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Abstract |
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 Top Abstract PurposeMethodsResultsDiscussionImplications for PracticeLimitationsConclusionReferences |
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• Objectives To describe hope in hospitalized patients with heart failure and to evaluate influences of demographic and health-related variables on hope.
• Methods Ninety-three patients with heart failure and 441 healthy control subjects completed questionnaires about sociodemographics, health indices, disease severity, and the Herth Hope Index.
• Results The patients with heart failure had a mean age of 75 years; 65% were men, and 47% lived alone. Lung diseases and diabetes were the most common comorbid diseases, with 58% classified as New York Heart Association class III. The mean global hope score among patients with heart failure was 37.69 (SD 5.3). Patients with skin (P = .01) and psychiatric (P = .02) disorders reported lower hope scores. Number of comorbid diseases was the only predictor of hope related to disease-specific variables (P = .01). Mean age of the control subjects was 60 years, and 66 (15%) lived alone. Once demographic variables were controlled for, patients with heart failure had significantly higher global hope scores than did control subjects.
• Conclusions Adaptation to a life-threatening illness may induce a "response shift" that causes such patients to have more hope than the general population. Patients with heart failure may be more concerned with the past than the future. How patients judge their health and satisfaction with life influences their hope. Interventions supporting hope in patients with heart failure may influence treatment goals.
| Heart failure is the only cardiovascular syndrome that is increasing in prevalence, incidence, and mortality.
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Heart failure is a syndrome affecting all aspects of daily life. One domain of quality of life is psychosocial perception, known to be greatly altered in patients with heart failure.4 In addition, emotional distress is a common problem in patients with heart failure.5 The signs and symptoms of heart failure and the severity of the disease can lead to anxiety and emotional responses such as depression, thereby creating uncertainty for patients with heart failure.6 Hirth and Stewart7 found that hope was the most important variable contributing to the effectiveness of coping in patients with heart failure who were awaiting cardiac transplantation.
The severity of heart failure and the resultant uncertainty among patients magnify the importance of hope in these patients. Hope is defined as "a multidimensional dynamic life force that is characterized by a confident yet uncertain expectation of achieving good, which is realistically possible and personally significant."8 Hope is future oriented and implies that expectations are focused on the future.8 When a patient has heart failure diagnosed, he or she may perceive a threat to the future, both because the disease may present daily physical discomfort and because of a possible change in expected life span. Hope has also been described as a feeling9 that is influenced by external factors such as physical function, life changes, and one’s surroundings. Hope is a feeling that can be undermined by suffering and is therefore viewed not as a stable trait but as a dynamic one.9,10
| The severity of heart failure and the resultant uncertainty for patients magnify the importance of hope in these patients.
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Several investigators have examined hope in patients with heart failure. Westlake and Dracup11 described the role of spirituality and emotional adjustment in patients with advanced heart failure. They described a 3-step process wherein spirituality contributed to emotional adjustment through (1) the development of regret about past behaviors and lifestyles, (2) the search for meaning within the present experience of heart failure, and (3) the search for hope for the future with reclamation of optimism.
Roberts et al12 described 4 dimensions of hope in patients with heart failure and focused on nursing interventions to support hope: (1) experiential hopefulness (provide exercise therapy, encourage reminiscence, and provide environmental structuring), (2) spiritual/transcendence hopefulness (meet support and reassurance needs, provide presence, and encourage prayer/meditation), (3) rational hopefulness (optimize interaction of patient with environment, provide concrete objective information, facilitate value clarification, and provide validation), and (4) relational hopefulness (use active listening, promote advocacy, encourage mutual goal setting, provide family support).
Johnson et al13 described a model of hopelessness in patients with heart failure and suggested strategies for increasing patients’ hope. These strategies encompass (1) a physiological sense of hope (eg, to restore control over the illness), (2) an affective-behavioral sense of hope (eg, to encourage reality-based perception), and (3) an affiliative-contextual sense of hope (eg, to establish relationships).
Variables such as the patient’s sex, demographics, or disease may influence hope levels in patients with heart failure, but these variables remain unstudied. Men and women respond differently to the burden of heart failure. Investigators14 report that physical limitations are associated with depression more often in men than in women. Patients with heart failure who are more than 65 years old experience an increased risk for rehospitalization and death,15 underscoring the need for patients’ education, support, and counseling. Understanding the relationship between hope, a patient’s sex, and demographic and/or disease-related variables may provide insight into methods of support and treatment for patients with heart failure.
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Purpose |
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Methods |
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All patients had heart failure diagnosed on the basis of the 1995 criteria for heart failure of the European Society of Cardiology.17 Inclusion criteria consisted of capability of reading and writing Norwegian and clear cognition. Subjects could solicit help from the nurses if they had difficulty with the questionnaires. All the nurses caring for these patients were given information about the study. All eligible patients who met the inclusion criteria were consecutively asked to participate in the study between October 2000 and August 2002. Most commonly, reasons for refusal to participate were fatigue or involvement in other research.
