I have my Evidence Based Practice paper due Saturday November 17 2018 and I need help with that. Attached is the instructions to follow with the article to be used thank you

ORIGINAL RESEARCH:

EMPIRICAL RESEARCH—QUALITATIVE Understanding patients and spouses experiences of patient education following a cardiac event and eliciting attitudes and preferences towards incorporating cardiopulmonary resuscitation training: A qualitative study Susie Cartledge 1,2 | Susan Feldman 3 | Janet E. Bray 1,2,4 | Dion Stub 1,2,5,6 | Judith Finn 1,4 1Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia 2Alfred Hospital, Melbourne, Vic., Australia3School of Primary Health Care, Monash University, Melbourne, Vic., Australia 4School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, WA, Australia 5Cabrini Hospital, Melbourne, Vic., Australia6Baker IDI Heart and Diabetes Institute, Melbourne, Vic., Australia Correspondence Ms Susie Cartledge, Monash University, Melbourne, Vic., Australia.

Email: [email protected] Funding information SC is supported by postgraduate scholarships funded through the National Health and Medical Research Council (NHMRC) (#1114966) and the Australian Resuscitation Outcomes Consortium (Aus- ROC) Centre of Research Excellence (CRE) (#1029983, www.ausroc.org.au). JB and DS are supported by co-funded NHMRC/ National Heart Foundation Fellowships (#1069985/100136 and #1090302/ 100516). DS is supported by a Viertel Clinical Investigator Grant.` JB and JF receive salary support from the NHMRC Aus-ROC CRE. JF receives salary support from St John Ambulance Western Australia. Abstract Aim:The aim of this study was to gain a comprehensive perspective about the experience of patient and spousal education following an acute cardiac event. The second objective was to elicit an understanding of patient and spousal attitudes, preferences and intentions towards future cardiopulmonary resuscitation training.

Background:Patients with cardiovascular disease require comprehensive patient and family education to ensure adequate long-term disease management. As cardiac patients are at risk of future cardiac events, including out-of-hospital cardiac arrest, providing cardiopulmonary resuscitation training to patients and family members has long been advocated.

Design:We conducted a qualitative study underpinned by phenomenology and the Theory of Planned Behaviour.

Methods:Semi-structured interviews were conducted with cardiac patients and their spouses (N=12 patient-spouse pairs) between March 2015–April 2016 purpo- sively sampled from a cardiology ward. Interviews were transcribed verbatim and thematic analysis undertaken.

Findings:Nine male and three female patients and their spouses were recruited.

Ages ranged from 47-75 years. Four strongly interrelated themes emerged: the emotional response to the event, information, control and responsibility. There was evidence of positive attitudes and intentions from the TPB towards undertaking car- diopulmonary resuscitation training in the future. Only the eldest patient spouse pair were not interested in undertaking training.

Conclusions:Findings suggest cardiac patients and spouses have unmet education needs following an acute cardiac event. Information increased control and decreased negative emotions associated with diagnosis. Participants’preferences were for inclu- sion of cardiopulmonary resuscitation training in cardiac rehabilitation programs.

KEYWORDS coronary heart disease, critical care, nursing, patient teaching, phenomenology, qualitative approaches Accepted: 17 December 2017 DOI: 10.1111/jan.13522 J Adv Nurs.2018;74:1157–1169. wileyonlinelibrary.com/journal/jan©2018 John Wiley & Sons Ltd |1157 1 | INTRODUCTION Cardiovascular disease (CVD) is a significant cause of illness, disabil- ity and premature death, affecting 22% of Australian adults (Aus- tralian Institute of Health and Welfare, 2013). While there have been many advances in the medical management of CVD, it is essen- tial that patients also take an active role in disease management.

This includes managing medications, recognising future symptoms and participating in aggressive risk factor modification (Chew et al., 2016). For this to occur, comprehensive patient and family education is required, beginning in the acute hospital phase through to sec- ondary prevention outpatient programs such as cardiac rehabilitation (Chew et al., 2016). Patient education is a component of guideline standard care with patients themselves identifying that receiving information after an acute cardiac event is of high priority (Blair, Volpe, & Aggarwal, 2014; Gentz, 2000; Moser, Dracup, & Marsden, 1993; Thompson, Ersser, & Webster, 1995).

A proposed topic of education for cardiac patients and family members has been cardiopulmonary resuscitation (CPR) training. This is due to the risk of repeat events for cardiac patients, including in the most extreme form, cardiac arrest. Australian data suggests that nearly 50% of cardiovascular events occur in people who have coro- nary heart disease (Briffa et al., 2011). The risk of cardiac arrest in those with clinically recognised heart disease has been quantified as seven times greater than the general public (Rea et al., 2004). As most cardiac arrests occur in private residences, of which half are witnessed (Ambulance Victoria, 2017; Benjamin et al., 2017), family members of cardiac patients have been identified as a logical target group for CPR training. Targeted training to this group is further supported by the International Liaison Committee on Resuscitation who have included this as a recommendations in their guidelines since 2010 (Soar et al., 2010).

While this is a worthy and important recommendation, there is a paucity of qualitative data from the target population—that is car- diac patients and their family members, on the contemporary experi- ence of education following a cardiac event and the role and place of CPR training in this education.

