Impact Of Heart Failure On Patients Nursing Essay


Developing nursing knowledge is one of the basic concerns of nursing research. Nursing knowledge is constantly subjected to changes with the ongoing discoveries and updates. Thus, nurses should continue striving for new enquiries and seek for answerers (Gerrish and Lacey, 2010).

"Nursing research is a systematic enquiry that seeks to add new nursing knowledge to benefit patients, families and communities. It encompasses all aspects of health that are of interest to nursing, including promotion of health, prevention of illness, care of people of all ages during illness and recovery or towards a peaceful and dignified death1. Nursing research applies the scientific approach in an effort to gain knowledge, answer questions, or solve problems"

The International Council of Nurses (ICN) prioritized the nursing research into two main categories, the health and illness and the delivery of care of services. The health and illness focuses on the health promotion, prevention, living with chronic conditions and enhancing quality of life, symptoms controlling, testing nursing interventions and outcomes, and caring. On the other hand, the delivery of care services focuses on the quality and cost effectiveness of care in general (ICN 2009). Accordingly, nursing research basically provides the foundation of evidence-based nursing practice, where the client is the center of the care (Gerrish and Lacey, 2010, Nieswiadomy, 2008).

The heart is considered to be one of the most affected vital organs in the body in relation to industrialization. Heart Failure (HF) or Congestive Heart Failure (CHF) is one of the striking chronic condition resulted from the worsening of hypertension and coronary heart diseases prevalence, specially in developing countries, as in Arab Gulf States. HF is characterized by the inability of the heart muscle to pump the blood effectively (Alqahtani et al., 2012). HF is a progressive condition resulting in poor quality of life to the patients, and irrespective to the age, around 20% of adults above the age of 40 are suspected to develop HF (Ramani et al., 2010).

Symptoms of HF are affecting the quality of life of the victims in different aspects of daily living activities. Symptoms vary from dyspnea on exertion, orthopnea and fatigue, peripheral edema to confusion in advance stages and other symptoms according to the side of the failure, right or left (Bender et al., 2011). Moreover, HF appears to affect the psychological wellbeing of the patients. Symptoms of anxiety and depression were associated with being diagnosed with HF (Heo et al., 2008). Moser and Worster (2000) defined quality of life as a "multidimensional concept referring to a person’s total well-being including his or her functional capacity, psychological status, social functioning, physical health and health perceptions". HF patients reported a low quality of life associated with HF symptoms and its effects on their daily activity, social interactions and relationships, as well as rest and sleep (Brostrom et al., 2004).

Therefore, its important to fully understand the experience of patient’s suffering from heart failure in order to have a full picture of how is it to live with heart failure. Information about patients’ experience with HF provides the guidance for nurses and healthcare providers to develop an intervention plan in order to improve the patients’ experience with the syndrome and contribute in future strategies to improve the nurses objectives and outcomes for HF patients (Deaton and Grady, 2004).

The writer being a cardiac nurse working for more than 9 years with different cardiac cases, has observed the impact of HF on patients on daily basis, the burden of symptoms, readmissions and the difficulties that the patients and families are facing after being diagnosed as a HF case, while less attention was given from healthcare worker to explore these experiences and work on improving patients’ life with this chronic disease. Thus, this study will focus in depth on the experience of patients diagnosed with HF from their own perspectives, quality of life in relation to the disease, the available services that are provided to HF patients and the role of nurses to improve the patients’ experience of living with HF in Bahrain.

Aims and Objectives

The aim of this study is to explore the lived experiences of men younger than 65 years old of age diagnosed with HF. The objectives are:

To explore the patients’ lived experience with HF.

To describe the effects of HF on the patients’ life style and activities.

To identify the support that maybe necessary to help men with HF.

The mentioned objectives are structured to answer the researcher question:

"What are the experiences of men under the age of 65 years living with heart failure in Bahrain?"

