially. Data analysis and statistics
The QLPMQ values were transformed z-scores according to conventional methods (Altman 1991). Table 4 shows the distributions of positive and negative z-values for the items. The mean z-score for each self-care factor was calculated. Subgrouping was done according to gender (man, woman), age (_<64, 65-84, >85 years of age), civil status (co-habiting, living alone), and occupation (blue-collar/housewife, white-collar, managerial). The level of QoL was reported for each subgroup and each self-care factor. Several quantitative variables were not normally distributed and most variables were ordinal. Therefore nonparametric tests were used. Relationships between variables were evaluated by Spearman's rank-order correlation coefficient (Altman 1991). A P-value of < 0.05 was regarded as significant. The items corresponding to Orem's self-care theory (1991) were taken from the QLPMQ. A global quality of life assessment was done by creating a QLPMQ index of QoL at three levels: low, acceptable and high. The criteria were defined from the frequency distributions of QLPMQ questions. A value below the first quartile was defined as a low QoL, values between the first and third quartiles were defined as an acceptable QoL, and above the third quartile was judged as a high QoL.
RESULTS Quality of life in general as related to Orem's self-care theory
The QLPMQ measurements for the pacemaker patients show that QoL was high for the self-care factors developmental status, environmental factors, mental health status, and family system factors. QoL as assessed by the other self-care factors was acceptable (see Figure) Quality of life as related to gender, age, civil status and occupation
QoL in pacemaker patients according to Orem's selfcare theory as related to gender, age, civil status and occupation are presented in Table 5. In regard to gender, it was found that men evaluated their QoL higher than women in all nine self-care factors. An age distribution showed that pacemaker patients in the age group _<64years assessed their QoL higher in developmental status, environmental factors, family
Coronary Health Care Table 4 Quality of life in pacemaker patients as related to the entire questionnaire comprising PGC-MAI (Lawton et al 1982), the QLI (Ferrans & Powers 1992), and the LPQ, based on Orem's self-care theory (1991), after subdivision into positive and negative answers (n= 182) Percentage positive answers
Percentage negative answers Developmental status
PGC-MAI = QLI = LPQ=
Health status PGC-MAI = QLI = LPQ =
60 87 53
68 74 87
40 13 47
32 26 13
Sociocultural orientation PGC-MAI = QLI = LPQ =
46 79 -
PGC-MAI = QLI = LPQ =
64 99 57
PGC-MAI = QLI = LPQ =
63 89 -
PGC-MAI = QLI = LPQ =
61 91 39
PGC-MAI = QLI = LPQ =
77 96 47
PGC-MAI = QLI = LPQ =
68 98 38
Health care system factors 36 1 43
Family system factors 37 11
Patterns of living 39 9 61
Environmental factors 23 4 53
Availability and adequacy 32 2 62
% 90 80 70 60 50 40 30 20 10 0
Figure Quality of life according to Orem's self-care theory (1991) as reported by pacemaker patients (n=182). Quality of life: 26-75% are regarded as acceptable.
system factors, resource availability and adequacy, patterns of living, and sociocultural orientation as compared with the older pacemaker patients aged 65-84 years and those >85 years of age. Those aged 65-84 years assessed their QoL as better in the self-care factor health care resources. The oldest
pacemaker patients, >85 years of age assessed their QoL as better in the self-care factor mental health status, while physical health was assessed the same by all pacemaker patients. For civil status, it was found that those pacemaker patients who were co-habiting assessed their QoL higher in eight of the nine
Quality of life in pacemaker patients from a nursing perspective
Table 5 Mean level (%) of quality of life in pacemaker patients according to Orem's self-care theory (1991) as related to gender, age, civil status and occupation (n=182). Quality of life: 2~75% are regarded as acceptable Self-care factors
Gender Men Women
Age <64 65-84 >85
Civil status Co-habiting Alone
Occupation Blue-collar White-collar Manager
Developmental status Environmental factors Health status mental physical Family system factors Availability and adequacy Patterns of living Health care system factors Sociocultural orientation
90 82 83 74 76 76 73 68 66
93 82 81 71 78 82 72 66 70
91 82 81 73 80 77 73 67 65
84 78 78 70 76 73 68 67 64
79 77 76 68 75 71 66 67 63
87 80 79 71 75 73 70 69 63
68 78 82 71 73 67 68 66 61
76 77 78 68 75 70 65 68 62
85 81 82 75 74 75 76 68 66
88 82 82 70 77 73 72 70 64
self-care factors as compared with those who lived alone. Those who lived alone evaluated their QoL as higher in the self-care factor health care resources. In the distribution for occupation, it was found that blue-collar workers assessed their QoL as higher than white-collar workers in the self-care factor family factors, and other self-care factors were assessed by blue-collar workers as giving lower QoL, with the exception of physical health status, resource availability and adequacy and sociocultural orientation, where managers assessed their QoL the same. Business leaders evaluated their QoL highest in the self-care factors developmental status, environmental factors, family system factors and health care system factors. White-collar workers assessed their QoL as highest in the self-care factors physical health status, resource availability and adequacy, patterns of living and sociocultural orientation.
