570129

research-article2015

QHRXXX10.1177/1049732315570129Qualitative Health ResearchRøysland and Friberg

Article

Unexplained Chest Pain and Physical Activity: Balancing Between Existential Uncertainty and Certainty

Qualitative Health Research 1­–12 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315570129 qhr.sagepub.com

Ingrid Ølfarnes Røysland1 and Febe Friberg1

Abstract Chest pain is one of the most common complaints in medical settings, but the majority of cases have no detectable cause. Physical activity is recommended, but is one of the major avoidance behaviors in patients with coronary heart disease. The article aims at achieving an understanding of the meaning of physical activity for people with unexplained chest pain. Fifteen people were interviewed using a phenomenological hermeneutic approach, with the results revealing four themes: “awareness of the influence of previous life experiences on the decision to be physically active,” “unanswered questions related to physical activity and unexplained chest pain,” “intertwinement of body and mind,” and “physical activity as a source of personal growth.” Comprehensive understanding was formulated as “Being physically active while living with unexplained chest pain means balancing between existential uncertainty and certainty.” The results are discussed in relation to capability. It is suggested that health professionals adopt a personcentered approach. Keywords pain; heart-health; exercise / physical activity; uncertainty; illness and disease, experiences; qualitative analysis; Ricoeur Chest pain is one of the most common complaints in medical settings (Laederach-Hofmann & MesserliBuergy, 2007; Niska, Bhuiya, & Xu, 2010). In Norway, the majority of people referred to a cardiac outpatient clinic for examination of chest pain are told that there are no signs of a cardiac condition (Jonsbu et al., 2009). Although chest pain is considered a characteristic symptom of coronary artery disease, a number of factors can contribute to the condition (Bass & Mayou, 2002; LaederachHofmann & Messerli-Buergy, 2007). Gastroesophageal reflux, esophageal motility disorders, visceral hyperalgesia, psychiatric disturbances, and autonomic dysfunction have been identified as sources of chest pain, according to Krarup et al. (2013). A number of terms, such as non-specific chest pain, non-cardiac chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy, have been used. Unexplained chest pain is used in this study as it covers many possible complaints. According to Sekhri, Feder, Junghans, Hemingway, and Timmis (2007), patients with unexplained chest pain have reduced health-related quality of life, persistent symptoms, emotional distress, and limitations in everyday life, despite good medical prognosis. Follow-up studies of chest pain without known cardiac cause have reported persistence of symptoms that affect daily life (Eslick & Talley, 2004; Sekhri et al., 2007). Unexplained

chest pain may lead to avoidance of physical activity, because of worry about the heart (Jerlock, GastonJohansson, & Danielson, 2005), depressive symptoms, and reduced health-related quality of life (Jonsbu, Dammen, Morken, & Martinsen, 2010). Røysland, Dysvik, Furnes, and Friberg (2013) and Price et al. (2005) found that people with unexplained chest pain had unanswered questions about physical activity in daily life. Positive effects of physical activities were shown by Jerlock, Gaston-Johansson, Kjellgren, and Welin (2006) in a multivariate analysis where more physical activity was associated with less use of emotive coping. Jonsbu, Dammen, Morken, Moum, and Martinsen (2011) use the term non-cardiac chest pain. According to them, exposures to physical activity in connection with cognitive behavioral therapy are effective treatment for people with non-cardiac chest pain. Eriksson et al. (2000); Feizi, Ghaderi, Dehghani, Khalkhali, and Sheikhi (2012); and Tyni-Lenne, Stryjan, Eriksson, Berglund, and Sylven (2002) use the term syndrome X. They argue that these 1

University of Stavanger, Stavanger, Norway

Corresponding Author: Ingrid Ølfarnes Røysland, Faculty of Social Sciences, Department of Health Studies, University of Stavanger, N-4036 Stavanger, Norway. Email: [email protected]

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patients benefit from physical training, resulting in increased exercise capacity and quality of life. Martinsen (2008) presents an overview of research involving the efficacy of exercise to prevent and treat depression and anxiety. He claims that exposure to physical activity might be a proper way to challenge the fear of bodily sensations by reinforcing the beliefs that the heart is fit. This is in line with Asbury and Collins (2005), who argue that clinicians should be aware of the psychological aspects of patients with unexplained chest pain. Taken together, these findings show that physical activity for people with unexplained chest pain is recommended, because it has shown positive effects. Findings also show that reduced physical activity is one of the major avoidance behaviors in patients with coronary heart disease (Amundsen, Wisløff, & Slørdahl, 2007). This calls for further exploration of the experience of physical activity in daily life for persons with unexplained chest pain. The aim of the article was to achieve an understanding of the meaning of physical activity for people with unexplained chest pain.

