Self-Motivation: A Driving Force for Elders in Cardiac Rehabilitation This study identifies the extent that self-motivation existed in patients aged 65 years and older in a cardiac rehabilitation program and whether self-motivation correlated with age. BY
ROSEMARY
RHODES/MARY
Jo
MORRISSEY/ALICE
oronary disease has continued to be the leading cause of disability and death in our society. Within the elderly population this disease affects one of every two people, and 70% of those affected will die) Since the late 1960s a dramatic decline has been seen in deaths from heart disease, but it continues to account for more than 30% of total deaths in the United States. 2 Each year 5.4 million people are diagnosed with coronary artery disease, which results in an estimated annual direct health cost of $8 billion. This figure, which does not reflect debits incurred through production losses, labor turnover, and personnel training, is estimated at $60 billion. 3 Changes occurring in the U.S. population have increased the rehabilitative needs of individuals with coronary disease. Every attempt should be made to alter the effects of this devastating disease on the nation's health. Hospital treatment of patients with cardiac disease has become highly technical, sophisticated, and expensive. In spite of this, many patients are readmitted later with the same problem. This is a self-defeating process that may be offset by the present-day emphasis on rehabilitation. However, the success of rehabilitation depends on patient motivation and adherence to a recommended regimen.4 In all preventive and rehabilitative programs that require adherence to certain behaviors, perseverance in these behaviors is a key to success. 5 According to Andrews et al.6 nonadherence to long-term health programs is very high. In fact, more than 50% of participants failed
WARD
c
ROSEMARY RHODES, RN, MN, is associate professor, MARY JO MORRISSEY, RN, MSN, is clinical assistant professor, and ALICE WARD, RN, EdD, is associate professor at the University of South Alabama College of Nursing in Mobile, Alabama. 34/1/37074
94 Geriatric Nursing March/April 1992
Photograph by Laura Paige Marsh. Courtesy of American Society on Aging. to maintain compliance with rehabilitation instruction given at discharge.S Many researchers have attempted to identify factors related to adherence. Dishman and Ickes7 purported that the construct of self-motivation as a "generalized nonspecific tendency to persist in habitual behavior regardless of extrinsic reinforcement and independent of situational influences" was a significant factor. Further, they characterized self-motivation as socially learned and dependent on the ability to delay gratification and on the capacity for self-reinforcement. Data regarding the presence of self-motivation in patients participating in cardiac rehabilitation could assist the nurse
to plan care based on sound theoretic knowledge. The purpose of this study was to identify to what extent self-motivation existed in patients participating in cardiac rehabilitation programs, how that affected compliance, and whether the existence of self-motivation varied with age. Literature R e v i e w
Dishman and Ickes7 consistently found self-motivation to be a factor when identifying adherence behaviors in a variety of settings, ranging from programs of preventive medicine in middle-aged and older men to athletic training for college women. The findings in these two samples supported the idea that the relationship between exercise adherence and self-motivation was not qualified by sex or age. Of the persons observed in clinical settings, 75% were men and 25% were women between the ages of 47 and 84 years. No differences were noted for sex and age in data collected concerning self-motivation. Other studies in the literature provided additional information concerning self-motivation. In Radtke's 8 research, 35 patients with myocardial infarcts who were discharged with home exercise programs were followed to determine whether compliance to a prescribed regimen was related to self-motivation. Results supported that scores on Dishman and Ickes' Self-motivation Inventory (SMI), a paper-and-pencil questionnaire, correlated positively with compliance to home exercise programs. Heiby et al. 9 explored the construct and concurrent validity of self-motivation with the intention of providing additional evidence for clarification of the characteristic measured by Dishman and Ickes. In their study of 220
members of a marathon clinic, a significant relationship between SMI scores and reports of engaging in a regular exercise regimen provided support for concurrent validity. Construct validity was derived from the positive rel a t i o n s h i p b e t w e e n s e l f - m o t i v a t i o n and s e l f reinforcement and from the negative relationship between self-motivation scores and measures of anxiety and depression. P u r p o s e a n d Data Collection This comparative descriptive study was designed to explore and describe self-motivation characteristics and related tendencies of patients participating in a cardiac rehabilitation program at a 450-bed urban teaching hospital and medical center. The director of the cardiac rehabilitation program was contacted for permission to conduct this research study and to collect data from patients participating in the cardiac rehabilitation program. The research proposal was submitted to the Institutional Review Board of the University of South Alabama to ensure protection of human rights. The primary objective of this research study was to compare the self-motivation levels of patients 65 years of age and older to those of patients less than 65 years of age. Self-motivation was measured by scores achieved on the SMI. All data were collected by two investigators, who attended three of the evening exercise sessions (phases I through III) to accommodate all participants in the cardiac rehabilitation program. After patients gave consent to be included in the study, they were asked to complete the demographic data sheet and the SMI.