2 | BACKGROUND Nurses are a crucial provider of patient education, from the hospital setting through to secondary prevention (Campbell, 2009). As such it is important that nurses have an understanding of both patients’and spouses’perceptions and experiences of patient education, particu- larly in the contemporary Australian cardiology setting which is char- acterised by rapid treatment pathways and decreasing lengths of hospital stay. Currently the inpatient stay for an acute coronary syn- drome admission is a median of 4 days (Chew et al., 2013). This is not only isolated to Australia, with some countries in Europe having similar short lengths of hospital stay (Wilkins et al., 2017). While there is recent international evidence about the experiences of car- diac patients (Esmaeili, Cheraghi, & Salsali, 2016; Fors, Dudas, &Ekman, 2014; Hasankhani et al., 2014), their educational experiences are largely unknown. The only qualitative study to specifically explore the information needs of cardiac patients was conducted over a decade ago (Hanssen, Nordrehaug, & Hanestad, 2005). This study, conducted in Norway found that there was a failure to meet patients’educational needs both in-hospital and after discharge. Why is this research needed?

●As length of hospital stay following an acute cardiac event is decreasing, this study provides contemporary data on the education experience of cardiac patients and spouses.

●While cardiac patients and their spouses are a logical group to be trained in cardiopulmonary resuscitation, there is a paucity of qualitative data on their attitudes, preferences and intentions towards cardiopulmonary resuscitation training.

●Having a better understanding of the experience of patient education following an acute cardiac event and preferences towards cardiopulmonary resuscitation train- ing allows future education and training interventions to be tailored to the needs of this group.

What are the key findings?

●Cardiac patients and spouses experienced a complex range of emotions following an acute cardiac event and described unmet education and information needs.

●Most patients and spouses had positive attitudes towards cardiopulmonary resuscitation and strong inten- tions towards undertaking cardiopulmonary resuscitation training in the future.

●Preferences were for cardiopulmonary resuscitation training to be included in a cardiac rehabilitation program.

How should the findings be used to influence policy/practice/research/education?

●New strategies for effective patient and family education are urgently required due to decreased length of hospital stay and thus decreased opportunities for nurses to pro- vide education.

●Cardiac patients and their spouses are interested in car- diopulmonary resuscitation training and therefore con- versations and education about cardiopulmonary resuscitation training should be incorporated into patient and family education early in recovery.

●Consideration should be given for cardiac rehabilitation programs to include CPR training into their programs where possible and appropriate. 1158 | CARTLEDGE ET AL . Local contemporary data which also includes the spouse, in the set- ting of decreasing length of hospital stay is essential to provide patient and family education in a way that responds to modern healthcare challenges.

In addition to disease management education, CPR training has long been advocated for cardiac patients and their family members (Goldberg, 1987) with the most recent study investigating the provi- sion of CPR training to cardiac patients and spouses before hospital discharge (Blewer et al., 2016). There have been many other quanti- tative studies examining methods and locations of targeted CPR training (Dracup, Heaney, Taylor, Guzy, & Breu, 1989; Haugk et al., 2006; Schneider et al., 2004). These studies investigated outcomes such as skill acquisition, subsequent use of skills, willingness to use skills and anxiety levels related to training. However, there has been a paucity of qualitative data examining the attitudes and preferences of the target population which could then be used to inform and tai- lor future interventions.

The appropriate theoretical framework to gather qualitative data surrounding attitudes, preferences and to understand the experience of patient education is phenomenology. Phenomenologists endeavour to look for meaning by taking note of what and how an individual observes, hears and understands. This they achieve by carefully describing the actions of others and as such ask how as a researcher they can then interpret and understand these ordinary events and actions (Schwandt, 2007). In this way, our phenomenological study dif- fers from previous quantitative studies which collected empirical data around targeting CPR training for cardiac patients and their family members (Blewer et al., 2016; Cheng, 1997; Dracup et al., 1989).

In addition, to gather data on intentions towards undertaking future CPR training post an acute cardiac event the theory of planned behaviour (TPB) (Ajzen, 1991) (Table 1) is appropriate. The theory proposes to predict intentions to perform behaviours by examining: (1) attitudes towards the behaviour; (2) the social pres- sures (subjective norms) to undertake the behaviour and (3) per- ceived behavioural control—that is the participants beliefs as to how easy or difficult performing the behaviour is likely to be. The TPB has been successfully applied to behaviours under volitional control (in our case CPR training) and thus has successfully been applied to many health research applications (Godin & Kok, 1996), including the intention to undertake CPR training in one previous study (Vaillan- court et al., 2014). This study investigated the attitudes and inten- tions of CPR training by a general older population, aged over 55 years. Using the TPB, Vaillancourt et al. (2014) found positive intentions towards CPR training and facilitators that could increase training in this population. However, intentions of a specific cardiac population are yet to be explored in the literature.