Method A qualitative approach was selected as the most appropriate for the study of the phenomenon of physical activity in daily life for persons living with unexplained chest pain. A phenomenological hermeneutic approach (Lindseth & Norberg, 2004) inspired by the philosophy of Ricoeur (1976) was used in this study. The prerequisites for creating knowledge about human experiences are that people communicate their lived experiences and that these are transferred to textual form. Knowledge can be created from these stories by means of a dialectic movement between the whole and the parts, from understanding to explanation and back to understanding, as well as from what the text conveys to what it says (Ricoeur, 1976). In all, the phenomenological hermeneutic approach guided the sample selection, data collection, analysis, and rigor considerations.

Participants and Data Persons with unexplained chest pain were recruited from a cardiac outpatient clinic at a university hospital in Norway. Inclusion criteria were unexplained chest pain, aged over 18, and ability to understand and speak Norwegian. A cardiologist in the outpatient clinic had ascertained that patients’ symptoms had no apparent organic cause. Eligible participants had a symptom-limited bicycle test in the outpatient clinic. They were also informed about the results, and in addition, received standard information about risk factors and lifestyle factors related to the development of heart disease. Exclusion criteria were absence of chest pain and pathological cardiac findings after the bicycle test.

Data consisted of two periods of interviews in two data sets. Individuals who met the inclusion criteria were consecutively invited to take part in the study via letter distributed by the head nurse in the cardiac outpatient clinic (Data Set I). This selection process continued for a 6-month period, with those who were interested in participating contacting the head nurse. Seven patients agreed to participate. Having been asked to describe information needs in relation to having unexplained chest pain, the participants talked about physical activity as an important concern. This prompted us to seek additional participants to deepen the understanding of being physically active in daily life. The second data set was more specifically oriented toward physical activity, which enabled variation in the data. Thus, after 27 months, a new group of patients were consecutively invited to participate (Data Set II). The head nurse selected patients with the same inclusion/exclusion criteria, and a nurse at the cardiac outpatient clinic called the patients to invite them to take part in the study. This selection process continued for 3 months. The first data set comprised four women and three men, and the second data set comprised five women and three men, making a total of nine women and six men participating in the study. The women were aged between 21 and 78, and the men between 42 and 65. Nine participants had academic qualifications and seven vocational ones. One was a student and two were pensioners. Four participants were working full-time and three were working part-time. Nine were on sick leave, or had a disability pension, and some of these were parttime. Seven participants lived in cities and eight in rural areas.

Data Collection The interviews were conducted between May 2010 and June 2010 and between October 2012 and December 2012. They took place in an undisturbed room either in the cardiac outpatient clinic or at the university, in accordance with the participants’ preferences. All interviews lasted for approximately 1 hour and were conducted by Røysland. The first seven interviews were semi-structured, with the participants being encouraged to describe their lived experiences and information needs—physical activity emphasized among these. The next eight interviews were more open-ended (Mishler, 1991), with the participants being encouraged to speak more in depth about what it was like to be physically active. Having been invited to talk in their own words, participants were also asked follow-up questions: “Could you expand on that?” and “Could you give more examples from daily life?” (Mishler, 1991). All interviews were audio-taped and transcribed verbatim. Non-verbal expressions such as crying, laughter, and pauses were noted in the transcripts (Mishler, 1991).

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Røysland and Friberg The transcription is a part of the phenomenological hermeneutical method of interpretation as described by Lindseth and Norberg (2004). When transcribing, audiorecording choices are always made in relation to methodological approaches (Davidson, 2009). When audiovisual recordings are used, one must consider the relationship between those recordings and the events that they provide information about, as well as the relationship between the recordings and transcripts (Duranti, 2006). In this study, as in all studies, transcriptions are carried out against certain cultural, historical, and biographical frames.

naïve interpretation, and the structural analysis in doing so. An example of the three-step thematic analysis to obtain meaning units, condensed meaning units, and subthemes is presented in Table 1. To preserve authenticity of results, we chose to present direct quotations from the participants, exemplifying any variance therein. These are examples of the lived experience of the meaning of physical activity for people with unexplained chest pain. It describes examples of the core commonality or variation.

Ethical Considerations

Methodological Considerations

The investigation conformed to the principles outlined in the Declaration of Helsinki. After attending the clinic, patients who met the inclusion criteria were invited to participate in this study, having been assured of anonymity and confidentiality and the option to withdraw at any time. Participants received oral and written information about the aim of the study. Approval was sought from the Regional Ethics Committee (2009/2243-7).