Geriatric Nursing March/April 1992 95
Phases o f Cardiac Rehabilitation The cardiac rehabilitation program is divided into three phases, with each phase having specific objectives and criteria for advancement into the next phase. • Phase I begins while the patient is in the surgical intensive care unit of the coronary care unit and ends when the patient is discharged from the hospital. Exercise during this period usually starts with the patient sitting on the side of the bed and advances to short walks several times a day. • Phase II begins 2 to 4 weeks after hospitalization and may last from 6 weeks to 1 year, according to the progress of the patient. In addition to exercise sessions, the patients are offered counseling and education programs: • Phase III emphasis is on health maintenance such as structuring a prescribed exercise program based on individual needs and education programs directed toward the elimination of risk factors? ° Criteria of this study required that subjects be in phase II or phase III of cardiac rehabilitation. Sample The research sample was a convenience sample of both men and women participating in an outpatient cardiac rehabilitation program. Twenty-seven volunteer subjects were selected as subjects of data collection. The 27 participants ranged in age from 24 to 77 years. The median age was 55 years and the mode was 44.5 years. Seventyeight percent (21 participants) were men and 22% (six participants) were women. Seventy-four percent (20 participants) were categorized by race as white and 26% (seven participants) as nonwhite. Twenty-three (85%) participants were married, one participant had never
Seventy percent (19 participants) were employed and 30% (eight participants) were unemployed. Of the eight participants who were unemployed, two stated that they were retired. Sixty-three percent (17 participants) indicated that they were in phase II of the program, which can last from
IME. SPENT
,ROG AM
1 to 12 months. Thirty-six percent (six participants) were in phase III. Note that phase II! is not covered by Medicare, which may contribute to the decrease in numbers of those participating in the program sponsored by the hospital; however, some exercise may possibly be continued in the home environment. The demographic data form included a question requesting the medical diagnosis that predicated the need for cardiac rehabilitation. These data were categorized according to sex and diagnosis. The subjects were also asked if they had other illnesses. Sixty-three percent (17 participants) stated that they had no other illnesses, although 30% (eight participants) indicated other illnesses were present. Two participants did not respond to this question. Other illnesses identified included diabetes, sarcoidosis, rheumatoid arthritis, cholelithiasis, and sinusitis. Instruments
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The SMI was used to measure self-motivation scores in the two groups (>__65 years and
ROSEMARY
RHODES/MARY
Jo
MORRISSEY/ALICE
oronary disease has continued to be the leading cause of disability and death in our society. Within the elderly population this disease affects one of every two people, and 70% of those affected will die) Since the late 1960s a dramatic decline has been seen in deaths from heart disease, but it continues to account for more than 30% of total deaths in the United States. 2 Each year 5.4 million people are diagnosed with coronary artery disease, which results in an estimated annual direct health cost of $8 billion. This figure, which does not reflect debits incurred through production losses, labor turnover, and personnel training, is estimated at $60 billion. 3 Changes occurring in the U.S. population have increased the rehabilitative needs of individuals with coronary disease. Every attempt should be made to alter the effects of this devastating disease on the nation's health. Hospital treatment of patients with cardiac disease has become highly technical, sophisticated, and expensive. In spite of this, many patients are readmitted later with the same problem. This is a self-defeating process that may be offset by the present-day emphasis on rehabilitation. However, the success of rehabilitation depends on patient motivation and adherence to a recommended regimen.4 In all preventive and rehabilitative programs that require adherence to certain behaviors, perseverance in these behaviors is a key to success. 5 According to Andrews et al.6 nonadherence to long-term health programs is very high. In fact, more than 50% of participants failed
WARD
c
ROSEMARY RHODES, RN, MN, is associate professor, MARY JO MORRISSEY, RN, MSN, is clinical assistant professor, and ALICE WARD, RN, EdD, is associate professor at the University of South Alabama College of Nursing in Mobile, Alabama. 34/1/37074
94 Geriatric Nursing March/April 1992
Photograph by Laura Paige Marsh. Courtesy of American Society on Aging. to maintain compliance with rehabilitation instruction given at discharge.S Many researchers have attempted to identify factors related to adherence. Dishman and Ickes7 purported that the construct of self-motivation as a "generalized nonspecific tendency to persist in habitual behavior regardless of extrinsic reinforcement and independent of situational influences" was a significant factor. Further, they characterized self-motivation as socially learned and dependent on the ability to delay gratification and on the capacity for self-reinforcement. Data regarding the presence of self-motivation in patients participating in cardiac rehabilitation could assist the nurse
to plan care based on sound theoretic knowledge. The purpose of this study was to identify to what extent self-motivation existed in patients participating in cardiac rehabilitation programs, how that affected compliance, and whether the existence of self-motivation varied with age. Literature R e v i e w