3 | THE STUDY 3.1 | Aims The purpose of this study was to firstly gain a comprehensive per- spective about the experience of patient and spousal educationfollowing an acute cardiac event. The second purpose was to elicit an understanding from cardiac patients and their spouses of their attitudes, preferences and intentions towards future CPR training. 3.2 | Design This was a qualitative, interview study underpinned by phenomenol- ogy and using TPB to examine intentions towards undertaking CPR training in the future. Combined, these two theoretical approaches allow for a more complex understanding of patients’and spouses’ lived experiences of patient education and their attitudes, prefer- ences and intentions towards the inclusion of CPR training in patient education following an acute cardiac event. In this qualitative study a phenomenological approach generated important knowledge for nurses and healthcare professionals so that they might gain a more comprehensive understanding and be able to plan and tailor future education interventions for patients and family members alike. This study is part of a targeted CPR training program of research and was used to inform an interventional feasibility study (Cartledge et al., 2017).

3.3 | Participants, setting and recruitment Between March 2015–April 2016, a purposive sampling strategy was used to recruit a heterogeneous sample of 12 cardiac patients and their spouses or partners. Sex and age of patients were considered in the sampling strategy as CVD is more likely to affect men (4% vs.

2% of women) and older age groups, (occurring more frequently from 55 years old) (Australian Institute of Health and Welfare, 2014).

Participants were recruited from the cardiology ward of a large metropolitan tertiary hospital in Melbourne, Australia. This hospital receives both metropolitan (80%) and rural (20%) patients. Daily screening of cardiology inpatient lists was used to identify eligible patients who were aged over 18 years, English speaking, had chest pain associated with a confirmed troponin rise, lived permanently with a spouse or cohabitant and had planned outpatient follow-up appointment at the same hospital. Eligible spouses or cohabitants were required to be over 18 years and English speaking.

TABLE 1The theory of planned behaviour (1) Behavioural beliefs Effect on intent Attitude towards the behaviour; positive or negative support towards undertaking the behaviour (2) Subjective norms Effect on intent The social pressure towards undertaking the behaviour (3) Control beliefs Effect on intent and behaviour The facilitators and barriers towards performing the behaviour which can also reflect on past experiences of the behaviour CARTLEDGE ET AL . |1159 Inpatients from the recruiting hospital are similar to those described in the Australian SNAPSHOT ACS study (Chew et al., 2013). The median length of hospital stay at the recruiting hospital is slightly less (median 3.8 days vs. 4.1 days). It is the practice of the recruiting hospital that all patients with confirmed acute coronary syndrome should receive a referral to a local cardiac rehabilitation program, however, like in the SNAPSHOT study this does not always occur. During the study period the study site was also trialling a new resource;“My Heart, My Life”from the National Heart Foundation of which all confirmed ACS patients received in hard copy (National Heart Foundation of Australia, 2015). This resource is a practical guide to managing heart health and is also available as a mobile phone application, which some patients may have also chosen to download.

After gaining permission from nursing staff, eligible patients were approached by an investigator (SC) who was not involved in the patients care. Information about the study was provided to the patient and spouse (if present) and if interested in the study, partici- pant information and consent forms were provided. After allowing time to read the information and ask questions, consent forms were signed. Arrangements were then made to undertake the interview on the same day as the patients’first outpatient appointment. 3.4 | Data collection Four types of data were collected: clinical data, survey data, inter- view data and field notes. After consent was obtained, basic clinical data were extracted from the patients’inpatient medical record. A short pre-interview questionnaire (supplemental materials) was com- pleted by both patients and spouses. This included demographic information such as country of birth and level of education not avail- able in the medical record and prior CPR training status. All partici- pants were assigned a study number and were offered to self-select a pseudonym.

A semi-structured interview schedule was developed by two investigators (SC, SF), informed by previous research (Hanssen et al., 2005; Vaillancourt et al., 2014) and approved by the co-authors.

Questions were open-ended and included a“warm-up”question which asked patients to describe the reason for their hospital admis- sion. This was followed by open ended questions about education experiences, attitudes and preferences towards CPR training and plans for cardiac rehabilitation. The interview guide is outlined in Table 2.

Interviews were conducted by an investigator (SC) at the patients’first outpatient cardiology appointment, which typically occurred 4-6 weeks posthospital discharge. Most interviews were conducted within or as close as possible to this time frame. All inter- views were face to face, with the exception of one rural patient— spouse pair which was conducted via Skype. Interviews were con- ducted in a hospital (N=8), in private cardiology consulting rooms (N=1), at a community centre (N=1) and at a private residence (N=1), all in a private room, away from clinical or busy areas.To complement the interviews, three different forms of field notes were kept (by SC) during the interview process: (1) short notes made at the time of the interview; (2) a fieldwork journal and (3) a running sheet outlining preliminary ideas and themes as each inter- view was completed. The fieldwork journal recorded thoughts, prob- lems and ideas that arose and was completed within 12 hours of each interview for maximum recall.

Interviews were audio recorded and then transcribed verbatim by one investigator (SC). Once the initial three interviews were com- plete, two investigators (SC, SF) reviewed the transcripts to assess the quality of the interview questions and to discuss interviewing techniques. Following this review an additional interview question was added to the schedule so as to capture the thoughts of those participants not interested in participating in CPR training. 3.5 | Ethical considerations This study was approved by Alfred Hospital (72/15) and Monash University ethics committees (CF15/794–2015000359).