self-care agency of these pacemaker patients, their QoL could be analyzed from a nursing perspective. This operationalization of theory to practice for the purpose of measuring the QoL of pacemaker patients can be considered satisfactory. The PGC-MAI (Lawton et al 1982), QLI (Ferrans & Powers 1985) and the LPQ contain interval and ordinal scales which can be considered good for assessing the QoL of individuals (Altman 1991). Measurement instruments such as the QoL instruments used in this study record ordinal response data, which is necessary with the respect to the quality of the instruments (Svensson 1993). It was found that the new instrument, QLPMQ, specifically for pacemaker patients has good validity. Regarding the reliability, the internal consistency shows that all three questionnaires as well as the whole instrument had an acceptable Cronbach's 0t (Altman 1991).
Aspects of quafity of fife related to Orem's self-care theory
Quality of life related to developmental status
Based on the aim of this study, it was necessary to develop a new instrument in order to meet the requirements of Orem's self-care theory (1991), which is confirmed by Spearman's rank-order correlation coefficient test (Altman 1991). No relationship was found between the LPQ and the QLI or the LPQ and the PCG-MAI, which motivated the development of the QLPMQ instrument, specifically for pacemaker patients. The instrument would be expected to function well due to the fact that the PGC-MAI (Lawton et al 1982) is designed to measure the subjective QoL in the elderly, irrespective of good health or poor health. The average age of the pacemaker patients in this study was 77 years supporting the use of the PCG-MAI. Furthermore, the QLI (Ferrans & Powers 1985) was developed for studying QoL in both sick and healthy individuals, regardless of age. With this well-known QoL instrument, the QoL in younger pacemaker patients should emerge. Finally, the LPQ was developed for the specific purpose of documenting the pacemaker patients' assessments of their QoL. By creating an index (see Table 4) as the basis of the
In general, QoL is experienced as high when developmental status is related to the pacemaker patients. On the other hand, it was shown that the oldest patients consider their QoL to be acceptable, and there was a clear difference in terms of a lower QoL in women and those who live alone. An explanation for this may be that those who live alone and the oldest pacemaker patients are not able to manage their daily activities as well as younger persons in regard to this self-care factor. Being unable to be of use to others, as well as having less possibility for a meaningful leisure time, results in old age affecting the developmental state of pacemaker patients in a negative way. Approximately 70% of the oldest pacemaker patients assess their developmental status as acceptable as compared to about 95% of those _<64 years who assess their QoL as good in regard to this factor. These results are somewhat inconsistent, as it has been found that the elderly assess their QoL as good (Carlsson et al 1991). In regard to primary self-care activities, the QoL in the elderly instead increases with increasing age (Steen & Djurfeldt 1993; Grimby & Wiklund 1994). It
Coronary Health Care
is possible that the older pacemaker patients experience this deterioration because they expect too much in terms of their physical activity. These great demands in regard to physical activity may be caused by having misunderstood the information they received about the pacemaker. In Grimby and Wiklunds' (1994) study it was found that the most negative factor for the elderly is a deterioration in primary self-care activities. In the present study, as well as in the study by Judge and Watanbe (1993) it was found that those with an earlier occupational life which was satisfactory also assessed their QoL as better, which may confirm why the managers assess their resource availability and adequacy as better than do blue-collar workers and white-collar workers.
Quality of life related to environmental factors The pacemaker patients assess their QoL as high in this self-care factor. Nevertheless, differences exist among the groups. Women, the oldest pacemaker patients, those who live alone and blue-collar workers assess their QoL as poorer, which can be due to less opportunity for an active social life. The age group 65-84 years evaluate their QoL as lower, and that is possibly due to a poorer financial situation upon retirement. Hildingh et al (1997) have also indicated these factors as being partially responsible for a poorer QoL. The oldest pacemaker patients may live in service flats for the elderly which offer a feeling of security, but at the cost of comfort and well-being, as shown by earlier studies (Caflsson et al 1991). Also indicative of this is the fact that more pacemaker patients up to the age of 64 years assess their QoL as higher in regard to environmental factors.