Background and Significance of the Study

Prevalence of HF

Heart failure is considered as a global epidemic all over the world, and a major cause of morbidity and mortality (Roger et al., 2011). According to data from National Health and Nutritional Examination Survey (NHANES) (2005-2008), around 5,700,000 Americans are diagnosed with HF. Moreover, it was indicated that HF will affect around 10 per 1000 population after the age of 65 years, and the estimation by the year 2030 for HF prevalence is three million people in the United States of America (USA) (Roger et al., 2011). The burden of HF syndrome on the health organizations is huge as HF is the most common reason for hospitalization in the USA costing billions annually spent on the management of this syndrome (Brostrom et al., 2004). There are no specific statistics found in concern with HF prevalence in the Arab Gulf states or in Bahrain. Yet, the estimated total number of patients admitted with hypertensive heart diseases in the year 2011 statistics were around 486 male patients and 447 female, 233 male were under the age on 65 years, while the female were only 110 from the same age category. In addition, the male patient that were admitted with pulmonary edema, which is one of HF symptoms, were 47 male and 39 female under the age of 65 years. Thus, statistically the number of men admitted with hypertensive diseases and pulmonary edema are more than female in the age category of 45-64 years, the age which is considered the older adulthood to average retirement age according to United Nation standard international age classification 1982 (Nations, 1982).

These statistics reveal the increasing number of HF patients, and the expected increase in number in the near future. Bahrain as a part of Arab Gulf States is subjected to an increase in the HF cases despite the improved access to advance technology. The society is tending for urbanization and inactivity, expanding the possibilities for cardiovascular diseases to be the main cause of morbidity and mortality in the region (Habeeb et al., 2009). Being confronted with these increments, the demands for planned management of HF based on evidences, as no cure is available, but symptoms management and improvement of patients life condition are the key elements of the treatment. Accurate educational program should be provided to the patients and their caregivers in order to ensure the high level of compliance to the treatment (Alqahtani et al., 2012) .Management should be based on research in order to provide high quality of care, reducing the length of stay, readmissions, cost and mainly maintaining a healthy, high quality life to HF patients in Bahrain.

Impact of heart failure on patients

HF is affecting the patient’s life from different dimensions. In the beginning, the physical symptoms might appear as the primary reason for seeking medical help to alleviate the symptom burden. As a sequence, the patient will start sensing the changes which is affecting his daily living circumstances that need understanding, adjustments and management in order to cope and improve the quality of life while living with a chronic, irreversible condition. Among HF patients, the health status is poorly understood, and even with intense medical therapy for symptom relief, patients are still suffering from progressive symptoms, hospitalizations and high rates of mortality (Jong et al., 2005).

HF patients experience a significant limitation in physical abilities, psychological and emotional health, cognitive abilities, social interaction and quality of life

(Deaton and Grady, 2004). Management of those limitations is an important aspect of patient’s adaptation with the health condition that should be a major focus of nursing care and interventions. Nursing care should be built on the strategy of improving the outcomes of HF treatment. Yet, the writer believes that those strategies should be based on the patients’ own experiences with the disease, needs and the desired outcomes. Large number of quantitative studies were done by different healthcare workers concerned with studying the predictors of health related quality of life (HRQoL) among patients suffering from HF, the correlation between different aspect of HF (physical, emotional, sleep, cognitive, etc..), prevalence and the burden of HF, but a limited number of studies have deeply explored what is it like to be a HF patient, and how life is changed after the diagnosis. Allowing the patients to express their feelings and experiences from their own point of view and perspective, provides a comprehensive understanding of the health condition and limitations in order to plan the care based on day-to-day challenges that HF patients face (Thornhill et al., 2008).

This study will explore the experiences of men living with HF from their own perspective, using their own words and expression to draw a full picture of HF patient’s daily experience with the syndrome, and look at the available resources, health education and support provided to HF patients in Bahrain. The study will be conducted at a large governmental, educational hospital in Bahrain, through in-depth interviews of a sample of 8 to 10 men under the age of 65 years diagnosed with HF in the setting of outpatient’s department and inpatients admitted on Cardiac wards. Men under the age of 65 years were chosen as the population of the study based on the statistical results that represented the men to be more affected by the incidence of new HF cases in the younger age (Roger et al., 2011). From a socio-cultural perspective in Bahrain, men are responsible mainly as a provider for the family financially, and being diagnosed with a chronic, disabling condition might be more influencing than female in the same age. Chronic illness as in HF will include the feeling of pain, tiredness, strength reduction that will deteriorate the aura independence and power associated with the masculinity in men playing the gender role in his society (Gibbs, 2005). On the other hand, recent study was conducted to analyze weather the nurses researchers were gender-biased to female, result showed that 74% of 300 published studies’ participants were female between the year 2010-2011, which blamed to create a problem with generalizability in nursing practice (Polit and Beck, 2013). Qualitative, interpretive phenomenological design will be used, and the data will be analyzed through Interpretive Phenomenological Analysis (IPA).