3.6 | Data analysis Recruitment of new participants into the study ceased once analysis of the transcripts indicated that there were no new themes or ideas emerging from interviews. On completion of each interview typed transcripts were read to identify and record recurring themes exam- ining the data from a phenomenological perspective, in addition to TABLE 2Interview guide Topics or questions asked Opening Re-introduction of interviewer. Explanation of interview process. Opportunity to ask questions Warm-up questionCan you please tell me why you were in hospital on XX date?

Education questionsWould you like to talk to me about the patient education you have receive during and since your admission?

Can you please tell me if you received any information on what to do in the following emergency Your spouse/partner experiences chest pain?

Your spouse/partner collapses?

CPR specific questionsWould you be willing to learn cardiopulmonary resuscitation skills?

Would you want CPR? Under what circumstance would you want CPR?(Question added after three interviews) If so, what are your preferences for when in your recovery period you would like to learn, where and modality?

Cardiac rehabilitationAre you planning on attending cardiac rehabilitation? 1160 | CARTLEDGE ET AL . incorporating the TPB for all data discussing or related to CPR train- ing. This analytical strategy was applied to all interviews until no fur- ther participants were recruited into the study and all interviews were completed (Grbich, 1999; Hansen, 2006).

Following established conventions of thematic analysis, the initial process of engaging with the qualitative data was an iterative one, which involves repeatedly moving between the different stages of research—from data collection to transcription, reading, reflecting and interpretation (Grbich, 1999; Hansen, 2006). Analysis of all of the qualitative interview data was undertaken by one investigator (SC), who conducted and transcribed all interviews and was therefore immersed in the data. Data were coded and themes identified follow- ing established processes by Grbich and Hansen (Grbich, 1999; Han- sen, 2006). First, audio of transcribed interviews was played so as the transcription could be checked and any other auditory information could be noted on the transcript, such as anger, laughter or crying.

Second, transcripts were then re-read, important sections of text underlined and thematic codes developed. Themes from CPR training data were examined and if applicable, were categorised according to the constructs of the TPB. Thirdly, codes were then sorted and refined using several processes such as reflection, re-reading and re-listening to interviews. This provided the opportunity for further reflection and finding new insights. Field notes were also reviewed during this period as an additional tool for reflection. These notes included documenta- tion of the mood of the participants, body language and atmosphere of the interview. Mind maps were then used as a visual representation of themes, which allowed the researchers to begin considering codes, overarching themes and their relationship (Braun & Clarke, 2006).

During this process, regular review of transcripts and discussion of themes was conducted with a second investigator (SF). Finally, major themes were identified along with interconnecting sub themes and transcripts were marked up and colour coded by hand. Discussion of key themes and presentation of data rich transcripts was conducted with the research team at regular intervals.

Clinical and questionnaire data were used to give a better under- standing of the profile of the participants. Using this data, a further step of data analysis was also initiated—the development of a matrix to explore the pattern of themes. Pre-identified categories were examined: sex of patient, age of participants, support level of rela- tionship, clinical acuity and overall patient education experience (positive or negative). Where categories had commonalities of themes, these are reported below.

3.7 | Rigour Qualitative researchers are“active participants in the research pro- cess”(Hertz, 1997, p. viii) bringing personal values, beliefs and expe- riences (Hamberg, Johansson, Lindgren, & Westman, 1994; Hewitt, 2007). In addition, self-reflection and reflexivity are vital components to achieve high quality data analysis and findings. In other words, views of and choices a researcher makes has an impact on the research questions, theoretical framework, data collection and how these data are analysed (Grbich, 2013).In this research, the interviewer (SC) was a practitioner- researcher, being both a specialist cardiothoracic nurse and a CPR instructor with experience and knowledge of the field. In addition, the interviewer also has experience as a researcher and has under- taken training in qualitative research and interviewing techniques.

Rapport was easily developed with participants due to the inter- viewers’extensive professional experience with this patient group.

Once rapport and trust had been established it was possible for the researcher to pose probing questions regarding attitudes and prefer- ences towards CPR training (Table 2). While it was possible that par- ticipants were likely to assume that the interviewer had strong beliefs about the topics under discussion, the interviewer did not offer her own opinions during the interviews. Both the fieldwork journal and regular research team meetings provided additional data and also allowed the interviewer to reflect on the process of each interview. We have further addressed rigour of this study through undertaking this process of critical reflexivity, in addition to purpo- sive sampling techniques and our transparent and detailed descrip- tion of the methods and data analysis (Hansen, 2006). 4 | FINDINGS 4.1 | Sample characteristics During recruitment, 120 patients were screened to assess study eli- gibility. Common reasons for exclusion were patients living alone, English as a second language or having a follow-up appointment elsewhere due to being private or rural patients. Twenty-four patients were approached, six refused and six were unavailable to participate. Of the 12 patients enrolled, nine were male, three were female with an average age of 62 years (range 47–75 years) (Tables 3 & 4). All participants were in heterosexual relationships of married or de-facto (hitherto referred to as spouse) status. Five patients each suffered a ST-elevation myocardial infarction (STEMI) or a non-ST elevation myocardial infarction (NSTEMI) and two patients were diagnosed with Takotsubo cardiomyopathy. On aver- age, interviews were conducted 7 weeks postdischarge (range 1–12 weeks) and were of 32 minutes duration (range 21–63 min).