Our goal was to achieve an understanding of the experience of the meaning of physical activity for people with unexplained chest pain. The findings are based on rich data from in-depth interviews with 15 Norwegian people with unexplained chest pain. The criteria of credibility pertain to the researchers’ ability to describe the way one became familiar with the context in relation to the participants. The first author participated in a cardiac outpatient clinic to become familiar with the context where the interviews were conducted. She also spoke to the health personnel, which gave a nuanced insight into the structure and environment of the unit. The credibility of the investigation was strengthened by discussing it in seminars for doctoral students and in the research group, and in meetings with the co-author. These were the verification strategies used throughout the process (Morse, Barrett, Mayan, Olson, & Spiers, 2002). During the analysis, we focused on establishing agreement between the different sets of themes and preliminary conclusions, achieving this by taking the levels of data into consideration along with our reflection on pre-understanding. Our intention has been to present the research process in a manner that enables the reader to follow the different steps, as well as the logic of and reasons behind the concluding remarks. According to Lindseth and Norberg (2004), the whole truth can never be fully understood. However, we searched for possible meanings in a continuous process from naïve reading and structural analysis through to comprehensive understanding. The linking of knowledge, claims, findings, and interpretations in the data is also part of confirming trustworthiness and the described theoretical foundation, findings, and data analysis are intended to fulfill the criterion of conformability.

Data Analysis The text was analyzed with a three-step method developed by Lindseth and Norberg (2004) inspired by Ricoeur (1976): naïve interpretation, structural analysis, and comprehensive understanding. Naïve interpretation. Each interview was repeatedly listened to and read as open-mindedly as possible to gain a naïve understanding of what it is like to be physically active in daily life for people living with unexplained chest pain. Our first assumptions guided and provided ideas for the subsequent analysis. Structural analysis.  The authors first systematically examined the two data sets to gain a deeper understanding of the interview content before dividing the text into meaning units for the purpose of expressing the essential meaning contained in everyday words. The units in each interview were subsequently compared for similarities and differences, after which the condensed meaning units were abstracted and organized before formulating subthemes and themes. Comprehensive understanding. After reflecting on the naïve reading, comparing the themes with the literature and finding the initial interpretation and subsequent structural analysis validated each other, the authors formulated a comprehensive understanding of the text as a whole. Taking the different levels of data into consideration, the authors reflected on pre-understanding, initial

Results Naïve Interpretation The participants discussed the risk of developing heart disease or the risk that physical activity could trigger a heart attack and even death. They expressed uncertainty

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Table 1.  Examples of Meaning Units, Condensed Meaning Units, and Subthemes. Meaning Unit No, I’m the kind of person, in one way, that on another occasion, when I was taking one of the kids up a (clears her throat) really steep hill, I don’t give up (smiles a little), because I’m going to the top, right? And then I had one of those episodes [of chest pain] again. But I could do with trying to stop and catch my breath a little. Because I’m a bit like, I might seem very calm on the outside but I’m not completely calm, you know. I think about everything beforehand and think the worst, as a mother, and you know. Now I don’t have small kids but I do have people in the house and then I think I have to make everyone happy—I mean for me in a way. So it gets very stressful.  Yes. But (swallows hard) the fact that you’ve experienced (sighs) such cliff hangers makes me react (sigh). So, it’s stuff you can’t manage (tearfully) to get away from . . . So, so (short pause, makes an agitated gesture) it’s hard to know (tearfully) to put it into words, you might say, because you feel it pressing and pushing and stabbing and well, at times. Yes. But when they can’t find anything tangible, then (short pause) you just have to believe it. So (tearfully) it’s simple things like (smiles a bit) you have to do, it leaves its mark.

related to how to exercise in a safe way, and appeared to struggle with the concepts of doing or not doing physical activity in an attempt to avoid heart disease. The participants also discussed health professionals’ suggestions for being physically active and voiced their own expectations in regard to fitness. The naïve assumption suggests that physical activity is practiced against a background of uncertainty, and this directed the structural analysis.

First Structural Analysis To gain an understanding of physical activity contexts for the purpose of situational framing, we asked the participants where their activities took place and how they did them. Respondents described various arenas or places: at home, outside in the natural environment, the work place, the cardiac outpatient clinic, and communal places for exercise, such as the health club, gymnastic hall, dance studio, or swimming pool. The most frequently used arena for physical activity was the natural environment. The participants experienced chest pain in all places apart from the cardiac outpatient clinic; but hardly ever in the natural environment or communal places of exercise. However, most participants did not experience chest pain while exercising. Different levels of physical activity were also identified. Some participants lived with a lot of limitations related to physical activity and struggled to even manage a short walk. Others exercised frequently and some at a

Condensed Meaning Unit

Subtheme

Being a certain kind of person •• not giving up •• being susceptible to anxiety

Considering/reflecting upon myself as a person

   

Lived life leaves its mark

Reflecting on life history as basis for chest pain

high level. Most found themselves at an activity level somewhere in between this, with regular exercise and trying to keep active with daily activities throughout the day. The participants’ uncertainty revealed in the naïve interpretation, along with a wide range of arenas for physical activity and the variety of activities and experiences of chest pain duration point to the need to know more about meanings of being physically active. The analysis of some of the narrative structures opens up the interpretive possibilities of the text.

