Denial in Coronary Heart Disease And Nursing Care

Afza.Malik GDA

Nursing Care and Denial Coronary Heart Disease

Denial in Coronary Heart Disease And Nursing Care

Denial in Coronary Heart Disease,Denial As A Psychological Ability Of And Individual ,Health And Unhealth Denial ,Denial And Coronary Disease, Use of Denial In Coronary, RSAI and Assessment ,Using RSAI.

Denial in Coronary Heart Disease

    Coronary heart disease, and the experiences associated with it, precipitate many sudden changes that severely disrupt the balance of psychosocial and environmental factors in an individual's life. 

    Those who experience these changes use various resources such as denial in an attempt to cope with the anxiety caused by the various types of threatened or real losses associated with the disease ( Cassem & Hackett, 1971; Ketterer et al., 1998; Robinson, 1988 , 1993, 1994, 2003).

Denial As A Psychological Ability Of And Individual 

    Denial is the ability of an individual to mentally ignore or push from one's consciousness the reality of the situation at hand. It is one of the first adaptive behaviors or mechanisms that an individual uses during the stress-producing event of an acute episode of chest pain (Hackett & Cassem , 1982). 

    Through this defense mechanism, the individual attempts to minimize or ignore the significance of the symptoms. For coronary patients, it is not difficult to use denial as a form of coping because once the pain has been alleviated and the person is resting comfortably, there are no other symptoms. 

    As a result, it is easy for the patient to rationalize or deny that anything significant has happened.

Health And Unhealth Denial 

    Denial can be either healthy or unhealthy. Denial of the fact that a coronary event has occurred can be adaptive behavior during the first few weeks of recovery, enabling the person to cope with the shock and confusion. 

    However, this denial can be maladaptive if it interferes with one's ability to deal with the lifestyle changes needed to recover from the acute phase of the illness ( Cassem & Hackett, 1971; Robinson, 1993, 1994). 

    That is, prolonged denial or disbelief might cause the individual to ignore necessary activity restrictions, fail to take prescribed medications, or realize the significance of the illness. The problem then becomes one of understanding when denial is helpful to the coronary patient and when it is harmful.

Denial And Coronary Disease

    Given that coronary events result in numerous real and threatened losses, and all loss, whether real, threatened, or perceived, produces a grief response (with denial, shock, and disbelief being the initial response) ( Engel , 1962), it becomes necessary to work through the grief process. 

    However, this process should not be prolonged, since movement from denial to the next phase of the grief process might have a long range effect on one's ability to work through the losses and changes in lifestyle caused by having coronary problems. 

    Since denial does not represent a single, easily understood phenomenon, it is often difficult to determine if denial is adaptive or maladaptive.

Use of Denial In Coronary

    The use of denial by coronary clients is described extensively in the literature. However, little attention has been given to measure it. In addition, clues that coronary clients are using denial may not be recognized through personal interviews or traditional assessment methods. 

    Therefore, the Robinson Self Appraisal Inventory (RSAI), a self report assessment instrument, was designed to identify denial in persons with coronary heart disease, quantify it, and aid in its further study (Robinson, 1988, 1994, 2003). It could also assist health care professionals to plan interventions to manage denial.

RSAI and Assessment 

    The RSAI has been under development for approximately 10 years. Earlier studies led to revisions and reconceptualization's (Robinson, 1988), which have resulted in Form.

    D. Even though the Hackett Cassem Denial Scale was available for measuring denial, the number of items on the scale regarding patients' personality traits and behaviors were not related to coronary heart disease and the general use of denial as a defensive trait. 

    An additional weakness of this measurement was that the nature of several questions in the scale required the interviewer to make inferences when rating denial behavioral characteristics of the participant; it was not a paper-and-pencil self-report (Hackett & Cassem , 1974). 

    Rather than measuring traits, the RSAI directly focuses on the patients' present reactions to illness and it is designed as a paper-and-pencil, self-administered instrument.

Using RSAI

    Using the RSAI-Form D, Robinson (1994) found a significant decrease in mean denial scores from the 2nd to the 4th hospitalized day of potential or actual myocardial infarction patients. 

    These findings were consistent with those reported by Cassem and Hackett (1971), who stated that feelings of denial are generally mobilized on the 2nd day; however, by the 4th day as the patient's condition stabilizes, denial decreases. 

    Factor analysis indicated that the 20-item RSAI- Form D probably is a multidimensional measure; however, a larger sample is needed with the addition of items to the scale to make the final determination.     

Four aspects of denial were extracted to include denial of secondary consequences, denial of illness and treatment, denial of anxiety, and denial of impact; thus, providing supportive evidence to the healthcare professional that using single specific or global criteria does not provide sufficient data for assessing denial.     

Some individuals may use one type of denial, whereas others may use another type. Each type of denial has its own purpose for the person. 

    Therefore, it is beneficial for the health care professional to observe and listen closely to patients to understand their perspective as well as determine the type of denial that is being utilized (Robinson, 1994).

    In summary, denial makes it possible for cardiac patients to block out information with which they cannot cope. It allows them to deal with reality in smaller, more manageable pieces. Denial can be adaptive, so instead of trying to push the patient out of denial before they are ready, one can assist them in adjusting to the loss.     

The nurse can determine the patient's degree of denial and its effectiveness as a coping strategy, listen closely to the patient, use counseling strategies, provide the patient with opportunities to express any fears, and should not directly confront the patient's denial.     

However, if the denial is maladaptive, the nurse should not directly confront the patient's denial, but rather focus on establishing a trust relationship with the patient, use reality focusing techniques, utilize teaching strategies, and provide a psychological professional to meet and discuss the diagnosis with the patient (Robinson, 1993).

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