Analysis of the interviews indicated that there were recurring themes particularly related to the acute cardiac event. Through their discussions and reflections, on experiences of the patient education they had received from symptom onset to the day of interview, four related key themes were identified from the interviews: the emo- tional response to the event, information, control and responsibility.

In addition, the attitudes and intentions towards CPR training, in relation to the participants’experience of patient education, are pre- sented.

4.2 | Emotional response to an acute cardiac event Participants reflected on their acute cardiac admission and trajectory of recovery and described a complex range of emotions linked to these events. This description provides important context to the CARTLEDGE ET AL . |1161 experience of an acute cardiac event and thus affects how partici- pants would receive and interpret patient education, especially dur- ing the acute hospital phase.

Denial featured as an initial response for both patients and their spouses, followed quickly by the emotions of shock on diagnosis of a myocardial infarction or Takotsubo cardiomyopathy. Strong visual metaphors such as bombs and explosions were used by many partic- ipants when describing their acute cardiac event. For example, one male spouse described how it was obvious to him that his female partner had suffered a heart attack and recalled speaking about the state of her health the weekend before with friends:

[She’s on] depression tablets, high blood pressure tables, diabetes, overweight, smokin’, that’sit.It’sgoing to blow up one day and it was only a week later. (Spouse 015, male, 59 years).

Similar visual metaphors were also used by this spouse, demon- strating the effect an acute cardiac event had on the entire family unit.

...it’s not something minor that happened to somebody’s family, it was a detonation....there’s an awful lot of, um, debris in the wake of an incident like this.... It goes off right in the middle of your family. And there’s causal- ities all around. (Spouse 005, female, 69 years). 4.3 | Information Participants talked about the importance of receiving information as part of their post cardiac event care. During the acute hospital phase, information and education were received from nurses and printed literature (National Heart Foundation,“My Heart, My Life” booklet). A main theme of most interviews (N=8) was a lack of both verbal and written information in this phase, with some having to find answers to health management questions for themselves. As one female spouse, the wife of a NSTEMI patient reflected:

It annoyed me, because I knew there was more informa- tion that we could have got and, um, once you were done, you were very quickly out of there [discharged home]. (Spouse 005, female, 69 years).

Another participant reflected on the lack of knowledge about her cardiac event in this way:

And I didn’tknowwhatI’d had and I didn’t really understand Takotsubo till Tuesday morning, when Brad actually googled it all and read it to me about TABLE 3Characteristics of participants Patients, N=12 Mean age, years (range) 62 (42–75) Male sex,n9 Median hospital length of stay, (IQR) 3.8 (1) Previous CPR training 6 Recent CPR training (during cardiac rehabilitation) 2 Spouses/partners, N=12 Mean age, years (range) 59 (42–72) Male sex,n3 Previous CPR training 7 Recent CPR training (during cardiac rehabilitation) 1 All participants, N=24 Marital status Spouse 22 Defacto 2 Location of residence Metro 22 Rural 2 IQR, interquartile range.

Participant numberPatients Partner or spouse Pseudonym Age (years) Diagnosis Pseudonym Age (years) 001 Larry 64 STEMI Helen 63 004 Jimmy 55 STEMI Nadia 55 005 Karl 69 NSTEMI Marg 69 006 Markus 75 NSTEMI Olivia 65 007 Liz 56 Takotsubo Sam 60 010 John 57 STEMI Bernadette 57 012 Dan 61 STEMI Rhonda 57 014 Martin 47 NSTEMI Daphne 42 015 Sally 59 STEMI Tim 59 017 Paul 70 NSTEMI Tia 42 018 Jen 63 Takotsubo Brad 68 STEMI, ST-elevation myocardial infarction; NSTEMI, non-ST elevation myocardial infarction. TABLE 4Participant pseudonyms, age and patient diagnosis 1162 | CARTLEDGE ET AL . what it was...So I didn’t understand that all, the Takotsubo side of it. And I had to ask for literature.

Could you print me out something so I can read it and absorb it? (Patient 018, female, 63 years).

Clinical acuity emerged in relation to the level of information participants received. With the exception of one (N=4), all STEMI patients had a positive experience of patient education early in the acute hospital phase. Rather than just delivering the “mechanical”nature of nursing care (described by Spouse 005, female, 69 years), STEMI participants described nurses regarding it as part of their role to educate patients and family members.

While patient 004, who had suffered a STEMI, could not recall all of the interactions with nurses on his transfer from the catheter lab to the ward (as could be expected), his wife could recall the professional and informative manner in which one nurse related to them:

Yeah, I felt like he [the nurse] was really taking it on as a really important part of his care and he’d been really assuring to you and explaining everything that was going on, as his brief. (Spouse 004, female, 55 years).

Another spouse described the importance of specific qualities for the delivery of information:

...but she [the nurse] was just exceptional. She was learned and she explained to him and patient and seemed to enjoy that part of it.