Second Structural Analysis: Themes In the thematic analysis, focus was directed toward the meaning of physical activity in life for people living with unexplained chest pain (against the background of uncertainty). Four themes and eight subthemes were formulated, and an overview of the subthemes and themes are shown in Table 2. Awareness of the influence of previous life experiences on the decision to be physically active.  This theme reflects what kind of people the participants considered themselves to be as a background to describing their experiences related to physical activity in daily life. They described themselves as responsible people who worked hard; often with a large workload and mental strain at work and/or at home. In this sense, the meaning of chest pain was seen in connection to their daily life. Other participants described

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Røysland and Friberg Table 2.  Overview of Subthemes and Themes. Subtheme

Theme

Considering/reflecting upon myself as a person Reflecting upon life history as a basis for chest pain Considering different explanations for the cause of my chest pain Experiencing a need for more knowledge Integrating physical activity to level of bodily strength and daily life Learning to interpret bodily signs while doing physical activity Experiencing strengthened body and mind while doing physical activity Recognizing physical activity as a source of community between oneself and others

Awareness of the influence of previous life experiences on the decision to be physically active Awareness of unanswered questions related to physical activity and unexplained chest pain

themselves as being constantly stressed and anxious, and talked about worrying about their health and other things. Panic anxiety was also described. Describing themselves personally was a way for the participants to put their chest pain into context, their individual experiences of being human in time, history, and culture framing the way they talked about chest pain and the opportunity to be physically active. This revealed something about their self-esteem and connected it to the meaning of the pain. Participants appeared to find it relevant to describe themselves as a certain “kind of person” when talking about their experiences related to chest pain and physical activity, and an explanation of themselves as “a person,” formed the backdrop to the meaning of physical activity to them. The participants also reflected upon life history as the basis for chest pain. Some described how pressure earlier in life had given them chest pain. Struggling to manage the family situation and/or workload was also described. Living with this pressure over time finally caused some participants to become overstretched. As one participant described it, “I was stretching and stretching, and finally there were nothing more to stretch.” Participants also described difficult issues in the family and among friends. Some described anxiety as especially limiting in relation to chest pain and physical activity, and were not exercising as they used to due to uncertainty about this. Appointments with a psychologist and/or group therapy were described as helpful in regard to physical activity. For these participants, chest pain meant anxiety and uncertainty about physical activity. The following participant described her anxiety like this:

loud, I’ve had this thing for 2 years now, and things are starting to happen that I’m just getting scared about.”

I have a, I have one of those, what d’you call it? I have the ability to totally worst-case scenario everything, everything can, yes this can happen, and that, and what then? And now, that’s why I’m saying to you, I’m kind of there now—I have so many things going on at home that I feel a bit like I’m walking on eggshells. And then, then I think: “For crying out

Awareness of intertwinement of body and mind

Awareness of physical activity as a source of personal growth

Awareness of unanswered questions related to physical activity and unexplained chest pain. The participants considered different reasons given for the chest pain and described the explanations given by the health professionals in the outpatient clinic that no signs of heart disease were identified. Despite this, their pain persisted and they were none the wiser about its cause. For some participants, the lack of an understandable explanation meant that they did not feel as though they were being taken seriously. Feelings of uncertainty concerning the cause of the chest pain emerged, and in the midst of this, many questions remained unanswered. One participant expressed the search for answers this way: “You have to put the pieces of the puzzle together to start building a picture.” Consequently, they pieced together the information available to them such as test answers, health professionals’ explanations, past experiences, and pressure in daily life. Unanswered questions about pain prompted a change in level of physical activity—some avoiding physical activity because they were afraid, and some exercising more in an attempt to strengthen the body. Some found it difficult to talk to anyone about the unexplained chest pain because there was no indication of heart disease. They also seemed to find it difficult to talk about avoiding physical activity for the same reason and experienced a feeling of loneliness related to questions about chest pain and physical activity. Some participants talked about making excuses for not doing hard physical activity such as long hikes, mountain climbing, and rafting in the river, which may have been activities they enjoyed before getting chest pain. One participant explained it like this: Because I’ve been one of those women who just kind of, you know, been out hiking and we went rafting and mountain climbing—always the really active one. And then, now—now

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Qualitative Health Research  this last year [after having had chest pains] I thought, no (draws a breath) I’m a bit scared . . . And so I just said like— at work that now I think—I said it like that—I didn’t say I had chest pains but I said—I—now I think my age is telling me to ease off a little. But deep down it was that [the chest pains] that was doing it.

