Researchin Nursing& Health, 1992, 15, 165-173
Psychosocial Outcome Six Months after Heart Transplant Surgery: A Preliminary Report Patricia Bohachick, Bonnie B. Anton, Powhatan J. Wooldridge, Robert L. Kormos, John M. Armitage, Robert L. Hardesty, and Bartley P. Griffith
With improvement in survival of patients treated with heart transplant, evaluation of recovery with respect to psychosocial function has become an important issue. In this study, psychosocial functioning of 44 heart transplant recipients pretransplant was compared to their functioning 6 months posttransplant. Before transplantation, patients experienced considerable psychosocial distress attributable to illness. At 6 months after transplantation, the majority of patients showed significant improvement in emotional, domestic, sexual, social, and vocational functioning. However, 25% of patients showed deterioration in psychosocial adjustment and 11% showed an increase in mood disturbance. Further effort is indicated to improve psychosocial outcome of heart transplantation.
The survival rate for patients treated with heart transplantation has steadily increased over the past two decades. Currently, approximately 85% of heart transplant recipients survive at least 1 year, and expected 5-year survival rates are over 70% (Kriett & Kaye, 1990). With improvement in survival of patients treated with heart transplantation, evaluation of recovery with respect to psychosocial functioning has become an important issue. End stage heart disease and its treatment with heart transplantation precipitates a life transition (Moos, 1982). The heart transplantation process has been conceptualized as a series of stressful stages. These involve such crises as recognition of life-threatening illness and decision for transplantation, waiting for a donor, and recovery from transplant surgery. The adaptive tasks, coping strategies, and responses of patients during these phases have been described (Allender, Shisslak, Kaszniak, & Copeland, 1983; Christopherson,
1987). Following transplantation, recipients must deal with the ongoing threat of rejection and other medical complications. The potential for maladaptation exists because of the unusually potent stressors associated with heart transplantation. On the other hand, survivors of transplantation can experience personal growth and integration and attain a high level of psychosocial functioning (Chnstopherson, 1987). Studies of recovery following heart transplantation have progressed from a primary emphasis on biomedical outcomes to an evaluation of other quality of life concerns (Brennan, Davis, Buchholz, Kuhn, & Gray, 1987; Caine, Sharples, English, & Wallwork, 1990; Evans & Broida, 1985; Hunt, 1985; Jones et al., 1988; Meister, McAleer, Meister, Riley, & Copeland, 1986). While this body of research indicates that survivors of heart transplantation achieve a quality of life superior to their pretransplant status, there appear to be a
Patricia Bohachick, PhD, RN, is an associate professor, School of Nursing, University of Pittsburgh; Bonnie 6.Anton, MN, is a clinical nurse, Presbyterian Hospital, Pittsburgh; and Powhatan Wooldridge, PhD, is an associate professor, School of Nursing, State University of New York at Buffalo. Robert Kormos, MD, and John Armitage, MD, are assistant professors of surgery, and Robert Hardesty, MD, and Bartley Griffith, MD, are professors of surgery, all at the University of Pittsburgh School of Medicine. This research was supported by grants from the University of PittsburghOffice of Research; Sigma Theta Tau, Eta Chapter; and Presbyterian Hospital of Pittsburgh. This article was received on March 8, 1991, was revised, and accepted for publication November 25, 1991. Requests for reprints can be addressed to Dr. Patricia Bohachick, School of Nursing, 314 Victoria Building, Pittsburgh, PA 15261. 0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/030165-09 $04.00
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substantial number of patients who do not achieve optimum recovery outcomes. For example, 26% of heart transplant survivors surveyed by Lough, Lindsey, S h i ~and , Stotts (1985) reported a change for the worse in life activities, and 13% of the patients in another study reported that they were not really satisfied with their life since transplantation (Samuelsson, Hunt, & Schroeder, 1984). McAleer, Copeland, Fuller, and Copeland (1985) observed a high prevalence of psychosocial problems in patients who had survived more than 3 months after transplantation. Problems included mood disturbance, negative body image, impotency, marital stress, and family-related problems. More recently, Shapiro and Kornfeld (1989) reported body image problems in 6%, family/marital problems in 19%, and sexual dysfunction in 34% of 64 transplant recipients. In a prospective study, Jones and coworkers (1988) found anxiety in 53%, depression in 34%, and negative body image in 34% of 36 patients before transplantation. At 4 months after transplantation, they found anxiety in 19%, no depression, and improvement in body image. These findings suggest that the psychosocial problems reported for heart transplant recipients also may be present before transplantation. Therefore, as noted by Caine and coworkers (1990), in order to identify potential benefits of heart transplantation in terms of improvement in psychosocial functioning, psychosocial status must be assessed before as well as after transplantation. The aim of the present study was to quantitatively evaluate the effect of heart transplantation on psychosocial functioning by comparing posttransplant against pretransplant functioning. Psychosocial variables included employment status, psychosocial adjustment to illness, and emotional states.
METHOD
Sample Forty-four patients (34 men, 10 women) who underwent heart transplantation at a single medical center completed our 6-month posttransplant evaluation of psychosocial outcome. The study patients came from a group of 116 patients who were evaluated for heart transplantation and consented to an ongoing study of recovery following heart transplantation. Patients who were less than 21 years of age, unable to read English, or respond to self-report questionnaires were excluded from participation. Fifty-three of the 116 patients underwent heart transplantation. Six patients died
within 6 months and three patients did not return their 6-month follow-up questionnaires; thus, outcome data are available for 44 patients. Characteristics of the sample are presented in Table 1. All 44 patients were Caucasian. Their ages ranged from 29 to 63 years (A4 = 50.4 years).
Measures The Psychosocial Adjustment to Illness Scale (PAIS) was chosen to assess adjustment (Derogatis & Lopez, 1983). The PAIS consists of 46 questions, grouped into seven domains of adjustment: health care orientation (8 items); vocational environment (6 items); domestic environment (8 items); sexual relations (6 items); extended family relationships (5 items); social environment (6 items); and psychological distress (7 items). Respondents are asked to indicate their response to each question on a 4-point scale of adjustment ranging from 0, indicating better adjustment, to 3, indicating worse adjustment. A score for each of the seven domains is calculated, as well as a total score for the 46 items (global or overall psychosocial adjustment). Thus, adjustment may be interpreted at the global level, the domain level, and the discrete item level (Derogatis & Lopez, 1983). Construct, concurrent, and predictive validity of the PAIS have been well documented. Internal consistency reliability (coefficient alpha) for the PAIS from a sample of cardiac surgery patients was .78 (Derogatis & Lopez, 1983). Internal consistency (alpha) for the PAIS total scale in the present sample was .84 (pretest data, N = 44). Internal consistencies for subscales were .65 for health-care orientation, .68 for vocational environment, .59 for domestic environment, .76 for sexual relations, .48 for extended family relations, .80 for social environment, and .77 for psychological distress. The Profile of Mood States (POMS) scale was used to assess the following emotional states: anxiety, depression, confusion, hostility, fatigue, and vigor (McNair, Lorr, & Droppleman, 1981). Respondents are asked to indicate on a 5-point scale, ranging from 0 (nor at all) to 4 (extremely), the degree to which each of 65 adjectives describes his or her functioning. A score for each emotional state is obtained by summing responses for the adjectives defining that state. A Total Mood Disturbance score is obtained by summing the five negative mood subscales and subtracting the vigor subscale. Concurrent and predictive validity of the POMS have been well documented (McNair, L o r , &
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Table 1. Sample Characteristics (N = 44) Characteristics
N
Marital status Married Single Divorced
37 5 2
a4 11 5
11 19
25
14
32
3 7 10 5 7
7 16 23 9 11 16
8
18
21 22
48 50
1
2
Educational level < 12 years 12 years > 12 years Occupational Group Professional Managerial Clerical, sales, technician Service worker Manual worker Housewife Retired Etiology of heart disease Ischemic heart disease Cardiomyopathy Congenital heart disease Length of disability < l year 1-4 years >4years
Droppleman, 1981). Internal consistency reliability (coefficient alpha) for the POMS Total Mood Disturbance scale in the present sample was .95 (pretest data, N = 44). Internal consistencies for subscales were .85 for anxiety, .88 for depression, .80 for confusion, .77 for hostility, .90 for fatigue, and .88 for vigor. Data on patients’ work status were obtained by interview.