(Spouse 008, female, 72 years) On average, patients were discharged at day 4 (Table 2) with some reflecting that they did not feel ready to leave hospital or suf- ficiently informed about their condition. At the time of interview some patients had started (N=3) or completed cardiac rehabilitation (N=1). Three patients did not receive a referral to cardiac rehabili- tation and this was rectified by the interviewer. For those yet to start, the wait for more information, education and support seemed lengthy. As one patient put it:

I think they [hospital staff] were really leaving it [patient education] up to rehab and they say don’t do much for a couple of weeks...(Patient 004, male, 55 years).

This view was reiterated by another spouse who was eagerly awaiting the commencement of her husbands’cardiac rehabilitation, yet had not received a referral and thus had an extended wait. She said:

...in the meantime you’ve got this two months where we’ve had...we felt dangled. Maybe rehabilitation should start sooner. (Spouse 005, female, age 69). 4.4 | Control Analysis of the interview data indicated information that participants received about their condition had a direct influence on the level of control participants felt. In addition, information had a positive effect on the emotional response to the event. This idea is reflected in the following comment:

...and because of all the information we’ve been given I’m, I’m not so panic stricken that you know he’s going to have another [heart attack], he’s got a fragile heart or anything. Because we’ve been very well informed as to um, what happened and what’s been done and what signs to look out for. (Spouse 010, female, 57 years) Having a sense of control was demonstrated in opposing forms; participants feeling both in and out of control. In the first instance, if an ambulance was activated for the acute cardiac event, control of the event was transferred to the paramedics, which was a relief to the patient in an uncertain and stressful time. On the other hand at other times the health system had control of the patient and their circumstances, with one patient, who lived rurally, describing:

I was captured by my local nurse.... She checked my blood pressure and she said I might give you an ECG and when she gave me the ECG she was very con- cerned, she said“this is not how it was before, there’s been a definite change. You are not going home. We’re not letting you go, we’re going to put you in an ambu- lance and send you to hospital.”So I was quite shocked. (Patient 017, male, 70 years).

The health system also controlled the way some patients described the symptoms of their acute cardiac event. One spouse described feeling frustrated about the way the nurses insisted on reclassifying the chest“discomfort”her husband experienced:

From the minute he came in here...they kept saying, “So how’s the pain?”And he kept trying to say to them “I don’t have any pain.”And one of the nurses said, “While you’re in here, if anything changes we regard it as pain.”(Spouse 005, female, 69 years) In other examples, patients and their spouses attempted to take control of their circumstances and of the system, particularly regard- ing follow-up cardiology appointments or confirming a place at car- diac rehabilitation. As one Takotsubo patient who was unsure of her prognosis after discharge and attempted to move her next appoint- ment said:

...the waiting was the hard part. I did try and move my appointments forward, um, but that was to no avail, CARTLEDGE ET AL . |1163 obviously busy!Um, I even tried to make an appoint- ment with the doctor at his um, private rooms but it just didn’t work out with everything. So the waiting was the big thing. (Patient 007, female, 56 years).

A constant question raised by participants waswhyan acute car- diac event had happened to them. The underlying motivation for this question appeared to be to gain control over the cause by modifying future behaviour and risk factors. This position was particularly evi- dent for female spouses. When participants were asked what the most important issue was for them right now, one spouse replied in this way:

I’m wanting to know how that heart attack came about, how it was driven, that’s what I want to know. So that we can work on that, or if it was food or whatever it was, I don’t know. (Spouse 012, female, 57 years).

Taking responsibility for controlling diet also featured as a strong recurring theme and is described eloquently by this spouse:

Well for me now [the most important issue] is to make sure that he takes his medications and take the medica- tion on time and also the diet and I’m watching his diet now and he said I’m cruel to him, not making enough cakes like before. I really watch his diet so much.

(Spouse 017, female, 42 years). 4.5 | Responsibility The notion of taking control was also coupled with shouldering responsibility. This sense of control was demonstrated particularly by female spouses with only a small representation of this theme seen in one male spouse. Female spouses took on the responsibility for the health of their partners as early as the acute hospital phase as described by this spouse:

I was pretty much here [hospital ward] 24/7. So any- thing they had to say I heard. Um and all the booklets and I read them from cover to cover and made sure I asked questions...(Spouse 014, female, 42 years).

The level of responsibility felt by female spouses increased as patients was discharged home, away from medical care as illustrated by the following:

Yeah, the first week or so was really bad, yeah. Yeah and because if he got up in the middle of the night, oh my[laughs]...I was checking [on him], which was really bad for him, but he had a lot of trouble sleeping. (Spouse 001, female, 63 years).While female spouses adopted a caring role and the associated responsibility, doctors also transferred responsibility to spouses. This was seen in several cases related to smoking cessation and one spouse in particular was given this message by two separate cardiologists:

And he [the cardiologist] goes,“Oh, you’re with Jimmy...

Don’t let him smoke ever again.”So that was a really amaz- ingly strong message I thought from these quite authorita- tive kind of figures. (Spouse 004, female, 55 years). 4.6 | Attitudes and intentions towards CPR training Given the themes that were found around the experience of liv- ing through an acute cardiac event and receiving patient educa- tion we were interested to know if patients and spouses would want CPR training included in their education. Participants were asked a two-stage question relating to the patient education— first as an introduction to this topic they were asked if they had received around chest pain management and then, should chest pain escalate- emergency management, with the need for CPR (Table 2).