The participants experienced a need for more knowledge. They described being told by the physician to contact the health care system for another consultation if their chest pains continued or changed, which reinforced their uncertainty because the physicians also indicated that they could not explain the pain for certain, possibly indicating that more information was needed to determine whether the pain had an organic cause or not. The participants also described how their unanswered questions drove them to seek attention from health professionals, and how some did this repeatedly when questions remained unanswered because they wanted the chest pain to be assessed holistically in relation to their specific life history—and test results equally so. Not having this assurance meant some participants felt physical exertion could threaten their life and health. No, so I, I, no—I don’t look like a typical heart patient do I? But I’ve felt what I’ve felt—I think it was the heart I felt, right? That isn’t muscular or anything. And er, it’s like in relation to anything purely medical, I feel it’s difficult to know when I’m training or doing something really hard, whether it’s dangerous to keep going or whether I should stop? Should I stop a bit earlier? It’s precisely those things I feel are difficult to work out myself.

Awareness of intertwinement of body and mind.  The participants described bodily symptoms which they attributed to the heart and spoke about how to integrate physical activity with level of bodily strength and daily life. Examples of bodily symptoms expressed by the participants were chest pain, palpitations, discomfort, arm pain, and back pain. They were hesitant about doing physical activity while having bodily symptoms that they could not identify. Interestingly, participants rarely described having actual chest pain while exercising, but some talked about loss of strength. Their line of enquiry was to find out how to start training with a body that was less prepared for training, and how to learn to increase physical activity gradually to adapt the activity to the strength of the body. One participant said, Yes, training, it’s er, I mean you can’t conquer Mount Everest straight away. You have to accept it and start somewhere, and everyone starts at zero. Well, I mean you don’t have to, you have to sense in your body where you are. And there’s no shame and looking back so to speak. But it gets better next time and better the next time and finally you are where you want to be. You just have to start somewhere.

Ways of thinking about physical activity seemed to influence ways of doing physical activity. Participants described their decisions not to let uncertainty take over. They nevertheless remained uncertain about their chest pain being a symptom of heart disease, and wanted to protect their bodies by avoiding physical activity. One participant described it like this: Yes, because if you’re going to be less skeptical, you have to, you have to have a reason for thinking less yourself. Because if you go into your own head and think: I wonder what this is. He [the cardiologist] said that everything was alright, but I’m still wondering. So you become skeptical and then it makes you, you don’t take up [physical activity] because you get worked up about trying to look after yourself.

This participant had to make an active decision to believe that physical activity was good for him. In fact, those participants who were physically active felt it was good both for their bodies and minds. One participant described it like this: “You’ll feel better as soon as you start training—physical activity is the alpha and omega for everyone, I’d say.” There seemed to be a desire to learn to interpret bodily symptoms while doing physical activity. Guidance from health professionals in interpreting bodily symptoms was described as important for understanding and being able to do something about the pain. Participants wanted someone to guide them and communicate with them about their experience of symptoms in relation to physical activity, and wanted these symptoms to be taken into consideration. Questions about how to listen to the body and interpret bodily signs to choose the appropriate level of physical activity were common: How hard shall I, you know, push myself—how much should I listen to my body, and like, that’s the thing that’s really quite tricky (short pause). So knowing just that would have been great—to get a bit of advice or follow-up, right? How much you should feel it (smiles a little) before you give up—and take it into account. Should you just keep going, er it’s a bit like that, I, I keep going, right? But, yeah hmmm.

Awareness of physical activity as a source to personal growth.  Participants talked about experiencing a stronger body and mind while doing physical activity. Some talked about periods of avoiding most kinds of exercise and also described how they bucked the trend by starting out exercising alone, by walking in the countryside. Physical activity was synonymous with enjoying the surroundings, which were described in terms of “beautiful sunsets,” “quiet lakes and wild animals,” “just me and the dog,” or “an opportunity for hunting.” Experiencing the natural environment while doing some kind of physical activity

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Røysland and Friberg seemed to ease anxiety and other problems as well, for example, worrying about illness in a close relative. The participants felt that improved physical training made them feel stronger and that it made them think less about the lack of explanation for the pain. In this sense, it meant both a stronger body and mind and anxiety seemed to require less space. Something like training. I really believe it’s a positive thing for you, for everything, almost anything. Both for the usual fitness, of course, and for your body to be better trained, but for your brain too. You get a different focus on this and that.

Physical activity was a way of rebuilding body and mind and also described as “a utility for sleep.” Sleeping problems were reduced or cured when the participants became physically active. The participants recognized physical activity as a source of community between themselves and others. They described physical activity as a source of energy to see new possibilities in doing things, for example, getting a better family life, new friends, and being able to rejoin the group of friends they were previously a part of. For some participants, it meant being able to work, which was experienced as positive. The energy-giving experiences of being physically active seemed transferred to other areas of life such as doing a better job at work and being a parent. Being able to do different kinds of exercise could mean being able to reach other goals in life. Physical activity also meant social relationships, with exercising in health clubs and hiking with others giving them pleasure and a feeling of connection to other people. Dancing was also described as imbuing a community spirit. All in all, shared moments with others such as having coffee breaks and maintaining and making new friendships brought joy. Well, well (tearfully) I feel when I make an effort and walk (sighs) up a steep hill or stuff, I’m in pain. Yes, but if I do other things like, that are fun. For example, I go dancing— and that’s a lot of fun. Then I don’t feel any pain at all.