4
19 12 13
(Oh
)
43
43
27 30
at home and a preaddressed envelope was provided for return of the forms to the investigators. Six months after transplantation, each patient was interviewed again during his or her clinic visit for follow-up medical evaluation and was given the self-report questionnaires to complete at home.
RESULTS
Procedure Data were collected immediately after patients’ acceptance to the waiting list for heart transplantation. The investigators interviewed hospitalized patients in their rooms; patients attending clinic were interviewed in an office adjacent to the clinic. During the interview, informed consent was obtained and sociodemographic data were documented. Patients then were given directions for completing the self-report questionnaires. Hospitalized patients completed the questionnaires at their leisure over a period of 1 day. Clinic outpatients were given the questionnaires to complete
Paired t tests were used to compare the pretransplant and 6-month posttransplant PAIS and POMS scores. As can be seen from Table 2, a significant decrease in PAIS total score was found 6-months posttransplant. Since high PAIS scores indicate problems in adjusting to illness, this change indicates that, on the average, patients substantially improved in adjustment after transplantation. This overall improvement was due primarily to improvements in their vocational, domestic, sexual, and social functioning. Changes in the other domain scores were in the direction indicating improvement, but were not statistically significant. Further
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Table 2. PsychosocialAdjustment to Illness Scores' Pretransplant and 6 Months Posttransplant
Domain Health care orientation Vocational environment Domestic environment Sexual relations Extended family relations Social environment Psychological distress Total scoreb
Potential Score Range 0-24 0-18 0-24 0-18 0-18 0-1 8 0-21 0-138
Pretransplant
Posttransplant
n
M
SD
M
SD
t
44 31 44 43 44 44 44 44
4.70 10.65 7.80 8.10 2.39 9.25 6.68 50.22
3.05 3.24 2.53 3.72 2.10 4.87 4.59 14.19
4.00 8.52 6.32 4.43 1.59 5.09 6.23 36.23
2.55 4.73 3.39 3.67 2.05 5.05 5.72 17.55
-1.44 -2.87' -3.02" -5.47'* - 1.74 -3.99" - .71 -4.86"
'Lower scores indicate better adjustment. 'For patients who did not complete the vocational environment (n = 13) or sexual relations (n = 2) domain, the sample mean for the missing domain was used in calculating the PAIS total score. ' p < .01."p < ,001.
analyses were performed to identify those items that contributed most to the significantly improved domain scores. The multiple Bonferroni technique (Holm, 1979) was used to adjust the level of significance in these analyses (see Table 3). For the vocational domain, posttransplant patients reported significantly less time lost at work due to their illness, less work impairment (physical performance of job), and diminished vocational problems attributable to their illness. Vocational investment, vocational goals, and patients' relationships with coworkers did not change to a statistically significant degree. With respect to the domestic environment domain, posttransplant patients reported less physical disability and domestic impairment (difficulties with duties around the house). No significant improvements were found in dependency posture, family communication, family adaptability, financial resources, patients' relationships with their partners, or relationships with other cohabitants, and such differences as were found were opposite in direction to the improved adjustment found for the domain as a whole. The sexual relations domain evaluates six aspects of sexual behavior and, of these, four were significantly improved: sexual performance, frequency of sexual activity, sexual interest, and sexual satisfaction. Quality of interpersonal sexual relationshipsand interpersonalconflictderived from sexual relationshipsdid not improve significantly. At the 6-month followup, patients reported significantly less impairment in their social life in terms of participation in individual, family, and social leisure activities. Interest in leisure activities also changed in the direction of improvement, but not to a statistically significant extent. As shown in Table 4, there was a significant decrease in POMS mean total score from pre-
transplant to 6 months posttransplant, indicating an overall reduction in mood disturbance. There were significant positive changes in five of the six subscales of the POMS posttransplant. Mean scores for anxiety, depression, and confusion decreased significantly. Fatigue scores declined markedly, whereas the degree of vigor dramatically increased. No significant overall change in hostility scores was found between the two examinations. Only two patients were working at the time of their evaluation for heart transplantation. Eight patients (18%) were retired because of medical status or age considerations. Seven patients (16%) were homemakers. At 6-months posttransplant, 10 patients (23%) had returned to work (4 parttime and 6 full-time). Nineteen patients (43%) remained unemployed at the 6-month followup. With a sample of only 44 patients, it was difficult to determine those factors which accounted for differences between patients in psychosocial outcomes. Exploratory analyses nonetheless were performed on selected variables of particular interest. Patients who returned to work posttransplant were compared to those who considered themselves to be still in the job market, but "disabled" (not retired or homemakers). The average length of unemployment at the time of evaluation for transplantation was 9.1 months for the 10 patients who returned to work; whereas for the 19 "disabled" patients, the average length of unemployment at the time of evaluation for transplant was 18.26 months. This difference was statistically significant, Mann-Whitney U = 51, p < .05, indicating that patients are more likely to return to work posttransplant if they have been recently employed. It seemed likely that vocational environmental domain scores for patients who completed this domain on the PAIS might be related to the patient's
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PSYCHOSOCIAL OUTCOME / BOHACHICK ET AL.