Most patients had received glyceryl trinitrate spray and had basic education on how and when to use it. Patients then went onto edu- cate their spouses about chest pain management. No participants in this research were provided with education on what to do should chest pain escalate to a serious emergency. However, all patients, with the exception of one, had positive attitudes towards learning CPR. CPR training was described as a“worthy”undertaking thus supporting the first intention of the TPB (Table 1). For the second intention, the social pressures to undertake the behaviour of CPR training were framed in a positive manner of having a duty to the community. When speaking about his recent CPR refresher training at work, this participant describes a level of social pressure:

Well I think it’s something you should know. You should know basic CPR if nothing else.

(Patient 001, male, 64 years).

One patient-spouse pair, who had recently undergone CPR train- ing together at cardiac rehabilitation discussed the positive social pressure to be trained amongst each other:

I don’t know, how did you feel, did you feel that it [CPR training session] was relevant to you...? (Spouse) I don’t think that way. Anyone in the street [should be trained]!...(Patient) So do I. (Spouse) That’s a good citizen basically...(Patient) (Spouse 008, female, 72 years & Patient 008, male, 65 years) 1164 | CARTLEDGE ET AL . Finally the third intention of the TPB—control beliefs (including facilitators and barriers towards undertaking CPR training), were also threaded through the data. One participant aptly recognised that linking concepts together would be a facilitator for this group to learn CPR skills:

I think it would be worth doing [CPR training], but having said that, we haven’t gone out actively and sought to do that. So it hasn’ttriggered...Probably if it was easier to get a hold of, [and there was] clearer linkage between the problem...if we better understood it, maybe we’dbemore inclined to do it. (Patient 012, male, 61 years).

In regard to timing of the training, cardiac rehabilitation was con- sistently identified by most participants as the right time and place to facilitate CPR training.

Well, I think [cardiac] rehab would be [the right time].

You know, you want to be empowered pretty much, er, the sooner the better. (Patient 010, male, 57 years) Cardiac rehabilitation was also identified by this patient:

It [CPR training] would be a good thing to learn at this stage [cardiac rehabilitation]. Because you’re going along, you’re there, your mind is open, you’re there to learn. I’m in [cardiac] rehab, what do we do? (Patient 004, male, 55 years).

Participants who were currently attending or had completed car- diac rehabilitation at the time of interview and undertaken CPR training at the program, overall had very positive experiences.

I was surprised it [the CPR training] came. I mean I didn’t know what was in the session, I just turned up and it was a very welcome opportunity....it gives you confidence, to me, anyway, that if I see someone collaps- ing I can do something. Maybe not accurately but I’ll do something. (Patient 008, male, 65 years).

There were differences in how participants viewed CPR training with the oldest patient (age 75) and spouse not interested in CPR training. In comparison, the youngest patient (age 47) and spouse did want to learn CPR and learn it as soon as possible—while in the acute phase. This difference in opinion may indicate the urgency for information to preserve life at the younger end of the age spectrum compared with those in their seventh decade of life.

What was not talked about in the interviews also needs to be considered. The potential fear and responsibility that spouses in particular may have felt, when thinking about their future health and any potential need for them to perform CPR on the patient was not raised often. One spouse however nervously broached the topic:Oh yeah, I’m willing to give the refresher or relearn but in the back of your mind is ohhh I just hope I don’t have to use it on Larry. But if it’s anyone else I think you know the adrenaline kicks in and you think I’ve got to do it because there is no-one else. But yeah, a little bit nervous. (Spouse 001, female, 63 years). 5 | DISCUSSION This study has addressed a gap in the literature related to the qual- itative investigation of the attitudes, preferences and intentions of cardiac patients and spouses towards targeted CPR training. We also explored their experiences and perceptions of patient educa- tion in the contemporary Australian cardiology setting. Our study found that while an acute cardiac event is an unexpected, emo- tional and stressful event, patients valued receiving patient educa- tion and information. For those that received adequate information, there appeared to be less negative emotions associated with their cardiac event and having relevant information increased their sense of control. In addition to standard patient education, most partici- pants would value the opportunity to undertake CPR training after an acute cardiac event, displaying strong beliefs, positive attitudes and a clear intent towards training. Preferences for undertaking CPR training were for later in the trajectory of recovery, in cardiac rehabilitation.

For some of the study participants, especially those who were yet to attend cardiac rehabilitation, participation in the interview process may have provided the first opportunity for in-depth reflec- tion on their cardiac event. The interview provided participants with an opportunity to have a guided discussion about their emotions and thoughts about their cardiac experiences with their spouse. To our knowledge, our study is the only qualitative study interviewing both patients and spouses together. For most of the participants this appeared to be the first time they had engaged in such discussions with their spouse as it was observed to be a new dialogue between them. Participants were sometimes surprised by what their spouse had said, seeking out more information by asking questions of each other. Participants appeared to enjoy and appreciate the chance to be heard, especially by a specialist cardiac nurse and for the oppor- tunity to clarify any outstanding questions. It has been suggested that chronic illness participants do receive therapeutic benefits from participating in qualitative interviews (Hutchinson, Wilson, & Wilson, 1994).

