Clinical Reviews
Clinical Reviews
With Comments from Lynn Keegan, RN, PhD, HNC, FAAN
Hostility and Coronary Artery Calcification
Source: Iribarren C, et al. Association of hostility with coronary artery calcification in young adults. JAMA 2000;283:2546-2551.
Context: Psychosocial factors may play a role in the development and expression of coronary artery disease. Several mechanisms have been proposed to explain why hostility may increase cardiovascular risk, including unhealthy lifestyle behaviors and cynical distrust.
Objective: To evaluate whether hostility is associated with coronary artery calcification, a marker of subclinical atherosclerosis.
Design: Prospective cohort study.
Setting and Participants: Volunteer subsample from Chicago, IL, and Oakland, CA, consisting of 374 white and black men and women, aged 18-30 years at baseline, who participated in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Cook-Medley hostility assessment data were collected at baseline (1985-1986) and at year 5 examinations (1990-1992). After the 10-year examinations (1995-1996), electron-beam computed tomographic scans were performed.
Main Outcome Measures: Presence of any detectable coronary artery calcification (coronary calcium score > 0), and coronary artery calcium scores of 20 or higher.
Results: In logistic regression analysis adjusting for age, sex, race, and field center, comparing those with hostility scores above and below the median of the distribution of the present sample, the odds ratio (OR) of having any coronary calcification was 2.57 (95% confidence interval [CI], 1.31-5.22), and the OR of having a calcium score of 20 or higher was 9.56 (95% CI, 2.29-65.9). The associations with any coronary artery calcification persisted after adjusting for demographic, lifestyle, and physiological variables. Results using a cynical distrust subscale were somewhat weaker than for those using the global hostility score. Power was inadequate to perform sex- or race-specific analyses.
Conclusion: This population-based study in young adults demonstrates a positive graded association between hostility scores at baseline and coronary artery calcification. These results suggest that a high hostility level may predispose young adults to coronary artery calcification.
Comment: The results of this study are consistent with the hypothesis that hostility may contribute to the development of coronary atherosclerosis not only through poor health habits, but also via other physiological mechanisms. Even though the statistical power was not great enough to generalize to sex or race, these results have important clinical implications for nurses and their patients.
Caring for Depressed Clients
Source: Mullaney JA. The lived experience of using Watson’s Actual Caring Occasion to treat depressed women. J Holist Nurs 2000;18:129-142.
Context: Each year, 19 million patients are treated for depressive episodes that last six to 12 months, and major depression is diagnosed twice as often in women as in men. The annual economic cost of depression is $16-43 billion.
Objective: To describe the essential structure of the lived experience of depressed women who enter therapy and experience Watson’s actual caring occasion (ACO) within the transpersonal caring relationship (TCR). (Many nurses practice from Jean Watson’s theoretical framework using the actual caring occasion. The ACO occurs when the nurse enters the patient’s phenomenal field, detects the patient’s condition of "being," and feels it within her own self-system. This event allows the nurse to respond vicariously and/or intervene so that the patient’s pent-up feelings and thoughts are shared and released. Key to this process is the replacement of negative feelings with healthy, positive ones. Thus, in ACO, the nurse and patient, together with their unique life histories and phenomenal field, interact in a human care transaction.)
Design: A phenomenological study following Spiegelberg’s research method of inquiry which seeks to uncover, analyze, and interpret the meaning of the lived experience.
Setting and Participants: A purposive sample of 11 depressed women, including one African-American and 10 Caucasians aged 30-48 years. All women were identified as experiencing a single episode of major depression according to DSM IV criteria.
Main Outcome Measures: Spiegelberg’s method was used for data analysis of 110 pages of therapist notes transcribed verbatim.
Results: Five essential themes emerged from data analysis of the diagnostic interview.
1. Despite the emotional pain and difficulty of sharing their feelings with a stranger in the initial interview, subjects felt understood, a process that enhanced their trust.
2. Subjects felt not only empowered for the first time since the depression set in, but also that there was a way out of the "dark abyss" of powerlessness, hopelessness, and depression.
3. As subjects became more reflective, they increased their sense of inner power, control, and empathetic perspective.
4. Although subjects expressed negative feelings like rage and self-loathing, their ability to do so enabled self-acceptance and revelation.
5. Subjects felt better and described engaging in behaviors that illustrate effective problem solving and healthy lifeways.
All 11 women stated Watson’s ACO caused them to persist in treatment and adopt health-seeking behaviors.
Conclusion: This finding supports the expense of appropriate clinician time for holistic healing in the transpersonal caring relationship.
Comment: This small study serves to remind nurses of the importance of having a caring attitude and approach to all patients and, in particular, depressed patients. Perhaps this investigation will stimulate interest in finding and incorporating other aspects of caring in all patient encounters.
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