Table 3. individual item Changes for PAlS Domains with Statistically Significant improvement Pretransplant to 6 Months Posttranspiant Domain/item Vocational environment (total) (n = 31) Lost time due to illness Poor physical performance Work impairment due to illness Feel job is not important Change in goals due to illness Increased problems with co-workers Domestic environment (total) (n = 44) Physical disability Illness interferes with household duties Need help and can't get it Decreased communication with family Family not able to help with duties Financial hardship Poor relations with spouse/partner Poor relations with other cohabitants Sexual relations (total) (n = 42) Problems with sexual performance Decrease in sexual activity Loss of sexual interest Loss of sexual satisfaction Problems leading to less closeness Arguments about impaired sexual relations Social environment (total) (n = 44) Reduced participation in personal leisure activities Reduced participation in family leisure activities Reduced participation in social activities Loss of interest in personal leisure activities Loss of interest in family leisure activities Loss of interest in social activities
Changea
P
-2.13 -1.00 -0.84 -0.53 0.06 -0.16 0.41 - 1.48 -1.14 -1.26 0.1 2 0.1 2 0.04 0.19 0.14 0.19 -3.67 - 1.20 - 1.02 -0.56 - 1.07 0.07 0.12 -4.16 -0.91 -0.79 -0.93 -0.47 -0.63 -0.49
-2.87" -4.50" -4.03" -3.26" 0.30 -0.68 2.28 -3.02' -6.52" -8.03" .90 1.04 0.36 1.14 1.77 2.24 -5.47" -5.94" -6.48" -2.64' -4.96" 0.57 1.70 -3.99-4.07" -3.48" -4.20" - 1.97 -2.57" -2.09
'Change - posttransplant mean - pretransplant mean. 'Statistical significance of individual items calculated from two-tailed r-test alphas, using the multiple Bonferroni technique. ' p < .05. " p < .01
Table 4. Profile of Mood State Scoresa Pretransplant and 6 Months Posttransplant (N = 44) ~
Anxiety Depression Confusion Fatigue Vigor Hostility Total
_
_
_
~
~~
Pretransplant
Posttransplant
M
SD
M
SD
12.95 10.98 7.68 13.00 11.80 5.80 38.27
6.42 8.83 6.1 7 6.86 6.28 4.91 28.29
10.43 7.16 5,18 6.91 18.45 5.79 17.02
6.32 8.98 3.40 5.64 6.87 7.48 29.53
'Lower scores indicate less disturbance. ' p < .05. " p < ,005. " ' p < ,001.
t
2.08' 2.41 3.1 5" 5.72"' 5.84"' .28 4.35"'
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posttransplant occupational status. A one way analysis of variance, with patients divided into three groups according to whether they were: ( 1 ) disabled ( n = 14), (2) homemakers ( n = 7), or (3) employed full- or part-time ( n = 10) showed a statistically significant difference, F(2, 28) = 4.71, p < .05. Patients who were disabled at 6month followup had higher mean scores on the posttransplant vocational domain than the other two groups; the difference between the disabled and those who returned to work was statistically significant at the .05 level by Scheffk test. An analysis of change scores in vocational environment, with pretest scores as a covariate, also showed statistical significance at the .05 level. The disabled showed increases in vocational environment scores (adjusted for the covariate), while the other two groups showed decreases. These results indicate that the overall improvement in vocational domain score posttransplant was attributable to improved vocational functioning of those who returned to work and homemakers. Although the pretransplant to posttransplant PAIS and POMS total scores improved for most patients, 1 1 (25%) of the patients had an increase in PAIS score and 5 patients ( 1 1%) had an increase in POMS total score. Those with an increase in mood disturbance (POMS) also had an increase in problems in adjusting to illness (PAIS). An adjustment for regression to the mean did not affect the sign of the change scores for these 1 1 patients, indicating that the deterioration in psychosocial functioning was not attributable to regression to the mean. The PAIS increases, after adjustment, ranged from 1 to 34 points, with an average of 10 points. The posttransplant PAIS total scores of 1 1 patients who experienced an increase in adjustment problems ranged from 46 to 83, with a mean of 58. The POMS scores of those with greater mood disturbance, after adjustment, ranged from 11 to 74 points, with an average of 33 points. The posttransplant POMS total scores of these 5 patients ranged from 46 to 96, with a mean of 65. The patients who experienced deterioration in adjustment or mood showed no major differences from other patients in their background characteristics. Race, gender, employment status, educational status, occupational status, and length of disability were not significantly correlated with any of the PAIS or POMS change scores, after adjustment for multiple comparisons.
DISCUSSION The major aim of this study was to evaluate the psychosocial outcome of heart transplantation by
comparing patients’ psychosocial functioning 6 months following transplantation against their pretransplant status. It should be noted that psychosocial functioning was assessed at the time that the patient was placed on the waiting list for transplantation. The question could be raised whether patients may alter answers to self-report questionnaires in order to appear excellent candidates for transplantation. If so, it might be expected that this response bias would have affected everyone’s score to some extent. Nonetheless, it is important to bear this consideration in mind when evaluating findings. The data revealed that, before transplantation, patients experienced considerable psychosocial distress attributable to illness. Less than 5% were working at the time of their evaluation for transplantation. The average PAIS total score for patients prior to transplantation was higher (worse adjustment) than the average of 40.32 reported for preoperative coronary artery bypass patients (Folks, Blake, Fleece, Sokol, & Freeman, 1986). Consistent with reports of improved quality of life following heart transplantation, the majority of this sample had dramatic improvement in psychosocial functioning within 6 months following surgery. These patients reported that their domestic, sexual, and social functioning were very much improved compared with prior to transplantation; vocational adjustment was moderately improved. The patients’ mood states improved most consistently of all. Although patients might not be expected to retum to employment within 6 months following transplant surgery, it was encouraging that 10 of the patients (23%)had returned to work. Our findings regarding employment can be compared with figures from other studies. In the National Heart Transplantation Study, Evans and Broida ( 1985) found that approximately 3 1% of 152 recipients were employed whereas 50% received medical disability. A great percentage of heart transplant recipients are physically able to work but fail to return to work because of psychological or social factors. Some freely choose not to reenter the work force, whereas others are either encouraged to retire or discouraged from working by their employers’ refusal to adjust work schedules to allow for frequent follow-up visits for health care following transplantation. Meister and colleagues (1986) reported that approximately 36% of their heart transplant recipients were physically able to work but remained unemployed because they were dependent on government-subsidized disability income and health insurance coverage. Meister and colleagues (1986) noted that the length of disability before transplant for “insurance
PSYCHOSOCIAL OUTCOME / BOHACHICK ET AL.