Quality of life related to mental and physieal health status The pacemaker patients assess their QoL in regard to mental and physical health status in general from acceptable to high. In this study, as well as in that of Hildingh et al (1997) there was a clear difference between women and men, where women evaluate their QoL as poorer, both mentally and physically. This can be due to the obstacles women experience in doing daily chores (Grimby & Wiklund 1994). Within age groups, physical health status shows the same QoL, which is somewhat inconsistent, since statistics in Sweden (Statistics Sweden 1992) showed that older persons have poorer physical ability than younger persons. Decreased physical activity can also explain the lower QoL in those who live alone (Grimby & Wiklund 1994). When QoL was studied in regard to occupation, it was found in this study that white-collar workers and managers experience their mental health status as higher than that of blue-collar workers, which may be because these persons have primarily had interesting,
stimulating occupations which have required a long period of education as well as greater perseverance, thereby contributing to better mental stability. This supports the results of Judge and Watanbe (1993), who demonstrated a significant relationship between QoL and occupational life. Physical QoL is assessed as acceptable, although white-collar workers evaluate their physical health somewhat higher. One reason for this can be that more than 90% have ventricle-controlled pacemakers, which approximately half (47%) of them got because of SND. A number of studies show that DDD pacemakers provide better hemodynamics and give the patient and improved capacity, thereby also providing an improved QoL (Linde et al 1995; Linde-Edelstam et al 1992; Hayes & Holmes 1993). Rosenqvist et al (1986) have shown that implantation of VVI pacemakers for SND increases the risk of atrial fibrillation (AF) (see Table 2) which impairs physical ability by up to 20%. According to the Framingham study (Wolf et al 1987), the proportion of all strokes increases with increasing age, and in the age group 80-89 years there is a 36% increase in the risk of stroke in the presence of AE Considering that the average age of the persons in this study was 77 years, those who had SND at the time of becoming ill should be expected to have had an atrium-controlled pacemaker implanted, as it has been found that atrial stimulation results in significantly less AF (Rosenqvist et al 1986; Carom & Katritsis 1990).
Quality of life related to family system factors A high QoL was generally found. Women and those who live alone assess their QoL somewhat lower. One reason can be that many are now alone after a long marriage, and this may have resulted in a sense of loss, less family happiness and difficulty initiating new relationships. The oldest pacemaker patients and whitecollar workers assess their QoL as worse. Elderly pacemaker patients who live alone have the same difficulty as other older persons in having a secure family relationship and a functioning social life with family and friends. Cross and Markus (1991), as well as Chappel (1991), showed that this was one of the most important factors in enabling the elderly to feel a sense of satisfaction in their lives. Being alone can also be difficult when these persons do not have close contact with their children, and they do not receive family visits as often as they wish. On the other hand, blue-collar workers and managers have a better QoL than white-collar workers, which could indicate that the two former groups have expended more effort on their social contacts and family relationships.
Quality of life related to availability and adequacy On the whole, the study shows that the QoL in pacemaker patients is acceptable in regard to being able to affect one's own situation. In this self-care factor,
Quality of life in pacemaker patients from a nursing perspective women and those who live alone assess their QoL lowest, which indicates that partner or family support is needed (Carlsson et al 1991; Hildingh et al 1997). Pacemaker patients younger than 64 years and whitecollar workers have the highest QoL in the respective self-care factors. This strengthens the contention that good education, a meaningful occupation and a sound financial situation are important aspects in the prerequisites for a good QoL (Judge & Watanbe 1993). The women's shorter education, lower salaries, and less chance for those who live alone to feel needed, plus questions about the pacemaker's function, may also be part of the reason they assess their life situation lowest in the respective self-care factors (Grimby & Wiklund 1994).