In order to better understand hope among patients with heart failure, a comparison group of healthy, similarly aged citizens from the Norwegian general population was recruited. In order to obtain the sample from the general population, 4000 Norwegian citizens 19 to 81 years old were randomly chosen from the Norwegian National Register of Statistics and were sent a questionnaire. Fifty-six questionnaires were returned either because they had been sent to citizens who had recently died or because the forwarding address of the citizen was unknown. Of 1912 questionnaires returned,18 1893 were complete and could be used in the analysis (1893/3944, response rate 48.5%). Of the 1893 respondents who completed the questionnaire, 441 respondents 48 years or older with reported good health were used as the comparison group.
Instruments and Scoring Procedure
Sociodemographic Characteristics.
The age, sex, marital status, living situation, and educational level of all subjects were recorded. Marital status was categorized as married, unmarried, divorced/separated, or widowed. Living situation was categorized as living with spouse/another adult or children or living alone. Educational level was categorized as primary school, secondary school, or university/college education. For the patients with heart failure, employment status was first categorized as being paid for work or not paid for work. Reasons for unpaid work were categorized as unemployed, sick leave, disability pension, or pensioned.
Health Indices in Patients With Heart Failure. By means of a questionnaire, the patients with heart failure were asked if they currently had or had previously had cancer; diabetes; musculoskeletal, skin, lung, and/or gastrointestinal diseases; or psychiatric disorders. The number of comorbid illnesses was collected. Patients were also asked to evaluate their own health status. They could describe their health as bad, not good, good, or very good.
The patients’ nurses or physicians provided additional health information. Length of time since the diagnosis of heart failure, New York Heart Association (NYHA) classification, and ejection fraction were obtained. Values for ejection fraction were categorized as 0.40 and higher versus less than 0.40. This categorization allowed us to broadly generalize the patients into 2 groups: patients with systolic heart failure and patients with diastolic heart failure.19
Measurement of Hope. Hope was measured by using the Norwegian version of the Herth Hope Index. This scale is based on the definition of hope developed by Dufault and Martocchio8 and contains 12 items measuring various dimensions of hope.20 Each item uses a 4-point Likert scale ranging from strongly agree to strongly disagree. The scale gives 1 global score in addition to single-item scores.20 Scoring range for the global score is from 12 to 48, with individual items scoring from 1 to 4. The scale has been used widely in international studies, both in hospitalized patients and in outpatient settings. Construct validity,20,21 divergent validity,22,23 internal consistency,21,24 and test-retest correlations20 were previously reported to be satisfactory in various samples.
The Herth Hope Index was translated from English into Norwegian according to internationally accepted guidelines.25 The Norwegian version had satisfactory reliability (Cronbach 
= .81) and content validity, with successful discrimination between subgroups of participants.18,26
Satisfaction With Life in Patients With Heart Failure. The patients with heart failure also answered an item about future perspective and life satisfaction level. For the question "In what way do you view your future?" a 7-point Likert scale (from extremely positive to extremely negative) was used. For another question, "When you think about your life these days, are you mainly satisfied or dissatisfied?" a different 7-point Likert scale (from extremely satisfied to extremely dissatisfied) was used.
Statistical Analysis
Data were analyzed by using SPSS for Windows software (version 10.0; SPSS Inc, Chicago, Ill). Missing values in the Norwegian Herth Hope Index were replaced with the item’s mean value if less than 40% were missing. If more than 40% of values were missing, the respondents were not included in the hope analyses. Descriptive statistics were used to evaluate demographic and clinical characteristics of the samples.
Multiple linear regression analyses were completed to analyze the level of hope in the sample of patients with heart failure and the sample from the general population while controlling for the sociodemographic variables (respondent’s sex, age, marital status, cohabitation, and education). Categorical variables with 3 or more response categories were represented in the regression analysis by sets of reference-coded dummy variables.
A 1-way analysis of variance was performed to evaluate differences in hope level related to the sex, living situation, marital status, and education level of respondents with heart failure. A 1-way analysis of variance was also performed to evaluate any possible differences in hope scores within the heart failure sample due to health-related variables such as NYHA class, ejection fraction, and number of comorbid diseases. Finally, 1-way analysis of variance was used to evaluate any differences between global hope score and individual item scores in the patients with heart failure and in the general population.
Pearson product moment correlations were determined between global hope score and all subjects’ age, sex, educational level, and living situation. Also, correlation analyses were completed between NYHA class, ejection fraction values, comorbid diseases, number of diseases, self-assessed health, future perspective, and life satisfaction level in the patients with heart failure.