Heart Failure is an end stage of a number of cardiovascular diseases, where the muscle loses its ability to perform its duty, pumping the blood to the body. Living with HF put the sufferer in a battle with the different symptoms and comorbidities that accompanied the condition. Understanding the details of HF patients’ life enables the health care workers, especially nurses to grasp more about their life and how they are affected in order to establish a comprehensive, patient-centered plan of care with help of the patients themselves. This chapter outlined the focus of the study and the purpose, the significance of exploring the experience of men under the age of 65 years living with HF, and the aim and objectives of the study were stated. The following chapter will present the literature reviewed, where the writer will explicit the complexity of the phenomena and the importance of exploring the life of men living with HF based on the studies findings and recommendations.

Chapter Two

Literature Review

2.1 Introduction

A literature review provides the extent of the knowledge regarding the topic of interest, as well as helping the researcher to develop the theoretical framework of the study and the appropriate methodology that will ensure that the research question/s are answered (Nieswiadomy, 2008). This chapter discusses the search strategies utilized by the researcher outlines what is already known about living with Heart Failure (HF), and summaries the methodological approaches used in the reviewed literature.

The aim of this study is to explore the experience of men younger than 65 years of age diagnosed with heart failure. Several themes emerged from the literature review that focused on the different aspects of HF as they affected patient’s life, for example: Sleep and rest, physical and psychological dimensions, effects of gender and age, social life and the cognitive impairment in HF patients. The literature reviewed established the framework for the proposed study, and helped in formulating the research question and objectives, as well as the research design that will be used in order to explore the experience of living with HF.

2.2 Search Strategy

The search was conducted using the search engines Medline, Cinahl, Wiley Online Library, and Proquest. The search used the terms’ concerns about living with HF, men with heart failure, heart failure epidemics, living with heart failure, heart failure and quality of life and the burden of heart failure. The searched was limited from 2000 to 2013 in order to obtain the most contemporary and recent information and results for farther relevance and reliance. A total of 36 research studies were used in order to cover all the aspects of the study aim and objectives.

Almost no research was found in the search that addressed HF in the Arabian Gulf region or the Middle East, which might be considered as a gap in the literature. There were a limited number of qualitative studies regarding the living experience of HF. The researcher used quantitative studies to develop the argument of the methodology that will be used.

2.3 Burden of HF

Heart Failure (HF) is the "pathophysiologic state in which an abnormality of cardiac function is responsible for the failure of the heart to pump at a rate adequate to meet the requirements of the tissue, either at rest or exercise" (Woods et al. 2000:560). HF is a complex clinical syndrome rather than a diagnosis, and its etiology should be sorted out carefully. Ramani and Colleagues defined HF as a "progressive syndrome that results in a poor quality of life for the patient" (Ramani et al. 2010:180).

Symptoms depend on the speed of the syndrome progress. The dominant symptoms of HF are the breathlessness and dyspnea in the early stages, while nocturnal dyspnea and orthopnea are more prominent in the end stages. Weakness and fatigue are due to decreased blood supply to the muscle, and the patient will complain of heaviness in the arms and legs. Furthermore, low cardiac output to the cerebral tissues can alter the mental status causing a state of confusion, restlessness, memory loss, agitation, insomnia, and nightmares. The pulmonary congestion progresses in different stages causing worsening of the associated signs and symptoms. Congestion of the bronchial mucosa increases the airway resistance, which contributes to the nocturnal dyspnea (Bender et al., 2011).

Due to the backing up of the blood volume to the system circulation, fluid accumulation begins in the lowest extremities represented in edema in the ankles, ascending to the thighs, genitals and the abdominal wall. In addition, most of the patients will experience weight gain as a result.Hepatomegaly is a common condition with a picture of congested tender liver and might be associated with ascites. The gastrointestinal system will be involved as well and the patient will experience nausea, anorexia and impaired absorptive mechanisms of the bowel (Woods et al., 2000, Bender et al., 2011).

Thus, the clinical manifestation revealed the huge burden of HF on patients, from the early stages that requires intensive management of the symptoms in order to improve the experience of patients with the condition, is the main aim of nurses towards HF patients. The following section presents the results of the literature review of patients experience with HF.

2.4 Living with HF: Quantitative Studies

HF is a rich subject for many investigators due to the constant increase in the number of patients diagnosed with HF globally, as well as the increase in the morbidity, recurrent admissions and increased burden of HF on the individuals affected, caregivers, as well as the healthcare institutions (Liao et al., 2008).