disabled’ recipients (M = 14.3 months) was longer than that of recipients who returned to work (M = 4.1 months) and concluded that the longer the disability before transplant, the more difficult it becomes for a recipient to return to work. Our findings support this view. Despite the improvement in vocational function observed by comparing pretransplant to posttransplant scores, it is noteworthy that among the seven psychosocial areas assessed by the PAIS, the vocational domain was highest scored, indicating that this was the major problem area after transplantation as well as before transplantation. Considering the high rate of unemployment and continuing expenses of medical care, it is not surprising that patients reported the persistence of financial problems following transplantation. Our finding of improved domestic functioning following transplantation was attributable primarily to improved physical functioning and ability to perform household duties. These findings closely agree with those of Wallwork and Caine (1985) who noted that “as most patients spend a considerable amount of their time in the home after discharge from hospital, one would expect them to notice the improvement in their functional capacity in this area” (p. 324). Constant sexual performance problems were reported by 74% of the patients prior to transplant but by only 28% of the patients at 6 months posttransplant. Hunt (1985) also observed a marked decline in the number of patients reporting distress in their sex life following transplantation (71% pretransplant versus 24%). Frequently occurring impotence has been reported by up to one third of heart transplant recipients (Wolpowitz & Barnard, 1978). It is interesting to note that the incidence of impotence after heart transplantation is comparable to that reported for patients after coronary artery bypass surgery (Grundle, Reeves, Tate, Raft, & McLaurin, 1980). Grundle and associates (1980) suggested that poor sexual adjustment despite improved functional capacity following coronary artery surgery may be due to “the patient’s persistent image of him- or herself as being damaged’ (p. 1592). Impotence after heart transplantation may be the result of immunosuppressive and antihypertensive therapy (Wolpowitz & Barnard, 1978). However, it is also possible that other, as yet unidentified, factors may contribute to persistent sexual dysfunction following heart transplantation. There are conflicting findings regarding the impact of heart transplantation on social activity. In separate studies, Brennan and colleagues ( 1987) and Lough and coworkers (1985) found little change in social activities for the majority of heart
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transplant recipients. On the other hand, Hunt (1985) and O’Brien, Burton, and Ferguson (1987) found that patients showed significant improvement in social life following transplantation. The present study supports the view of improved social functioning after heart transplantation. That is, whereas 68% of patients reported marked impairment in social activities before transplantation, only 27% indicated that their social functioning was markedly impaired at 6-month followup. Considering the extreme physical and psychosocial stress imposed by end-stage heart disease and its treatment, the overall level of mood disturbance prior to heart transplantation did not seem excessive. POMS scale scores, except for fatigue and vigor, were either lower than (less disturbance) or comparable to those reported for normative samples by McNair, Lorr, and Droppleman (1981). The average Total Mood Disturbance score for patients prior to transplantation was similar to that reported for preoperative coronary artery bypass patients (M = 38.65) by Rankin (1990). However, the average fatigue score for pretransplant patients was higher than the average of 7.4 reported for coronary artery bypass patients (Rankin, 1990). With end-stage heart disease, functional capacity is severely impaired resulting in marked limitation of physical activity. Therefore, the increased fatigue and diminished vigor that patients demonstrated before transplantation were not surprising. In comparing the emotional status of patients before and after transplantation, improvement in energy level after transplantation, as reflected in the marked rise in vigor and decline in fatigue, was impressive and consistent with improved functional capacity. In a prospective study of heart transplant patients using the Nottingham Health Profile, Hunt (1985) also found that patients showed substantial gains in energy and physical mobility by 3 months after transplantation. Following evaluation for transplantation, most candidates must pass through a stressful period of waiting for a donor organ and transplant surgery. After transplantation, patients must cope with the threat of graft rejection, other medical complications, and uncertainty about long-term survival. Therefore, the overall improvement in anxiety and depression after transplantation was encouraging. The confusion score also improved after transplantation. McNair et al. (1981) suggest that this factor may represent a by-product of anxiety. Although the majority of patients showed improvment in overall psychosocial adjustment, 25% of the patients reported more psychosocial adjustment problems at 6 months after transplantation than they had before transplantation. and 11% also reported more mood disturbance than they
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had before transplantation. This finding is consistent with work indicating that patients who are more depressed and anxious also tend t o have more limitations in psychosocial function (Baider & Kaplan De-Nour, 1984; Kaplan De-Nour, 1982; Prigatano, Wright, & Levin, 1984). However, as noted by Baider and Kaplan De-Nour (1984), the question of whether anxiety and depression lead to psychosocial adjustment problems or whether these negative emotional states represent the patient’s reaction to problems in coping with the demands of illness remains unanswered. In addition, risk factors that would predict whether or not a patient will deteriorate in psychosocial adjustment or mood state have yet to be identified. The results of this study support the body of research that indicates that most survivors of heart transplantation achieve a quality of life superior t o their pretransplant status. By 6 months after transplantation, the great majority of patients demonstrated significant improvement in psychosocial adjustment and emotional states. However, given that one-quarter of the patients showed a negative change in their psychosocial adjustment following heart transplantation, further study is indicated to identify factors important to posttransplant psychosocial adaptation. Such information could help identify those patients at risk for psychosocial problems following heart transplantation or, perhaps, provide a basis for designing more effective nursing interventions for full rehabilitation of heart transplant recipients.
REFERENCES Allender, J . , Shisslak, C., Kaszniak, A., & Copeland, J. (1983). Stages of psychological adjustment associated with heart transplantation. Heart Transplantation, 2 , 228-231. Baider, L.G., & Kaplan De-Now, A. (1984). Couples’ reactions and adjustment to mastectomy: A preliminary report. International Journal of Psychiatry in Medicine, 14, 265-276. Brennan, A.F., Davis, M.H., Buchholz, D.J., Kuhn, W.F., &Gray, C.A. (1987). Predictors of quality of life following cardiac transplantation. Psychosomatics, 28, 566-571. Caine, N., Sharples, L.D., English, T.H., & Wallwork, J. (1990). Prospective study comparing quality of life before and after heart transplantation. Transplantation Proceedings, 2 2 , 14371439.