Hierarchical regression analyses with 2 blocks were conducted to evaluate the effects of selected demographic, disease-specific, and self-assessed variables in the patients with heart failure. Variables that had significant univariate associations with hope were entered in the regression model. Significance was defined as P less than .05, and data are presented as means and SDs where appropriate.
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Results |
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). The mean age of the sample was 75.1 years (SD 9.7, range 48–93). Almost half of the sample (47%) lived alone, and 45% were married. As many as 79 patients (85%) were not paid for work and were either disabled or receiving a pension. Only 18 (21%) were college or university educated.
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). A large majority were married (331, 76%) and 145 (33%) had university or college education. Most subjects (375, 85%) lived with a spouse or children.
Health-Related Characteristics of the Patients With Heart Failure
More than half of the patients with heart failure (58%) had the heart failure diagnosed in the year 2000 or later. Most cases were classified as NYHA class III, and more than half (63%) of the patients with heart failure had systolic heart failure with ejection fractions less than 0.40 (Table 2).
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). Nineteen patients (20%) reported no chronic disease in addition to heart failure. One disease in addition to heart failure was reported by 44 (47%), 2 diseases by 15 (16%), 3 diseases by 12 (13%), and 4 and 5 additional diseases were each reported by 3 respondents (3%).
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Hope Scores: Patients With Heart Failure Versus the General Population
Five participants with heart failure were excluded from the analysis because less than 80% of the Herth Hope Index was complete. The mean global hope score among the patients with heart failure was 37.69 (SD 5.3, range 20–48). Mean scores on individual items measuring hope varied from 3.70 (range 1–4) on the item "I can recall happy/joyful times" to 2.68 on "I have short-, intermediate-, and or long-range goals" (Table 4). The mean global hope score was 36.35 (SD 4.0) in the sample from the general population. The differences between the scores on the individual items are outlined in Table 4. Hope scores differed significantly between patients with heart failure and the general population for 7 of the 12 individual items. Patients with heart failure had a significantly higher global hope score than did the general population and when the demographic variables were controlled for in the regression analyses (F1,500 = 9.96, P = .002).
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| Compared with subjects in the general population, hospitalized patients with heart failure had a higher global hope score.
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The future perspective of the patients with heart failure was reported as extremely positive by 3 patients (3%), very positive by 8 patients (9%), quite positive by 30 patients (32%), both positive and negative by 36 patients (39%), quite negative by 7 patients (8%), very negative by 5 patients (5%), and extremely negative by 4 patients (4%). The correlation between mean global hope score and future perspective was significant (r=0.48, P< .001) in the patients with heart failure.
Satisfaction With Life Among Patients With Heart Failure
Among 91 patients with heart failure, level of satisfaction with life was reported as extremely satisfied in 5 patients (6%), very satisfied in 13 patients (14%), quite satisfied in 32 patients (35%), both satisfied and dissatisfied in 30 patients (33%), quite dissatisfied in 5 patients (6%), very dissatisfied in 3 patients (3%), and extremely dissatisfied in 3 patients (3%). The correlation between mean global hope score and patients’ level of satisfaction was 0.54 (P < .001).
Effects of Demographic Variables, Health-Related Variables, and Self-Assessment of Health on Hope in Patients With Heart Failure
According to the correlational analysis, none of the demographic variables (patients’ age, sex, marital status, cohabitation, or education) was significantly correlated with hope in the patients with heart failure. Hope scores were not significantly correlated with NYHA class or ejection fraction. The patients with heart failure who reported skin diseases and psychiatric disorders had lower levels of hope than did patients not reporting these comorbid diseases (Table 3). Furthermore, variables that were significantly correlated with hope in the patients with heart failure were number of comorbid diseases (r = –0.27), comorbid skin disease (r = 0.26), and comorbid psychiatric disease (r = 0.25), satisfaction with life (r = –0.54), and self-assessed health (r = 0.39). These variables were entered in the hierarchical regression model with 2 blocks.
| Hope scores were not associated with stage of heart failure or ejection fraction.
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In the first block, number of comorbid diseases was entered in the model. Presence of a skin or psychiatric disease was included as a comorbidity variable; single disease variables were not entered in the model. In the next block, satisfaction with life and self-assessed health were entered in the model (Table 5).