The number of HF patients are increasing constantly due to the rising elderly population in the last decades, the advanced treatment of coronary artery diseases like myocardial infarction, and the improvement of medical treatment which increased the survival rate of HF patients (Stewart et al., 2003). The need to improve the experiences of HF patients is important, as most of the studies had shown a significant reduction in the quality of life for HF sufferers (Wang et al., 2010, Brostrom et al., 2004, Juenger et al., 2002, Britz and Dunn, 2010).

Quantitative studies were mainly focusing on health related quality of life (HRQoL) in HF patients and had determined the most vital predictors of individual well-being and experience with HF. Quantitative studies were categorized into six main themes: (I) The effects of HF on Sleep and Rest, (II) Physical Health and Capabilities, (III) Psychological Dimension, (IV) Age and Gender Effect on HF Experience, (V) Effect of HF on The Patient’s Social Life, as well as (VI) The Impact of Social System Integration on The Patient’s Adjustment with HF. Lastly, (VII) The Association of HF and Cognitive Impairment.

2.4.1 Sleep and Rest

Sleep quality is defined as "perceived satisfaction with sleep" which will be evaluated through the subjective satisfaction of the individual and objectively by assessing the amount of sleep (Wang et al. 2010:1731). Limited studies were conducted in concerns with the patient’s experience in sleeping disturbance related to HF. A study conducted by Brostrom and Colleagues (2004) to describe sleeping difficulties as experienced by the patients, daytime sleepiness and Health Related Quality of Life (HRQoL) in men and women comparing with normal population. The results showed that the most common sleeping disorders that HF patients complain from was initiating, maintaining sleep and early morning awakening. Moreover, 21% of the study population reported daytime sleepiness that affects the quality of nighttime sleeping habits. Psychological stress, anxiety and depression were the proposed factors of sleep disturbances among HF patients.

Wang et al. (2010) studied the factors that influence the sleeping quality of HF patients. A perspective correlational design used on a convenient sample of 101 patients diagnosed with HF from different cardiology clinics in Taiwan. The majority of the sample as a whole experienced poor quality of sleep varying from short duration of night-time sleep, frequent awakening for urination, lack of effective sleeping (Calculated by the actual hours of sleep divided by the hours spent in the bed), and sleepiness during daytime. Additionally, 30 patients reported using sleeping medication for more than 3 times per week. The researchers emphasized the positive relationship between sleep quality and New York Heart Association (NYHA) [1] functional class, hospitalizations, number of comorbidities, medications and depression. On the other hand, sleep quality and self-perceived health were negatively associated.

Knowing the patients own expression would give a significant impression of the patients’ experience, especially when defining the sleep quality as a "perceived satisfaction", surprisingly, no qualitative studies were found to explore the sleep and rest difficulties that patient experiences with HF. Nurses can play a major role in educating HF patients by addressing the contributing factors of sleep disturbance and ways to modify them to maintain healthy sleeping habits (Wang et al., 2010).

In summary, sleep quality is the individual’s perceived satisfaction of sleep. The literature concerned with patient’s sleeping and resting experience related to HF was limited. Initiating and maintain sleep, early morning awakening, short duration of nighttime sleep, frequent awakening for urination and lack of effective sleeping were the most common sleep disturbances. Psychological stress, anxiety and depression were also addressed in the literature that might be other contributions that play a significant role in HF-Related sleep disturbance. The following section will cover the physical dimension of HF experience.

2.4.2 Physical Dimension

The prognosis of HF and the signs and symptoms that accompany the condition were considered a huge burden on patient’s daily living activities, particularly the physical experience. The majority of the studies with HF patients, considered the physical impact as a major predictor of quality of life among this group. Physical and mental health were always related to the meaning of life among HF patients, and significantly linked with the prognosis and outcomes of HF (Park et al., 2008). Physical symptoms result in a number of limitations that affects the patient’s routine and daily activities. Difficulty in stairs climbing, housekeeping, carrying items, sexuality and other activities of daily living (Mithal et al., 2001).

Juenger et al. (2002) assessed the HRQoL of HF patients compared to healthy population and other chronic diseases in relation to physical variables. Results showed that the NYHA class was an independent predictor of HRQoL in HF patients. Thus, the more advanced physical symptoms of HF, the worse HRQoL scores. The results were supported by Jong et al. (2005), which showed that the better NYHA class is a predictor of greater physical activity, which was due to factors such as fatigue, dyspnea and impaired skeletomuscular function.