Christopherson, L.K. (1987). Cardiac transplantation. Circulation, 7 5 , 57-62. Derogatis, L.R., & Lopez, M.C. (1983). PAIS and PAIS-SR administration, scoring and procedures
manual I . Baltimore: Clinical Psychometric Research. Evans, R.W., & Broida, J.H. (1985). National Heart Transplantation Study Executive Summary. Seattle: Batelle Human Affairs Research Centers. Folks, D.G., Blake, D.J., Fleece, L., Sokol, R.S., & Freeman, A.M. (1986). Quality of life six months after coronary artery bypass surgery: A preliminary report. Southern Medical Journal, 79, 397-399. Grundle, M.D., Reeves, B.R., Tate, S . , Raft, D., & McLaurin, L.P. (1980). Psychosocial outcome after coronary artery surgery. American Journal of Psychiatry, 137, 1591 - 1594. Holm, S. (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6 , 65-67. Hunt, S.M. (1985). Quality of life considerations in cardiac transplantation. Quality of Life and Cardiovascular Care, I , 308-3 16. Jones, B.M., Chang, V.P., Esmore, D.,Spratt, P., Shanahan, M.X., Farnsworth, A.E., & Downs, K. (1988). Psychological adjustment after cardiac transplantation. The Medical Journal of Australia, 149, 118-122. Kaplan De-Nour, A.K. (1982). Psychosocial adjustment to illness scale (PAIS): A study of chronic hemodialysis patients. Journal of Psychosomatic Research, 2 6 , 1 1-22. Kriett, J.M., & Kaye, M.P. (1990). The Registry of the International Society for Heart Transplantation: Seventh Official Report- 1990. Journal of Heart Transplantation, 9, 323-330. Lough, M.E., Lindsey, A.M., Shinn, J.A., & Stotts, N.A. (1985). Life satisfaction following heart transplantation. Heart Transplantation, 4,446449. McAleer, M.J., Copeland, J . , Fuller, J., & Copeland, J.G. (1985). Psychological aspects of heart transplantation. Heart Transplantation, 4 , 232233. McNair, D.M., Lorr, M., & Droppleman, L.F. (1981). Manual for the Profile of Mood States. San Diego: Educational and Industrial Testing Service. Meister, N.D., McAleer, M.J., Meister, J.S., Riley, J.E., & Copeland, J.G. (1986). Returning to work after heart transplantation. Heart Transplantation, 5, 154-161. Moos, R.H. (1982). Coping with acute health crises. In T. Millon, C . Green, & R. Meagher (Eds.), Handbook of clinical health psychology (pp. 129- 151). New York: Plenum Press. O’Brien, B.J., Burton, M.J., & Ferguson, B.A. (1987). Measuring the effectiveness of heart transplant programmes: Quality of life data and their relationship to survival analysis. Journal of Chronic Disease, 40, 137s-153s. Prigatano, G.P.,Wright, E.C., & Levin, D. ( 1984). Quality of life and its predictors in patients with mild hypoxemia and chronic obstructive pul-
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monary disease. Archives of Internal Medicine, 144, 1613-1619. Rankin, S.H.(1990). Differences in recovery from cardiac surgery: A profile of male and female patients. Heart Lung, 19, 481-485. Samuelsson, R.B., Hunt, S . A . , & Schroeder, J.S. (1984). Functional and social rehabilitation of heart transplant recipients under age thirty. Scandinavian Journal of Thoracic Cardiovascular Surgery, 18, 97- 103. Shapiro, P.A., & Kornfeld, D.S.(1989). Psychiatric
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outcome of heart transplantation. General Hospital Psychiatry, 1 1 , 352-357. Wallwork, J., & Caine, N . (1985). A comparison of the quality of life of cardiac transplant patients and coronary artery bypass graft patients before and after surgery. Quality of Life and Cardiovascular Care, I , 317-331. Wolpowitz, A., & Barnard, C.N. (1978). Impotence after heart transplantation. South African Medical Journal, 5 3 , 693.
Psychosocial Outcome Six Months after Heart Transplant Surgery: A Preliminary Report Patricia Bohachick, Bonnie B. Anton, Powhatan J. Wooldridge, Robert L. Kormos, John M. Armitage, Robert L. Hardesty, and Bartley P. Griffith
With improvement in survival of patients treated with heart transplant, evaluation of recovery with respect to psychosocial function has become an important issue. In this study, psychosocial functioning of 44 heart transplant recipients pretransplant was compared to their functioning 6 months posttransplant. Before transplantation, patients experienced considerable psychosocial distress attributable to illness. At 6 months after transplantation, the majority of patients showed significant improvement in emotional, domestic, sexual, social, and vocational functioning. However, 25% of patients showed deterioration in psychosocial adjustment and 11% showed an increase in mood disturbance. Further effort is indicated to improve psychosocial outcome of heart transplantation.
The survival rate for patients treated with heart transplantation has steadily increased over the past two decades. Currently, approximately 85% of heart transplant recipients survive at least 1 year, and expected 5-year survival rates are over 70% (Kriett & Kaye, 1990). With improvement in survival of patients treated with heart transplantation, evaluation of recovery with respect to psychosocial functioning has become an important issue. End stage heart disease and its treatment with heart transplantation precipitates a life transition (Moos, 1982). The heart transplantation process has been conceptualized as a series of stressful stages. These involve such crises as recognition of life-threatening illness and decision for transplantation, waiting for a donor, and recovery from transplant surgery. The adaptive tasks, coping strategies, and responses of patients during these phases have been described (Allender, Shisslak, Kaszniak, & Copeland, 1983; Christopherson,
1987). Following transplantation, recipients must deal with the ongoing threat of rejection and other medical complications. The potential for maladaptation exists because of the unusually potent stressors associated with heart transplantation. On the other hand, survivors of transplantation can experience personal growth and integration and attain a high level of psychosocial functioning (Chnstopherson, 1987). Studies of recovery following heart transplantation have progressed from a primary emphasis on biomedical outcomes to an evaluation of other quality of life concerns (Brennan, Davis, Buchholz, Kuhn, & Gray, 1987; Caine, Sharples, English, & Wallwork, 1990; Evans & Broida, 1985; Hunt, 1985; Jones et al., 1988; Meister, McAleer, Meister, Riley, & Copeland, 1986). While this body of research indicates that survivors of heart transplantation achieve a quality of life superior to their pretransplant status, there appear to be a
Patricia Bohachick, PhD, RN, is an associate professor, School of Nursing, University of Pittsburgh; Bonnie 6.Anton, MN, is a clinical nurse, Presbyterian Hospital, Pittsburgh; and Powhatan Wooldridge, PhD, is an associate professor, School of Nursing, State University of New York at Buffalo. Robert Kormos, MD, and John Armitage, MD, are assistant professors of surgery, and Robert Hardesty, MD, and Bartley Griffith, MD, are professors of surgery, all at the University of Pittsburgh School of Medicine. This research was supported by grants from the University of PittsburghOffice of Research; Sigma Theta Tau, Eta Chapter; and Presbyterian Hospital of Pittsburgh. This article was received on March 8, 1991, was revised, and accepted for publication November 25, 1991. Requests for reprints can be addressed to Dr. Patricia Bohachick, School of Nursing, 314 Victoria Building, Pittsburgh, PA 15261. 0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/030165-09 $04.00
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substantial number of patients who do not achieve optimum recovery outcomes. For example, 26% of heart transplant survivors surveyed by Lough, Lindsey, S h i ~and , Stotts (1985) reported a change for the worse in life activities, and 13% of the patients in another study reported that they were not really satisfied with their life since transplantation (Samuelsson, Hunt, & Schroeder, 1984). McAleer, Copeland, Fuller, and Copeland (1985) observed a high prevalence of psychosocial problems in patients who had survived more than 3 months after transplantation. Problems included mood disturbance, negative body image, impotency, marital stress, and family-related problems. More recently, Shapiro and Kornfeld (1989) reported body image problems in 6%, family/marital problems in 19%, and sexual dysfunction in 34% of 64 transplant recipients. In a prospective study, Jones and coworkers (1988) found anxiety in 53%, depression in 34%, and negative body image in 34% of 36 patients before transplantation. At 4 months after transplantation, they found anxiety in 19%, no depression, and improvement in body image. These findings suggest that the psychosocial problems reported for heart transplant recipients also may be present before transplantation. Therefore, as noted by Caine and coworkers (1990), in order to identify potential benefits of heart transplantation in terms of improvement in psychosocial functioning, psychosocial status must be assessed before as well as after transplantation. The aim of the present study was to quantitatively evaluate the effect of heart transplantation on psychosocial functioning by comparing posttransplant against pretransplant functioning. Psychosocial variables included employment status, psychosocial adjustment to illness, and emotional states.