Dishman and Ickes7 consistently found self-motivation to be a factor when identifying adherence behaviors in a variety of settings, ranging from programs of preventive medicine in middle-aged and older men to athletic training for college women. The findings in these two samples supported the idea that the relationship between exercise adherence and self-motivation was not qualified by sex or age. Of the persons observed in clinical settings, 75% were men and 25% were women between the ages of 47 and 84 years. No differences were noted for sex and age in data collected concerning self-motivation. Other studies in the literature provided additional information concerning self-motivation. In Radtke's 8 research, 35 patients with myocardial infarcts who were discharged with home exercise programs were followed to determine whether compliance to a prescribed regimen was related to self-motivation. Results supported that scores on Dishman and Ickes' Self-motivation Inventory (SMI), a paper-and-pencil questionnaire, correlated positively with compliance to home exercise programs. Heiby et al. 9 explored the construct and concurrent validity of self-motivation with the intention of providing additional evidence for clarification of the characteristic measured by Dishman and Ickes. In their study of 220
members of a marathon clinic, a significant relationship between SMI scores and reports of engaging in a regular exercise regimen provided support for concurrent validity. Construct validity was derived from the positive rel a t i o n s h i p b e t w e e n s e l f - m o t i v a t i o n and s e l f reinforcement and from the negative relationship between self-motivation scores and measures of anxiety and depression. P u r p o s e a n d Data Collection This comparative descriptive study was designed to explore and describe self-motivation characteristics and related tendencies of patients participating in a cardiac rehabilitation program at a 450-bed urban teaching hospital and medical center. The director of the cardiac rehabilitation program was contacted for permission to conduct this research study and to collect data from patients participating in the cardiac rehabilitation program. The research proposal was submitted to the Institutional Review Board of the University of South Alabama to ensure protection of human rights. The primary objective of this research study was to compare the self-motivation levels of patients 65 years of age and older to those of patients less than 65 years of age. Self-motivation was measured by scores achieved on the SMI. All data were collected by two investigators, who attended three of the evening exercise sessions (phases I through III) to accommodate all participants in the cardiac rehabilitation program. After patients gave consent to be included in the study, they were asked to complete the demographic data sheet and the SMI.
Geriatric Nursing March/April 1992 95
Phases o f Cardiac Rehabilitation The cardiac rehabilitation program is divided into three phases, with each phase having specific objectives and criteria for advancement into the next phase. • Phase I begins while the patient is in the surgical intensive care unit of the coronary care unit and ends when the patient is discharged from the hospital. Exercise during this period usually starts with the patient sitting on the side of the bed and advances to short walks several times a day. • Phase II begins 2 to 4 weeks after hospitalization and may last from 6 weeks to 1 year, according to the progress of the patient. In addition to exercise sessions, the patients are offered counseling and education programs: • Phase III emphasis is on health maintenance such as structuring a prescribed exercise program based on individual needs and education programs directed toward the elimination of risk factors? ° Criteria of this study required that subjects be in phase II or phase III of cardiac rehabilitation. Sample The research sample was a convenience sample of both men and women participating in an outpatient cardiac rehabilitation program. Twenty-seven volunteer subjects were selected as subjects of data collection. The 27 participants ranged in age from 24 to 77 years. The median age was 55 years and the mode was 44.5 years. Seventyeight percent (21 participants) were men and 22% (six participants) were women. Seventy-four percent (20 participants) were categorized by race as white and 26% (seven participants) as nonwhite. Twenty-three (85%) participants were married, one participant had never
Seventy percent (19 participants) were employed and 30% (eight participants) were unemployed. Of the eight participants who were unemployed, two stated that they were retired. Sixty-three percent (17 participants) indicated that they were in phase II of the program, which can last from
IME. SPENT
,ROG AM
1 to 12 months. Thirty-six percent (six participants) were in phase III. Note that phase II! is not covered by Medicare, which may contribute to the decrease in numbers of those participating in the program sponsored by the hospital; however, some exercise may possibly be continued in the home environment. The demographic data form included a question requesting the medical diagnosis that predicated the need for cardiac rehabilitation. These data were categorized according to sex and diagnosis. The subjects were also asked if they had other illnesses. Sixty-three percent (17 participants) stated that they had no other illnesses, although 30% (eight participants) indicated other illnesses were present. Two participants did not respond to this question. Other illnesses identified included diabetes, sarcoidosis, rheumatoid arthritis, cholelithiasis, and sinusitis. Instruments
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2:_2
£.z.,.
The SMI was used to measure self-motivation scores in the two groups (>__65 years and