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Discussion |
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). This result is perhaps counterintuitive because heart failure is associated with high morbidity and mortality, whereas the sample from the general population was reportedly healthy. Although the 2 samples differ with respect to age, living situation, marital status, and educational level, the difference in global hope score cannot be explained by differences in the measured sociodemographic variables because the difference persists when the variables are controlled for. The mean global hope scores in the patients with heart failure may reflect adaptation to a life-threatening chronic disease. This adaptation may be due to a "response shift." Response shift is defined as a "change in the meaning of one’s self-evaluation of quality of life as a result of change in values or internal standards."27,28 Sprangers and Schwartz28 suggest that changes in quality of life result from an interaction of (1) a catalyst, or something that changes the health status of the patient, (2) antecedents or personality traits present in a patient, (3) mechanisms to accommodate changes in health status, and (4) response shift or changes in the meaning of quality of life. Such a notion of response shift is used to explain higher levels of quality of life reported by individuals with a variety of diseases compared with the general population and response shift may affect levels of hope.
Individual items on the Herth Hope Index can be further explored to evaluate the difference between the patients with heart failure and the general population. The 2 groups differed on 7 of 12 individual items from the Herth Hope Index. Patients with heart failure scored highest on the individual hope item, "I can recall happy/joyful times" (Table 4). The group from the general population scored highest on the items, "I have a positive outlook toward life" and "I have short-, intermediate-, and/or long-range goals." We speculate that the older and unhealthy patients with heart failure may be more concerned with the past than the future. Therefore, these subjects do not focus on goals or the future. The patients with heart failure also had the lowest mean score on the item measuring the significance of goals, further supporting this focus of attention on the past. Snyder29 emphasized that "recalling past success" was one way to nurture hope. This idea is also supported by aging theory, which emphasizes that elderly persons are future oriented in a different way than are their younger counterparts.30 Nurses are often goal oriented, encouraging their patients to reach for milestones. Perhaps encouragement of reflection and recollection would be more helpful for these older patients with heart failure. Past experiences also form the basis for evaluation of the past and future, whether it is it favorable or not.31
| Patients with heart failure may focus on the past, recalling past successes as a way to nurture hope.
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The statement "I have a faith that gives me comfort" received higher scores from the patients with heart failure than from the sample of the general population. Spirituality is described as a domain of quality of life.11 In a study11 in the United States in which patients with heart failure were interviewed about the role of spirituality, faith was emphasized for development of hope in one third of the sample. A chronic illness such as heart failure may result in questions related to life priorities. Spirituality is one way by which individuals may make sense of life priorities, thereby adjusting to new expectations. We speculate that the chronicity, disability, and poor prognosis associated with heart failure spur patients to seek support and comfort in their faith. Perhaps faith is related to hope levels.
| Encouragement of recollection and reflection may be a helpful strategy for elderly patients with heart failure.
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Interestingly, measures of disease severity, such as NYHA class or ejection fraction, were not related to hope levels. This finding is consistent with results of a study of female recipients of heart transplants, in which ejection fraction had no relationship to hope.32 Rideout and Montemuro16 described similar findings. They found very little relationship between psychosocial variables and the physical variables of physiological status and physical function. They suggested that patients who are more hopeful maintain their involvement in life regardless of physical limitations imposed by heart failure. In our study, however, we found that patients with heart failure who had more associated comorbid diseases had lower global levels of hope.
The most important predictors for hope in this study were number of comorbid diseases, self-assessed health, and satisfaction with life (Table 5). One question that might be asked is, If these comorbid diseases were attended to and successfully treated, would patients with heart failure have a higher level of hope? Attention to signs and symptoms of heart failure, as well as other comorbid diseases, is important in these complex cases to maximize comfort. Findings also suggest that concomitant psychiatric and skin disorders threaten hope levels. Skin disorders are more common in elderly persons, ranging from mildly uncomfortable to intolerable. In addition, elderly persons and persons with cardiovascular problems are at higher risk for various skin disorders such as venous insufficiency, diabetic and arterial ulcers, psoriasis, and eczema.33 Although these problems may not be life-threatening, they may cause daily discomfort (in addition to the discomforts associated with heart failure) that requires treatment to ensure relief. The effect of skin disorders on levels of hope is not clear because the group studied was small. Further research is needed to better understand which comorbid diseases influence levels of hope and why they do so.
Self-assessed health and satisfaction with life were the most important variables for hope in our study, and further research on these variables is needed. According to our results, it is not the severity of the heart failure, but the number of comorbid diseases and self-assessed health that influence hope. Naturally, care is focused on hemodynamic indices, signs and symptoms, and reduced physical function; patients’ self-evaluation must be carefully considered.
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Implications for Practice |
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Encouraging patients to recall past successes or reflect on the past may encourage adaptation to life changes. Evaluation of the past and how it provides meaning to their lives may support older patients with heart failure. In addition, encouraging treatment of psychiatric and skin disorders may influence overall levels of hope. If patients find comfort in faith, offering them spiritual resources, especially while the patients are in the hospital, may provide support. Finally, attention to treatment of comorbid diseases may influence hope levels.
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Limitations |
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Conclusion |
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ACKNOWLEDGMENTS |
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REFERENCES |
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