Comprehensive Understanding The interpretation can now be taken one step further. The meaning of physical activity in life among people with unexplained chest pain was formulated in the themes: Awareness of the influence of previous life experiences on the decision to be physically active, unanswered questions related to physical activity and unexplained chest pain, intertwinement of body and mind, and physical activity as a source of personal growth. Out of this, a comprehensive understanding was formulated: Being physically active while living with unexplained chest

pain means balancing between existential uncertainty and existential certainty. Having chest pain and doing physical activity is seen as a threat to health and life; at the same time, physical activity is seen as improving health and life. The participants were balancing between doing and avoiding physical activity, and therein lies an existential dimension. Exposed to existential aspects such as vulnerability during physical activity, the respondents bring themselves in the vicinity of illness and even death. They are vulnerable in their uncertainty. There is a suspicion that physical activity means a threat to health and life, and herein also lies a vulnerability. Even participants who were doing physical activity at a high level expressed suspicion in this regard. For people with unexplained chest pain, the experience of being physically active implies a process where existential uncertainty is challenged and reformulated, based on influencing beliefs. These beliefs are related to having or acquiring heart disease and also thoughts about physical activity as good for the heart. “Balancing between existential uncertainty and existential certainty” is highlighted by the French philosopher Paul Ricoeur’s theory of the capable person, “homo capax” (Ricoeur & Kristensson Uggla, 2011). The participants discussed “physical activity” and “chest pain,” and being “capable” of different achievements. According to Ricoeur (Ricoeur & Kristensson Uggla, 2011), the capable person is someone who has the ability to make rational choices and the ability to reflect on these. It is important to point out that the capable person is personally responsible for their own actions (Ricoeur & Kristensson Uggla, 2011) where responsibility is exercised by remembering and reflecting upon these actions. The participants in our study well exemplified this, which indicates a significant human potential. They made rational choices about doing or avoiding physical activity and reflected on the level of physical activity that was good for them, what the pain meant and what to do accordingly. Ricoeur states that the capable person with personal growth and self-esteem is dependent on establishing a point of reference about the “good life” that is worth living. Between the participants’ aim of having a “good life” and their particular choices of doing physical activity or not, a sort of hermeneutical circle is traced by virtue of the backand-forth motion. A good life in relation to the results of this study is about being able to balance existential uncertainty and existential certainty. For our participants, this reference can be deduced from discussions with health personnel in which beliefs, suspicions, and questions were put on the agenda. Ricoeur (Ricoeur & Kristensson Uggla, 2011) argues that the good life is, for each of us, the nebula of ideals and dreams of achievements with regard to which a life is held to be more or less fulfilled or unfulfilled.

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Discussion

Suspicion

The article aims at achieving an understanding of the meaning of physical activity for people with unexplained chest pain. The comprehensive understanding formulated as “Being physically active while living with unexplained chest pain means balancing between existential uncertainty and existential certainty” and highlights that this balancing act is essential to be “capable” in daily life. Key issues from comprehensive understanding in relation to previous research form subheadings in the following discussion.

It appears from the findings that participants expressed suspicion or doubt in relation to being physically active. Penrod (2007) claims that uncertainty is a perception of doubt. According to her, both cognitive and precognitive ways of knowing are influential in ascribing meaning, anticipating outcomes, and adapting strategies. This is in line with Weixel-Dixon (2003) who proposed doubt as an experience. She claims that the concern about self-hood, often expressed as problematic by clients, indicates doubt about something that was formerly or apparently known. In addition, she argues that upon further explanation, it usually comes to light that the person feels suffering about the loss of whatever certainty or knowledge they “had” in this regard. New body sensations like chest pain might not be anchored in meaning. It is when the selfconcept is soundly shaken that we cannot deny the incongruity between our notions of who we are and how we are, and are forced to reconsider our assumptions about self. This was true of the participants in our study, who revealed previous life experiences such as crises of different kinds. It is in these instances that doubt arises and a sense of loss ensues. According to Weixel-Dixon (2003), doubt can infuse all of our existence with a sense of contingency. The participants undergoing unexplained chest pain would often like to return to a state of knowing, a state of certainty. Research (Routledge, Juhl, & Sullivan, 2009) suggests that given certain situational or dispositional factors, people can sometimes attain existential security from more explorative activity. This can be achieved through, for example, creative thought processes in discussions to find different solutions with the intention of managing uncertainty. In this way, professionals can be open to the patients’ narratives about encountering existential threat. There are, however, different ways to counter existential threat that do not always involve efforts to bolster certainty (Routledge et al., 2009). This supports the idea of the balancing act in our study.