Quality of life related to patterns of living The pacemaker patients' patterns of living generally demonstrate an acceptable QoL. It was shown that, for gender and civil status, women and those who live alone assess their QoL lower. In regard to patterns of living, it is seen that those >85 years have the lowest QoL. One reason can be that these patients lose touch with their friends and also that they do not have to use so many intellectual functions (Carlsson et al 1991). The study shows that white-collar workers assess their QoL higher than managers and blue-collar workers. It is already known from earlier studies that those with less education and often monotonous work have difficulty finding meaningful free-time activities (Fridlund et al 1994). This supports the findings that blue-collar workers have a lower QoL than managers and whitecollar workers in regard to patterns of living. This is possibly because managers and white-collar workers evaluate their occupational lives as more satisfying (Judge & Watanbe 1993). Possible problems in giving information to blue-collar workers, as well as an inadequate pacemaker system, causing them to feel uneasy and physically not to have enough energy, may also be contributing causes (Wikblad 1991).
Quality of life related to health care system factors The general QoL of the pacemaker patients is acceptable in regard to health care system factors. The study shows that those who live alone and managers are more satisfied with health care, and are more pleased with the results of the care they have received. A reasonable explanation can be that the better educated white-collar workers and managers can take in the information they are given better than the bluecollar workers. Schaie (1983) has shown that those with academic education's experience deterioration in intellect very late in life, if there is a deterioration at all. This could mean that the information provided often does not reach the patient, since around 70% of the pacemaker patients are blue-collar workers. This study, as well as others, also shows that the QoL of
women is lower than that of men (Hildingh et al 1997; Statistics Sweden 1992). One reason for this may be that women are not so demanding in regard to treatment results as men are.
Quality of life related to sociocultural orientation Sociocultural orientation is generally assessed by the pacemaker patients as giving an acceptable QoL. At the same time, the study shows differences where women, those who live alone and those >85 years of age assess their QoL lowest. The reasons may be difficulty in maintaining personal contacts and being able to take part in free-time activities. It has been found in earlier studies that this is important in being able to assess QoL as high (Cross & Markus 1991). It also emerges that white-collar workers assess their QoL higher than blue-collar workers and managers, which gives support to the idea that a good education provides a better basis for an occupational life including a sense of social wellbeing (Grimby & Wiklund 1994). Any possible difficulties or problems which arise when giving information to patients who are immigrants probably are not due to culture shock or language difficulties. It is well known that those immigrants who come in contact with Swedish health care reappraise their assessments from their homeland and acquire increased confidence in Swedish health care (Bacal 1989). CONCLUSION In conclusion, with the support of Orem's theory, this study demonstrates that pacemaker patients with an average age of 77 years have an acceptable QoL. QoL is difficult to define, but by focusing on pacemaker patients from a nursing perspective, this study has provided increased knowledge about their QoL. It was revealed that men, those who were co-habiting, whitecollar workers and managers, and those <64 years of age assess their QoL as good. Steps should be initiated to aid women, individuals living alone, the very old and blue collar workers, all of whom have a lower QoL. Some of the causes for this are a generally poorer physical and mental status, a worsening cognitive ability, not working at some occupation, a poorer financial situation and social relationships. By means of information that is better adapted to the elderly and to persons with less education, the possibilities for self-care by pacemaker patients can be increased. It is therefore important that members of the nursing staff support these persons in such a way that is very clear why the pacemaker is implanted, what its function is, and how long it takes before it wears out. CLINICAL IMPLICATIONS Postoperatively, nursing care becomes primarily a matter of supporting and teaching, with emphasis on
women, those who live alone, those who are blue-collar workers, and elderly pacemaker patients. Continuous education for nurses can improve the possibilities of supporting and helping pacemaker patients and their relatives. By means of on-going follow-up with information meetings for these persons and their relatives, they can be given an increased opportunity for a good QoL as a result of their pacemakers.
It would be of interest to study whether improvements in information and education could result in improved QoL in pacemaker patients. The effects of information given by nurses to these persons and their relatives should be evaluated through an interventive randomized study. It could also be important to carry out another interventional randomized study to investigate whether improved education of nursing personnel would make any difference in regard to the QoL in pacemaker patients and their relatives. Furthermore, it would be interesting to study, by means of cost analysis, whether the total costs for the more expensive, more physiological pacemaker systems are more profitable in terms of QoL and the costs incurred by the community. ACKNOWLEDGEMENTS The authors acknowledge the support from the Department of Medicine, County Hospital Ryhov, J6nk6ping, Sweden. For technical assistance we are most grateful to Elisabeth Svensson PhD, Biostatistics, Chalmers University of Technology, G6teborg, Sweden; Pacesetter St Jude Medical Sweden AB, Sweden; and University College of Health Science, J6nk6ping, Sweden.
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