METHOD
Sample Forty-four patients (34 men, 10 women) who underwent heart transplantation at a single medical center completed our 6-month posttransplant evaluation of psychosocial outcome. The study patients came from a group of 116 patients who were evaluated for heart transplantation and consented to an ongoing study of recovery following heart transplantation. Patients who were less than 21 years of age, unable to read English, or respond to self-report questionnaires were excluded from participation. Fifty-three of the 116 patients underwent heart transplantation. Six patients died
within 6 months and three patients did not return their 6-month follow-up questionnaires; thus, outcome data are available for 44 patients. Characteristics of the sample are presented in Table 1. All 44 patients were Caucasian. Their ages ranged from 29 to 63 years (A4 = 50.4 years).
Measures The Psychosocial Adjustment to Illness Scale (PAIS) was chosen to assess adjustment (Derogatis & Lopez, 1983). The PAIS consists of 46 questions, grouped into seven domains of adjustment: health care orientation (8 items); vocational environment (6 items); domestic environment (8 items); sexual relations (6 items); extended family relationships (5 items); social environment (6 items); and psychological distress (7 items). Respondents are asked to indicate their response to each question on a 4-point scale of adjustment ranging from 0, indicating better adjustment, to 3, indicating worse adjustment. A score for each of the seven domains is calculated, as well as a total score for the 46 items (global or overall psychosocial adjustment). Thus, adjustment may be interpreted at the global level, the domain level, and the discrete item level (Derogatis & Lopez, 1983). Construct, concurrent, and predictive validity of the PAIS have been well documented. Internal consistency reliability (coefficient alpha) for the PAIS from a sample of cardiac surgery patients was .78 (Derogatis & Lopez, 1983). Internal consistency (alpha) for the PAIS total scale in the present sample was .84 (pretest data, N = 44). Internal consistencies for subscales were .65 for health-care orientation, .68 for vocational environment, .59 for domestic environment, .76 for sexual relations, .48 for extended family relations, .80 for social environment, and .77 for psychological distress. The Profile of Mood States (POMS) scale was used to assess the following emotional states: anxiety, depression, confusion, hostility, fatigue, and vigor (McNair, Lorr, & Droppleman, 1981). Respondents are asked to indicate on a 5-point scale, ranging from 0 (nor at all) to 4 (extremely), the degree to which each of 65 adjectives describes his or her functioning. A score for each emotional state is obtained by summing responses for the adjectives defining that state. A Total Mood Disturbance score is obtained by summing the five negative mood subscales and subtracting the vigor subscale. Concurrent and predictive validity of the POMS have been well documented (McNair, L o r , &
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PSYCHOSOCIAL OUTCOME / EOHACHICK ET AL
Table 1. Sample Characteristics (N = 44) Characteristics
N
Marital status Married Single Divorced
37 5 2
a4 11 5
11 19
25
14
32
3 7 10 5 7
7 16 23 9 11 16
8
18
21 22
48 50
1
2
Educational level < 12 years 12 years > 12 years Occupational Group Professional Managerial Clerical, sales, technician Service worker Manual worker Housewife Retired Etiology of heart disease Ischemic heart disease Cardiomyopathy Congenital heart disease Length of disability < l year 1-4 years >4years
Droppleman, 1981). Internal consistency reliability (coefficient alpha) for the POMS Total Mood Disturbance scale in the present sample was .95 (pretest data, N = 44). Internal consistencies for subscales were .85 for anxiety, .88 for depression, .80 for confusion, .77 for hostility, .90 for fatigue, and .88 for vigor. Data on patients’ work status were obtained by interview.
4
19 12 13
(Oh
)
43
43
27 30
at home and a preaddressed envelope was provided for return of the forms to the investigators. Six months after transplantation, each patient was interviewed again during his or her clinic visit for follow-up medical evaluation and was given the self-report questionnaires to complete at home.
RESULTS
Procedure Data were collected immediately after patients’ acceptance to the waiting list for heart transplantation. The investigators interviewed hospitalized patients in their rooms; patients attending clinic were interviewed in an office adjacent to the clinic. During the interview, informed consent was obtained and sociodemographic data were documented. Patients then were given directions for completing the self-report questionnaires. Hospitalized patients completed the questionnaires at their leisure over a period of 1 day. Clinic outpatients were given the questionnaires to complete
Paired t tests were used to compare the pretransplant and 6-month posttransplant PAIS and POMS scores. As can be seen from Table 2, a significant decrease in PAIS total score was found 6-months posttransplant. Since high PAIS scores indicate problems in adjusting to illness, this change indicates that, on the average, patients substantially improved in adjustment after transplantation. This overall improvement was due primarily to improvements in their vocational, domestic, sexual, and social functioning. Changes in the other domain scores were in the direction indicating improvement, but were not statistically significant. Further
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Table 2. PsychosocialAdjustment to Illness Scores' Pretransplant and 6 Months Posttransplant
Domain Health care orientation Vocational environment Domestic environment Sexual relations Extended family relations Social environment Psychological distress Total scoreb
Potential Score Range 0-24 0-18 0-24 0-18 0-18 0-1 8 0-21 0-138
Pretransplant
Posttransplant
n
M
SD
M
SD
t
44 31 44 43 44 44 44 44
4.70 10.65 7.80 8.10 2.39 9.25 6.68 50.22
3.05 3.24 2.53 3.72 2.10 4.87 4.59 14.19
4.00 8.52 6.32 4.43 1.59 5.09 6.23 36.23
2.55 4.73 3.39 3.67 2.05 5.05 5.72 17.55
-1.44 -2.87' -3.02" -5.47'* - 1.74 -3.99" - .71 -4.86"
'Lower scores indicate better adjustment. 'For patients who did not complete the vocational environment (n = 13) or sexual relations (n = 2) domain, the sample mean for the missing domain was used in calculating the PAIS total score. ' p < .01."p < ,001.