Furthermore, physical health was related to self-care in HF patients in Britz and Dunn’s (2010) on the self-care deficit of HF patients. An interesting result showed that there was a significant relationship between self-care confidence and physical quality of life and emotional life. This result suggests that the better confidence in the physical ability is related to a better ability to manage the symptoms and improve the wellbeing among HF patients.

In order to improve the patients’ experiences with HF, identification of the variables predicting physical symptoms is essential. A total of 84 HF patients were studied and results showed that 95% of the sample experienced physical symptoms (e.g. dyspnea and fatigue) and 94% had functional impairment due to the symptoms. Also, it was showed that the physical symptoms were the most dominant HRQoL predictor, and it was strongly related to emotional symptoms, like depression and anxiety, which was considered to be a significant predictor of HF patient’s quality of life as will follow next (Heo et al., 2008).

In summary, patients’ routine activities are affected by the physical symptoms accompanying HF that causes a great limitation. Difficulties in housekeeping, carrying items, sexuality and other daily activities were discussed as undesirable experiences that HF patient faces on daily basis. In addition, self-care confidence and physical and emotional experience were significantly associated, as decline in confidence will worsen the ability to manage the physical and emotional symptoms related to HF. On the other hand, most of the literature agreed that NYHA classification is the most reliable tool to classify the extent of physical impairment in HF patients. In addition, psychological dimension is considered as important as the physical dimension as is shown in the studies presented in the following section.

2.4.3 Psychological Dimension

The psychological aspects of HF have been the focus of many investigators, specially depression and anxiety as a predictor of the emotional experience of patients living with HF (Sykes and Simpson, 2011). Along with the physical burden of HF on the patients, the psychological wellbeing is an important area of care that has its own effect on physical stability of the patients and vise versa (Heo et al., 2008).

Shen et al.’s (2011) study conducted to examine the depression and anxiety as a predictor of the decline in physical activity in HF patients over six months period. It was concluded that anxiety and depression and their worsening course were independent predictors in physical function of HF patients. Moreover, Britz and Dunn’s (2010) study showed a significant conclusion that emotional quality of life was strongly related to self-care confidence, as higher self-care confidence in managing HF symptoms results in a better emotional wellbeing.

Accordingly, emotional elements of HF symptoms have been found to be an important health care predictor of HF patients as supported by De Jong et al.’s (2005) study. Moreover, psychological variables including anxiety, vital exhaustion (fatigue, troubles falling asleep, apathy, general malaise, loss of energy, demoralization) and depression, were associated with higher readmission rates (Volz et al., 2011).

HF patients may develop depressive symptoms over time from being diagnosed with HF. In a study done to investigate the predictors of the onset of depressive symptoms in HF patients, the initial baseline information of 245 patients showed no depressive symptoms, while 52 had developed significant depressive symptoms in the follow up. Investigators found that living alone, financial problems associated with HF medical care, alcohol abuse, and HF related health status were the independent predictors of depression, as an increase in the number of risk factors in turn increases the depressive symptoms from 7.9% in patient without baseline symptoms, to 69.2% if patient is having three of the listed risk factors (Havranek et al., 2004).

As explained in the literature, depression and anxiety are common among HF patients, and they can affect the experience of patient living with heart failure in physical wellbeing, adhering to treatment, and self-care confidence. Nursing care should be linked to identification of those factors and early detection of the symptoms in order to plan the care according to HF physical and psychological needs.

In summary, psychological wellbeing is an important aspect of the patient’s experience with HF along with physical dimension, and both can disturb each other. Depression and anxiety are the most common psychological disturbances that HF patient experiences along with vital exhaustion, and all are related to a higher readmission rates. Living alone, HF treatment financial problems, alcohol abuse and health status due to HF considered as independent predictors of depression among HF patients, and increases in those predictors will consequently aggravate the depressive symptoms. Patient’s gender also plays a significant role in defining their symptoms and experience relationship with HF and will be explored in the coming section.

2.4.4 Age and Gender

The biophysiological and psychological status differences between men and women determine the impact of gender on living with HF. From an etiological aspect, the common cause of HF in men is underlying ischemia, while hypertension and diabetes mellitus are the main causes to develop HF in women (Heo et al. 2007). American Heart Association (AHA) heart and diseases statistics (2011 update) showed that at the age of 45 to 64 years, 8% of men will develop HF following MI, and 18% of women will, while in the 65 years group and above, 20% of men and 23% of women are suspected for HF related to MI. Moreover, HF incidence affects 10 per 1000 population after the age of 65 (Roger et al., 2011).