Uncertainty The participants were uncertain and on a quest for certainty—searching for specific certainties to handle their chest pain. Adamson (1997) and van den Bos (2009) argue that there are two forms of uncertainties: One with existential and one with clinical aspects. Existential uncertainty has issues of illness experience. van den Bos (2009) uses the term personal uncertainty, which he defines as “the aversive feeling that you experience when you feel uncertain about yourself.” Existential uncertainty is central to the patient’s experience of idiopathic disease, such as unexplained chest pain. An idiopathic condition is one that arises spontaneously or from an obscure or unknown cause. In our study, the participants strived for certainty, which is existential in nature. Previous experiences influenced the balancing act between uncertainty and certainty. For people with unexplained chest pain, it is important to clarify beliefs in relation to this balancing act, which is parallel to what van den Bos (2009) describes as self-regulation and also existential sense-making. Furthermore, and also as requested by the participants in the present article, it is important to listen to the patients’ fear and anxiety, not only in relation to the examination but also in relation to how they manage their everyday life with the risk. Our suggestion is therefore that health professionals should be open to discussion as a structured part of the medical consultation with patients regarding how they can exert themselves physically in daily life. The participants in our study also expressed uncertainty about clinical aspects marking the diagnosis and treatment of disease and for them this meant having less information than they ideally would have liked. As a result, they requested more information to be able to confidently assess whether it was safe and good for their health to do physical activity. This strongly indicates that health professionals must be prepared to meet both verbalized and more implicitly posed information needs, that is, it points to a need for structured communication in consultations.

Vulnerability In the balance of doing and avoiding physical activity, the participants had individual reactions to the pain. Vulnerability is a human condition and with that, a constant human experience. From a phenomenological perspective, it is related to our embodied state in particular and makes us most vulnerable when we are exposed to harm (Gjengedal et al., 2013). In our study, the participants may be regarded as more vulnerable than people, who do not have chest pain. Carel (2009) makes a distinction between subjective and objective vulnerability in

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Røysland and Friberg relation to illness. People are exposed to objective risks and thus to objective vulnerability. However, because our responses to illness vary, there is no necessary relationship between illness and feelings of subjective vulnerability. According to Gjengedal et al. (2013), our vulnerability is to be accepted and considered rather than fought, as it is an existential phenomenon that belongs to the basic conditions of life. The degree of vulnerability will vary depending on the situation and cultural context, making vulnerability a contextual phenomenon. This dependent relation we have with others is part of our “existential vulnerability,” and our identities are only complete through our commitment to others, according to Purcell (2013). As the data in our study show, the participants’ degree of vulnerability varied depending on different situations and contexts. This vulnerability lies in the balancing between existential certainty and uncertainty. In our participants, narratives of strong and sometimes touching life histories indicated a vulnerability as did unanswered information needs and feelings of loneliness. Health professionals must consider this fact in the dialogue with patients, allowing the medical consultation to have an atmosphere where patients’ vulnerability is taken into consideration.

Beliefs Participants in our study experienced that physical activities strengthened their bodies. However, the findings show that they also had to believe in the fact that physical activity strengthened them. It is through associative thinking that we derive generalizations, and the capacity for abstract thinking (Nanda, 2009). In their intervention study, Jonsbu, Martinsen, Morken, Moum, and Dammen (2013) indicate that changing perceptions for people with non-cardiac chest pain are based on experiences when being physically active. Jonsbu et al. (2013) explained this delayed effect by the fact that the participants in their study focused on maintaining physical activity after the intervention and experienced changed perceptions about physical activity. Participants in our study experienced their hearts to be fit during physical activity. This challenged their thoughts, and presumably, their beliefs about having heart disease. Jonsbu et al. (2013) suggests that when such thoughts are continually challenged, they might become weaker, less frightening, and maybe even replaced by other, more appropriate thoughts. Jonsbu et al. (2013) suppose this as an important factor in perceptions of chest pain, which would indicate health professionals should take patients’ health beliefs into consideration in the clinical dialogue. This is in line with what is reported for patients with panic disorder (Meuret, Rosenfield, Seidel, Bhaskara, & Hofman, 2010). Jonsbu et al.’s (2009) study reveals that

there is a high prevalence of panic disorder among people with unexplained chest pain.