analyses were performed to identify those items that contributed most to the significantly improved domain scores. The multiple Bonferroni technique (Holm, 1979) was used to adjust the level of significance in these analyses (see Table 3). For the vocational domain, posttransplant patients reported significantly less time lost at work due to their illness, less work impairment (physical performance of job), and diminished vocational problems attributable to their illness. Vocational investment, vocational goals, and patients' relationships with coworkers did not change to a statistically significant degree. With respect to the domestic environment domain, posttransplant patients reported less physical disability and domestic impairment (difficulties with duties around the house). No significant improvements were found in dependency posture, family communication, family adaptability, financial resources, patients' relationships with their partners, or relationships with other cohabitants, and such differences as were found were opposite in direction to the improved adjustment found for the domain as a whole. The sexual relations domain evaluates six aspects of sexual behavior and, of these, four were significantly improved: sexual performance, frequency of sexual activity, sexual interest, and sexual satisfaction. Quality of interpersonal sexual relationshipsand interpersonalconflictderived from sexual relationshipsdid not improve significantly. At the 6-month followup, patients reported significantly less impairment in their social life in terms of participation in individual, family, and social leisure activities. Interest in leisure activities also changed in the direction of improvement, but not to a statistically significant extent. As shown in Table 4, there was a significant decrease in POMS mean total score from pre-
transplant to 6 months posttransplant, indicating an overall reduction in mood disturbance. There were significant positive changes in five of the six subscales of the POMS posttransplant. Mean scores for anxiety, depression, and confusion decreased significantly. Fatigue scores declined markedly, whereas the degree of vigor dramatically increased. No significant overall change in hostility scores was found between the two examinations. Only two patients were working at the time of their evaluation for heart transplantation. Eight patients (18%) were retired because of medical status or age considerations. Seven patients (16%) were homemakers. At 6-months posttransplant, 10 patients (23%) had returned to work (4 parttime and 6 full-time). Nineteen patients (43%) remained unemployed at the 6-month followup. With a sample of only 44 patients, it was difficult to determine those factors which accounted for differences between patients in psychosocial outcomes. Exploratory analyses nonetheless were performed on selected variables of particular interest. Patients who returned to work posttransplant were compared to those who considered themselves to be still in the job market, but "disabled" (not retired or homemakers). The average length of unemployment at the time of evaluation for transplantation was 9.1 months for the 10 patients who returned to work; whereas for the 19 "disabled" patients, the average length of unemployment at the time of evaluation for transplant was 18.26 months. This difference was statistically significant, Mann-Whitney U = 51, p < .05, indicating that patients are more likely to return to work posttransplant if they have been recently employed. It seemed likely that vocational environmental domain scores for patients who completed this domain on the PAIS might be related to the patient's
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PSYCHOSOCIAL OUTCOME / BOHACHICK ET AL.
Table 3. individual item Changes for PAlS Domains with Statistically Significant improvement Pretransplant to 6 Months Posttranspiant Domain/item Vocational environment (total) (n = 31) Lost time due to illness Poor physical performance Work impairment due to illness Feel job is not important Change in goals due to illness Increased problems with co-workers Domestic environment (total) (n = 44) Physical disability Illness interferes with household duties Need help and can't get it Decreased communication with family Family not able to help with duties Financial hardship Poor relations with spouse/partner Poor relations with other cohabitants Sexual relations (total) (n = 42) Problems with sexual performance Decrease in sexual activity Loss of sexual interest Loss of sexual satisfaction Problems leading to less closeness Arguments about impaired sexual relations Social environment (total) (n = 44) Reduced participation in personal leisure activities Reduced participation in family leisure activities Reduced participation in social activities Loss of interest in personal leisure activities Loss of interest in family leisure activities Loss of interest in social activities
Changea
P
-2.13 -1.00 -0.84 -0.53 0.06 -0.16 0.41 - 1.48 -1.14 -1.26 0.1 2 0.1 2 0.04 0.19 0.14 0.19 -3.67 - 1.20 - 1.02 -0.56 - 1.07 0.07 0.12 -4.16 -0.91 -0.79 -0.93 -0.47 -0.63 -0.49
-2.87" -4.50" -4.03" -3.26" 0.30 -0.68 2.28 -3.02' -6.52" -8.03" .90 1.04 0.36 1.14 1.77 2.24 -5.47" -5.94" -6.48" -2.64' -4.96" 0.57 1.70 -3.99-4.07" -3.48" -4.20" - 1.97 -2.57" -2.09
'Change - posttransplant mean - pretransplant mean. 'Statistical significance of individual items calculated from two-tailed r-test alphas, using the multiple Bonferroni technique. ' p < .05. " p < .01
Table 4. Profile of Mood State Scoresa Pretransplant and 6 Months Posttransplant (N = 44) ~
Anxiety Depression Confusion Fatigue Vigor Hostility Total
_
_
_
~
~~
Pretransplant
Posttransplant
M
SD
M
SD
12.95 10.98 7.68 13.00 11.80 5.80 38.27
6.42 8.83 6.1 7 6.86 6.28 4.91 28.29
10.43 7.16 5,18 6.91 18.45 5.79 17.02
6.32 8.98 3.40 5.64 6.87 7.48 29.53
'Lower scores indicate less disturbance. ' p < .05. " p < ,005. " ' p < ,001.
t
2.08' 2.41 3.1 5" 5.72"' 5.84"' .28 4.35"'
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RESEARCH IN NURSING 8 HEALTH
posttransplant occupational status. A one way analysis of variance, with patients divided into three groups according to whether they were: ( 1 ) disabled ( n = 14), (2) homemakers ( n = 7), or (3) employed full- or part-time ( n = 10) showed a statistically significant difference, F(2, 28) = 4.71, p < .05. Patients who were disabled at 6month followup had higher mean scores on the posttransplant vocational domain than the other two groups; the difference between the disabled and those who returned to work was statistically significant at the .05 level by Scheffk test. An analysis of change scores in vocational environment, with pretest scores as a covariate, also showed statistical significance at the .05 level. The disabled showed increases in vocational environment scores (adjusted for the covariate), while the other two groups showed decreases. These results indicate that the overall improvement in vocational domain score posttransplant was attributable to improved vocational functioning of those who returned to work and homemakers. Although the pretransplant to posttransplant PAIS and POMS total scores improved for most patients, 1 1 (25%) of the patients had an increase in PAIS score and 5 patients ( 1 1%) had an increase in POMS total score. Those with an increase in mood disturbance (POMS) also had an increase in problems in adjusting to illness (PAIS). An adjustment for regression to the mean did not affect the sign of the change scores for these 1 1 patients, indicating that the deterioration in psychosocial functioning was not attributable to regression to the mean. The PAIS increases, after adjustment, ranged from 1 to 34 points, with an average of 10 points. The posttransplant PAIS total scores of 1 1 patients who experienced an increase in adjustment problems ranged from 46 to 83, with a mean of 58. The POMS scores of those with greater mood disturbance, after adjustment, ranged from 11 to 74 points, with an average of 33 points. The posttransplant POMS total scores of these 5 patients ranged from 46 to 96, with a mean of 65. The patients who experienced deterioration in adjustment or mood showed no major differences from other patients in their background characteristics. Race, gender, employment status, educational status, occupational status, and length of disability were not significantly correlated with any of the PAIS or POMS change scores, after adjustment for multiple comparisons.