Robertson et al. (2012) studied the age and gender-specific rate index among Australian patients diagnosed with HF, results showed that the rate increases consistently with age and is higher in men than women in all age groups, while the length of stay was relatively longer for most of the age groups. The study disclosed that the typical patient in the study was aged over 75 years, likely to be a woman with two or more co-morbidities, which shows that the burden of the disease is in the elderly, and prevention is the controlling key.

Hou et al. (2004) published a study examining the differences in HRQoL among four groups of HF patients based on age (<65 and ≥65 years) and gender over 6 months. Outpatients were interviewed as a baseline and 26 weeks later. Results showed that women under the age of 65 years had the poorest HRQoL among all groups. Women’s poor quality of life was related to the higher rate of depressive symptoms and stressful life events that improved with the 6 month follow up. In contrast, a correlational study determined that there were no gender variances in physical and emotional symptoms, NYHA functional class, and HRQoL in the HF sample in the study. However, men’s HRQoL was strongly disturbed by depression, and more likely to be affected by physical symptoms in women (Heo et al., 2007).

Furthermore, the age and gender-specific risk of death in HF patients after first admission was studied through a nationwide cohort followed through linkage of national registries. The study showed that clear differences in age and gender risk of death in short and long term period. After the first hospitalization with HF, men represented a higher long and short-term risk of death than women, while the risk of death increases with age in the three periods in both men and women (Vaartjes et al., 2010). In addition, a study aimed to uncover the gender aspects on HF incidence and mortality, results showed that women are at lower risk of HF, and HF-related death on two decades follow up (Tasevska-Dinevska et al., 2009) , supporting (Vaartjest et al., 2010) study results.

In Summary, gender and age plays a significant role the patients experience with respect of the physical and emotional differences between the two genders and the differences presenting among each age group. Recognizing the differences by nurses and other health care workers is vital to plan age and gender-specific plan of care.

The literature showed some variations regarding the experience differences between men and women with HF, especially in regard to the physical and emotional experiences, as well as the admission rates and length of stay. An interesting result informed that men under the age of 65 years are experiencing emotional distress represented in depressive symptoms that are most likely to be related to physical symptoms. In addition, short and long-term mortality was higher in men than women, while the risk increases with age in both genders. Despite the differences in gender and age groups, social support is considered a cornerstone in exploring the patient’s experience with HF which will be enlightened in the next section.

2.4.5 Social Life (Support)

Social support was defined as "the presence or absence of emotional support, being able to count on someone with whom to talk over problems, and as instrumental support, being able to count on someone for help with daily tasks if needed" (Moser and Worster, 2000:108). Social support is fundamental for HF patients so that they can adjust with the chronic and irreversible health condition (Britz and Dunn, 2010). Lack of social support was associated with depression and anxiety, influencing the health of HF patients (Shen et al., 2011); and greater social support is associated with less depression (Bekelman et al., 2007).

Sayers et al. (2008) investigated the outcome of social support and self-care including medications and dietary adherence, as well as monitoring HF symptoms. 74 HF patients were recruited from cardiology clinics. Results confirmed that married patients showed an increase in self-care levels in the presence of a close partner (e.g. reminding of medications). Controversy, the research also showed that support from significant others led to lower self-care confidence.

In a literature review by Luttik et al. (2005), the importance of social support and its impact on the outcomes on HF patients was discussed. It was concluded that lack of social support was considered a significant predictor of readmission and mortality among HF patients. Moreover, good social support, particularly from spouse or partner, plays a huge effect on decreasing depressive symptoms. However, it seemed that there was no association between social support and quality of life .

Bennett et al. (2001) described the perceived social support during a baseline hospitalization with HF and 12 months later. Differences examination in social support with gender and sex, and examining the social support as HRQoL predictor was studied on 147 HF patients. The results of social support showed that many of the patients were receiving moderate to high social support. Furthermore, some patients had reported little or no social support at all, specifically in men under the age of 65 years.

It seems that the presence and absence of emotional support, the presence of someone to count on and help to carry on the daily living tasks are the elements of social support definition. The relationship between the social support and HF patients’ experience was not clearly presented in the literature. Also, it has been shown that the presence of friends and family or significant others who are involved in the care would certainly increase treatment compliance, management of symptoms, and adhering to dietary instructions.