Capability In our study, the participants felt that physical activity made them stronger and that their capacity for exercise increased. This is in line with other studies (Asbury & Collins, 2005; Eriksson et al., 2000; Feizi et al., 2012; Samim, Nugent, Mehta, Shufelt, & Merz, 2010; TyniLenne et al., 2002). By adopting a habit of regular exercise, health and life improves (Martinsen, 2008). Angus et al. (2005) conducted a qualitative study in which participants at a high risk of or diagnosed with heart disease participated. They suggest that habits and practices linked with stress are enduringly associated with context, arguing that place, body, and health are inseparably co-constituted. Helping patients with unexplained chest pain to verbalize their experiences and become cognizant of influences on the pain experience is of great value (Angus et al., 2005; Jerlock et al., 2006). Ricoeur (Ricoeur & Kristensson Uggla, 2011) deals with “capability” based on philosophical anthropology (view of man as a person). The actual achievement of the individual is the functioning; what the person actually achieves through being or doing (Mitra, 2006). Functioning is doing or ways of being, such as being physically active: walking, running, and hiking. To achieve particular functioning, capability is dynamically shaped by interactions between individuals and their environments, including social relationships. Being part of a social group can mean doing physical activity, as it did for some of our participants. Having capabilities for valued functioning is the basic idea of the capabilities approach (Entwistle & Watt, 2013). What people are free and able to do and be, and what they have reason to value doing and being is the focus approach generally encouraged. The participants in the present study wanted to be seen holistically in the dialogue with health personnel. The capabilities approach characterizes person-centered care as “a care that recognizes and cultivates the capabilities associated with the concept of persons” (Entwistle & Watt, 2013, p. 29). Behind calls for person-centered care is an ethical concern of how health care personnel understand the value of their interactions with patients (Entwistle & Watt, 2013). According to Ricoeur (Ricoeur & Kristensson Uggla, 2011), some aspects of life seem important to all humans. Further details of what is good for individuals vary. This is also stated by the participants in our study. According to Ricoeur (Ricoeur & Kristensson Uggla, 2011), the person is “the hub of” the meeting. He sees man as a synthesis of abilities. Taking each patient’s subjective experiences seriously, being attentive and responsive to patients’ unique biographies, social contexts, and the

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relationships that matter to them, and being careful to avoid damaging personal identities that they value are a main idea in the capability approach. Entwistle and Watt (2013) propose a guiding idea that treating patients as persons involves recognizing and cultivating their personal capabilities. In the context of interactions with others, experiences of inclusion (or not) in the community of ethically significant persons arises in the context of interactions with others. The participants had symptoms such as chest pain, but no signs. They experienced illness despite their physicians’ assurances about the health of their heart. This is in line with Jerlock et al. (2005), in which participants stated that they did not exercise because they were uncertain about how much they could exert themselves with their undiagnosed chest pain. Patients’ beliefs, exaggerated fears of death, marked conviction of disease, or intense bodily preoccupations need to be elicited. Maintaining both integrity or sense of self and ability to carry on role responsibility were shown to be of significance in a study by Turris and Johnson (2008), in which women were seeking treatment for symptoms of potential cardiac illness. According to Ricoeur (Ricoeur & Kristensson Uggla, 2011), symptoms become a “sign-posted path,” the idea being that the path will lead to a particular “destination” (diagnosis). The symptoms are a riddle to the patient and are volatile in nature, causing him to feel vulnerable. The relational ontology behind patient-centered care can also encourage us to look beyond task-oriented information and to think in a less “remote” way about interpersonal communication (Ekman et al., 2011). Thus, it leads us to understand that the ways health services and staff relate to people to some extent affirms those persons’ personal capabilities. The participants in our study wanted to interpret bodily symptoms in relation to doing physical activity. Most of them had no chest pain when exercising. They hardly experienced chest pain when exercising in nature or with others. Corbin (2003) argues that the body speaks to the person through sensations that are anchored in meaning. Dahlberg and Segesten (2010) enquire whether the fact that we have difficulties speaking about our existential pain means we have to attribute it to an illness category to make space for it in daily communication. Health professionals must have exact knowledge about signs and diagnosis, but at the same time, they should know what these symptoms mean for each person. A person-centered approach (Ekman et al., 2011) is suggested to meet patients as persons in their balancing act between existential uncertainty and existential certainty in relation to physical activity.

Conclusion The results reveal challenges for clinical practice in understanding the vulnerability in people’s balancing act

between existential uncertainty and certainty in connection with doing or avoiding physical activity while living with unexplained chest pain. The study contributes with aspects and nuances related to what it means to live with this balancing act—knowledge that is of significance to developing clinical practice. A person-centered approach is suggested to encourage people to feel capable about making rational choices related to doing or avoiding physical activity. This includes openness to the fact that persons live their lives in the balancing act and may need support in explicating and discussing beliefs and questions. One suggestion for future research is interventions focused on physical activity for persons with unexplained chest pain to understand critical aspects to more fully. Acknowledgments We are especially grateful to the participants for their time and contributions to the study. We also thank Alf Inge Larsen and Lars Edvin Bru for their support.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Norwegian Nurses Association and Prekubator TTO (Technology Transfer Office).

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Author Biographies Ingrid Ølfarnes Røysland, RPN, MSc, is a doctoral student in the Department of Health Studies, Faculty of Social Sciences at the University of Stavanger, Stavanger, Norway. Febe Friberg, RN, PhD, is a professor in the Department of Health Studies, Faculty of Social Sciences at the University of Stavanger, Stavanger, Norway.

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