DISCUSSION The major aim of this study was to evaluate the psychosocial outcome of heart transplantation by
comparing patients’ psychosocial functioning 6 months following transplantation against their pretransplant status. It should be noted that psychosocial functioning was assessed at the time that the patient was placed on the waiting list for transplantation. The question could be raised whether patients may alter answers to self-report questionnaires in order to appear excellent candidates for transplantation. If so, it might be expected that this response bias would have affected everyone’s score to some extent. Nonetheless, it is important to bear this consideration in mind when evaluating findings. The data revealed that, before transplantation, patients experienced considerable psychosocial distress attributable to illness. Less than 5% were working at the time of their evaluation for transplantation. The average PAIS total score for patients prior to transplantation was higher (worse adjustment) than the average of 40.32 reported for preoperative coronary artery bypass patients (Folks, Blake, Fleece, Sokol, & Freeman, 1986). Consistent with reports of improved quality of life following heart transplantation, the majority of this sample had dramatic improvement in psychosocial functioning within 6 months following surgery. These patients reported that their domestic, sexual, and social functioning were very much improved compared with prior to transplantation; vocational adjustment was moderately improved. The patients’ mood states improved most consistently of all. Although patients might not be expected to retum to employment within 6 months following transplant surgery, it was encouraging that 10 of the patients (23%)had returned to work. Our findings regarding employment can be compared with figures from other studies. In the National Heart Transplantation Study, Evans and Broida ( 1985) found that approximately 3 1% of 152 recipients were employed whereas 50% received medical disability. A great percentage of heart transplant recipients are physically able to work but fail to return to work because of psychological or social factors. Some freely choose not to reenter the work force, whereas others are either encouraged to retire or discouraged from working by their employers’ refusal to adjust work schedules to allow for frequent follow-up visits for health care following transplantation. Meister and colleagues (1986) reported that approximately 36% of their heart transplant recipients were physically able to work but remained unemployed because they were dependent on government-subsidized disability income and health insurance coverage. Meister and colleagues (1986) noted that the length of disability before transplant for “insurance
PSYCHOSOCIAL OUTCOME / BOHACHICK ET AL.
disabled’ recipients (M = 14.3 months) was longer than that of recipients who returned to work (M = 4.1 months) and concluded that the longer the disability before transplant, the more difficult it becomes for a recipient to return to work. Our findings support this view. Despite the improvement in vocational function observed by comparing pretransplant to posttransplant scores, it is noteworthy that among the seven psychosocial areas assessed by the PAIS, the vocational domain was highest scored, indicating that this was the major problem area after transplantation as well as before transplantation. Considering the high rate of unemployment and continuing expenses of medical care, it is not surprising that patients reported the persistence of financial problems following transplantation. Our finding of improved domestic functioning following transplantation was attributable primarily to improved physical functioning and ability to perform household duties. These findings closely agree with those of Wallwork and Caine (1985) who noted that “as most patients spend a considerable amount of their time in the home after discharge from hospital, one would expect them to notice the improvement in their functional capacity in this area” (p. 324). Constant sexual performance problems were reported by 74% of the patients prior to transplant but by only 28% of the patients at 6 months posttransplant. Hunt (1985) also observed a marked decline in the number of patients reporting distress in their sex life following transplantation (71% pretransplant versus 24%). Frequently occurring impotence has been reported by up to one third of heart transplant recipients (Wolpowitz & Barnard, 1978). It is interesting to note that the incidence of impotence after heart transplantation is comparable to that reported for patients after coronary artery bypass surgery (Grundle, Reeves, Tate, Raft, & McLaurin, 1980). Grundle and associates (1980) suggested that poor sexual adjustment despite improved functional capacity following coronary artery surgery may be due to “the patient’s persistent image of him- or herself as being damaged’ (p. 1592). Impotence after heart transplantation may be the result of immunosuppressive and antihypertensive therapy (Wolpowitz & Barnard, 1978). However, it is also possible that other, as yet unidentified, factors may contribute to persistent sexual dysfunction following heart transplantation. There are conflicting findings regarding the impact of heart transplantation on social activity. In separate studies, Brennan and colleagues ( 1987) and Lough and coworkers (1985) found little change in social activities for the majority of heart
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transplant recipients. On the other hand, Hunt (1985) and O’Brien, Burton, and Ferguson (1987) found that patients showed significant improvement in social life following transplantation. The present study supports the view of improved social functioning after heart transplantation. That is, whereas 68% of patients reported marked impairment in social activities before transplantation, only 27% indicated that their social functioning was markedly impaired at 6-month followup. Considering the extreme physical and psychosocial stress imposed by end-stage heart disease and its treatment, the overall level of mood disturbance prior to heart transplantation did not seem excessive. POMS scale scores, except for fatigue and vigor, were either lower than (less disturbance) or comparable to those reported for normative samples by McNair, Lorr, and Droppleman (1981). The average Total Mood Disturbance score for patients prior to transplantation was similar to that reported for preoperative coronary artery bypass patients (M = 38.65) by Rankin (1990). However, the average fatigue score for pretransplant patients was higher than the average of 7.4 reported for coronary artery bypass patients (Rankin, 1990). With end-stage heart disease, functional capacity is severely impaired resulting in marked limitation of physical activity. Therefore, the increased fatigue and diminished vigor that patients demonstrated before transplantation were not surprising. In comparing the emotional status of patients before and after transplantation, improvement in energy level after transplantation, as reflected in the marked rise in vigor and decline in fatigue, was impressive and consistent with improved functional capacity. In a prospective study of heart transplant patients using the Nottingham Health Profile, Hunt (1985) also found that patients showed substantial gains in energy and physical mobility by 3 months after transplantation. Following evaluation for transplantation, most candidates must pass through a stressful period of waiting for a donor organ and transplant surgery. After transplantation, patients must cope with the threat of graft rejection, other medical complications, and uncertainty about long-term survival. Therefore, the overall improvement in anxiety and depression after transplantation was encouraging. The confusion score also improved after transplantation. McNair et al. (1981) suggest that this factor may represent a by-product of anxiety. Although the majority of patients showed improvment in overall psychosocial adjustment, 25% of the patients reported more psychosocial adjustment problems at 6 months after transplantation than they had before transplantation. and 11% also reported more mood disturbance than they
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had before transplantation. This finding is consistent with work indicating that patients who are more depressed and anxious also tend t o have more limitations in psychosocial function (Baider & Kaplan De-Nour, 1984; Kaplan De-Nour, 1982; Prigatano, Wright, & Levin, 1984). However, as noted by Baider and Kaplan De-Nour (1984), the question of whether anxiety and depression lead to psychosocial adjustment problems or whether these negative emotional states represent the patient’s reaction to problems in coping with the demands of illness remains unanswered. In addition, risk factors that would predict whether or not a patient will deteriorate in psychosocial adjustment or mood state have yet to be identified. The results of this study support the body of research that indicates that most survivors of heart transplantation achieve a quality of life superior t o their pretransplant status. By 6 months after transplantation, the great majority of patients demonstrated significant improvement in psychosocial adjustment and emotional states. However, given that one-quarter of the patients showed a negative change in their psychosocial adjustment following heart transplantation, further study is indicated to identify factors important to posttransplant psychosocial adaptation. Such information could help identify those patients at risk for psychosocial problems following heart transplantation or, perhaps, provide a basis for designing more effective nursing interventions for full rehabilitation of heart transplant recipients.
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Christopherson, L.K. (1987). Cardiac transplantation. Circulation, 7 5 , 57-62. Derogatis, L.R., & Lopez, M.C. (1983). PAIS and PAIS-SR administration, scoring and procedures
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outcome of heart transplantation. General Hospital Psychiatry, 1 1 , 352-357. Wallwork, J., & Caine, N . (1985). A comparison of the quality of life of cardiac transplant patients and coronary artery bypass graft patients before and after surgery. Quality of Life and Cardiovascular Care, I , 317-331. Wolpowitz, A., & Barnard, C.N. (1978). Impotence after heart transplantation. South African Medical Journal, 5 3 , 693.