On the other hand, social support might have a negative impact on HF patients, as in some cases it was reported that social support was perceived as overprotecting and undermining owns abilities of self-care. Despite the increasing number of HF cases worldwide, less attention was given to cognitive impairment (CI) than other symptoms and disabilities in HF (Clark and McDougall, 2006). Cognitive impairment among HF patients will be deliberated in the following section.

2.4.6 Cognitive Impairment

Cognitive Impairment in not just memory loss, it’s a complex entity that involves a number of deficits, especially decision-making functions, which affects the patient’s health outcomes. Furthermore, the cognitive Impairment interferes with the patient’s ability to recognize the worsening of the symptoms, adhering to the complex medications and seeking medical care when needed (Gaviria et al., 2011).

A number of studies were conducted to reveal the relationship between HF and cognitive Impairment and the possible effects on HF management. An Italian study by Trojano et al. (2003) compared the cognitive patterns of HF patients and cardiovascular patients whom are not complicated with HF (no- HF). Researchers concluded that the cognitive Impairment is common in HF patients and worsened along with NYHA class worsening, and its related as well with depression in HF as well as hypertension based on the different tests that were used . Vogels et al. (2007) conducted a similar study to determine the pattern and frequency of cognitive Impairment in outpatients with HF and pinpoint correlated demographic and clinical dimensions. Results supported Trojano et al.’s (2003) finding, however, the percentage of cognitive Impairment found was less as the sample were outpatients rather that hospitalized patients.

Another study by Debette et al. (2007) assessed the prevalence and causes of cognitive Impairment in hospitalized patients with HF. Results showed that 61% of the patients had cognitive Impairment and 31% had "overt" cognitive Impairment. Also, cognitive Impairment was frequent in HF patients whether they have a history of Cerebrovascular Accidents (CVA) or Transient Ischemic Attack (TIA) or not. Similar to Vogals et al.’s (2007) study, the sample consisted of hospitalized elderly patients representing advanced HF, and cannot be generalized as young and stable HF patients . In the matter of the effect of cognitive Impairment in elderly patients with HF, three Swedish researchers (Ekman et al., 2001)studied whether the cognitive Impairment was associated with poor participation in outpatient treatment program for HF patients and its relation to specific patient characteristics. Results concluded that cognitive Impairment is an important indicator of participating in nurse-directed treatment programs, and cognitive functions should be included in clinical evaluation in order to individualize the plan of care.

It seemsobviously? that in HF patients, memory and attention deficits are common cognitive Impairment symptoms that lead to difficulties in problem solving and slow motor response. Moreover, the prevalence of cognitive Impairment in HF patients was around 30% to 80% depending on the age and other characteristics of the patient’s sample. The connection between EF and cognitive Impairment was inconsistent, and the pathophysiology of cognitive Impairment in HF patients was either cerebral hypoperfusion or cerebral infarction, or both(Bennett and Sauve, 2003).

Overall, despite the importance of assessing the cognitive Impairment among HF patients and how it affects their experiences with the syndrome, less attention was given to this subject. Management of HF depends highly on self-detection of worsening of the symptoms and adhering with the treatment, with the presence of cognitive Impairment the ability of decision-making functions will be affected. The literature revealed that the worse the HF classification correlates to the worsening in the cognitive Impairment symptoms. Therefore, nurses should be aware of the importance of clinical evaluation of cognitive abilities of HF patients in order to plan the care and involve others in the management plan.

2.5 Living with HF: Qualitative Studies

With the increasing number of HF patients, and increasing demands of life modifications that are requested from HF patients to adopt, its important to reveal the meaning of experiencing and living with HF from patient’s perspective in order to plan the changes. Qualitative research aims to describe in-depth the people events, researchers explore the patterns and themes of the collected data rather than testing hypothesis (Nieswiadomy, 2008).

A qualitative interpretive phenomenological study exploring the experience of living with HF conducted by Thornhill et al. (2008). The data collected using in depth semi-structured interviews revealed four major themes: (I) Diagnosis process, (II) The change, (III) Role of others, and (IV) Emotional reaction. The diagnosis theme expressed patient’s experiences with identifying the symptoms of the disease, seeking medical help and accepting the diagnosis with HF. The second theme was the change of activities and lifestyle following the diagnosis of HF, as well as change of work and changes in self and identity. The role of others described the relationship with others after being diagnosed with HF and their role in improving the experience of living with HF. Lastly; the emotional reaction theme explored the participants’ different reactions. Negative reaction occurred when they recognized that their life would change permanently, they were sad, annoyed and feeling low. On the contrary, other participants viewed the disease as a starting point for life-style changing and self-improvement.

A focus group study conducted by Bosworth et al. (2004) found that the constituents of quality of life as described by patients with HF. The themes included symptom’s negative burden, role loss, affective responses represented in depression and anxiety, fear, low self-worth and guilt. Coping theme included the positive and negative coping, and the last theme was the social support and its effect on patient’s experience with HF. Rogers et al.’s (2000) study aimed to explore the patients’ understanding of HF in order to explore their communications and information needs and two main domains were identified. The first domain was the knowledge about HF, most of the patients lack the information about why they developed HF, and were interested in knowing the nature of the illness and the possible prognosis. The second domain was the barrier to ask questions, as patients expressed difficulties in communication mainly with their doctors.

Westlake and Dracup’s (2001) phenomenological study described the role of spirituality in the adjustment with HF. The themes consisted of the feeling of regrets about the past lifestyles and ideas of regret that the past behavior caused the HF. The second theme was the patient’s desire to look for the meaning and the purpose of experiencing HF. The last theme was searching for hope and being optimistic as a third step of adjustment. Hope among patients was mostly found in spiritual beliefs, confidence in medical treatment and social support. The study confirmed the importance of maintaining the hope, viewing the future optimistically and this can be achieved by cognitive behavioral therapy and support in order to adjust with HF.

A review of qualitative studies was done by Jeon et al. (2010) to find the studies conducted concerned with the experience of living with chronic HF. The results showed that under the impact of HF on everyday life, social isolation was a key concept in the literature found. Social isolation arises from the lifestyle modifications, medications, physical restriction and fear. Relocation to nursing home was a significant result of loss of control in a phenomenological study due to the loss of independence. On the other hand, sharing experiences with peers, adapting to the changes in the circumstances accompanying the disease, were the most common finding of coping with HF. Being religiously inspired and maintaining faith was covered in a limited number of studies. The last theme is the factors affecting self-care. This theme showed that insufficient information led to poor outcomes, anxiety, frustration, unrealistic and ambiguity about expectations. Personal relationships were covered by 26 studies in the review, reporting the unavoidable changes in family role and relationship with others, that indeed affecting the individual’s self care and management of the disease.

Hopp et al.’s (2010) systemic literature review addressed the need for more studies concerned with information about the experience of living with HF and drawing the strategies of coping. Thematic qualitative studies exploring the lived experience of HF were reviewed and two dominant themes were illustrated, the challenges related to HF and methods coping with it. These challenges were summarized from the studies concerned with the involvement of formal healthcare system and social services, disturbance of life and activities, social isolation, loss of friendships, physical and psychological symptoms burden, feeling of uncertainty about living with HF and inability to plan the life due to the accompanying symptoms. The second theme, coping resources, focused on the management of the condition, adjusting to live with HF, coping through social support system and finally dealing with end stage process.

???In summary, the qualitative studies and reviews were aiming to fully understand the living experience of HF patients from different perspective. The most important themes were concerned with the symptoms burden on the patients’ daily life, social isolation, lose of role and productivity and the coping mechanism used by HF patients. Other themes were concerned with communication gap existed between HF patients and healthcare workers and its effects on patient’s experience with the condition and the management. Coping was found to be one of the main focuses of the studies concerned with the patient’s experience.

Gender plays a significant role in shaping the health behavior, specifically in the decision of being engaged with the healthcare system (Liburd et al., 2007). (bring this up) Masculinity was a subject of studies concerned with identifying the factors affecting men involvement in health care. With the different models of masculinity, generally its defined as the common understanding of what is the meaning of being a man, in how to behave, to look like, and so forth, and influenced by the sociocultural context that defines the masculinity (Liburd et al., 2007, Gibbs, 2005). O’Brien et al. (2007) had interviews fifty-nine men in 15 focus groups, and 9 individual interview in order to study men’s experience with chronic illness (coronary heart diseases (CHD), testicular or prostate cancers, depression) in relation to masculinity. In concern with CHD patients, result showed that issues with men’s identity was disturbed immediately after the diagnosis, and affected by being diagnosed with life-threatening disease, as well as the social challenge as the men will be engaged in different social activities in order to rebuild their identity. A second research was conducted to explore the experience of men with chronic condition (arthritis) and the impact on joining self-management programs. The results of the interview showed a number of factors affected men’s access to the self-management program, including structural, conceptual and sociocultural factors. They author stated that the issue of masculinity was dominating in the men experiences and their discussion regarding the decision making in relation to the health services (Gibbs, 2005).