For some, the interview became quite emotional as they relived the cardiac event and shared their feelings and fears with their spouse and the interviewer. The range of the emotional themes identified in our analysis are consistent with other reports of this population (Astin, Closs, McLenachan, Hunter, & Priestley, 2009; Fors et al., 2014), including the use of strong language and meta- phors such as“bombs”when describing their cardiac event (Fleury & Moore, 1999; Pattenden, Watt, Lewin, & Stanford, 2002; Thompson et al., 1995; Vosbergen et al., 2013). CARTLEDGE ET AL . |1165 This study provides contemporary data on the education experi- ence of cardiac patients and spouses following an acute cardiac event. This is particularly important given length of hospital stay is decreasing, therefore providing less opportunity and time for edu- cation. Most participants in our study described having information deficits on discharge, persisting through to outpatient follow-up.

This is a long-standing problem also described in previous studies (Fleury & Moore, 1999; Hanssen et al., 2005; Thompson et al., 1995; Valaker et al., 2017). Most recently Valaker et al. (2017) found like our participants, patients were satisfied with the techni- cal care provided but lacked information on what to expect and how to navigate the health system after hospital discharge. For our participants it may be the case that information and education were provided during the inpatient stay, however, was unable to be absorbed in such a short time period. New strategies for patient and family education at later stages of recovery are required. This could include the use of technology such as smart phone applica- tions or text message interventions which are proving successful in other cardiac applications for behaviour change (Chow et al., 2015; Redfern et al., 2014).

In contrast to what is discussed in the interviews, an important aspect of qualitative research is to also consider what was not talked about by participants (LeCompte, 2000). While participants very easily expressed their views on the patient education they received, there was little discussion on any fear or anguish they may have felt thinking about the potential for performing CPR on their spouse in the future. Even though questions related to CPR training were later in the interview, once rapport and trust had been established, fear of performing CPR on a spouse was not a major theme found in the data. While the interviews gave patients and spouses the space and opportunity to discuss emotions felt after the acute cardiac event, the same was not seen for fear felt towards future emergencies, ill health or the need to perform CPR. It may be that these feelings were not felt by the majority, as CPR training was described by two participants as“empowering”, or it may be a self-protecting beha- viour to simply not talk about it.

Spouses may also feel a personal pressure to be skilled in CPR after experiencing their spouse being affected by an acute cardiac event and female spouses certainly took on responsibility in other areas of care. The TPB acknowledges that personal feelings of moral obligation or responsibility will also have an impact on all constructs of the theory, making a potentially significant contribu- tion to the intention (Ajzen, 1991). In addition, the construct of perceived behavioural control takes into account past experience as well as anticipated obstacles. As most participants had under- gone previous CPR training (N=13), this may also have shaped their perceptions. Most importantly, when people are eager to undertake CPR training it is important that there are few obstacles and they are presented with the opportunity to easily engage in training, such as including training in a cardiac rehabilitation program.

The level of responsibility felt by spouses is not surprising. The gendered nature of care has been well documented not only incardiovascular health but in other domains (Allen, 1994; Thompson et al., 1995). However, male spouses in our sample did not appear to feel the same level of responsibility. While spouses did feel a responsibility to care for their partners, the desire to learn CPR did not always directly stem from the feeling of responsibility as train- ing was seen as a worthy skill to have. Previous research with this population has identified that knowing what to do in an emergency is of high priority to both patients and spouses (Moser et al., 1993). Further to this, it has been demonstrated that knowing CPR aids in increasing a sense of control around the patients’condition (Moser & Dracup, 2000) and is important in preventing delays in treatment so often seen for this population (Bray et al., 2015; McKinley et al., 2011), should a future event take place. The role a spouse plays in a patients’recovery and care poses important ques- tions and implications as what the experience is like for patients who live alone or who do not have extended family networks to rely on.

The only other qualitative work surrounding attitudes and inten- tions towards CPR training has been conducted by Vaillancourt et al.

(2014). Positive attitudes and intentions were also found in their sample of urban and rural Canadians aged 55 years and older. This study also used the TPB and similar to our study found positive out- comes for each construct for both undertaking CPR training and per- forming CPR for a victim. The authors identify that facilitators to training would be to increase the peer pressure to learn for those who live with a spouse or care for grandchildren. In addition, making training convenient, or in our case, routinely part of secondary pre- vention programs is important. 5.1 | Limitations Our study needs to be considered with the following limitations. The sample may be subject to bias as those who participated are likely to be more proactive and motivated individuals. Participants, how- ever, received no compensation for their time, other than the chance to speak with a healthcare professional who undertook the inter- views and is from the acute care setting. We also only included Eng- lish speaking patients—further research is required with those from non-English speaking backgrounds. While our sample was small and from one hospital, we are confident that the themes we identified reflect the most typical emotions and intentions of patients as they are consistent with international literature.

6 | CONCLUSION Cardiac patients and their spouses described unmet patient educa- tion and information needs following an acute cardiac event. Cardiac staff need to be made aware of the emotional toll that both patients and particularly spouses face during a cardiac admission, which might not be clearly evident during the inpatient admission. New strategies are required to ensure adequate education both during the inpatient phase and beyond hospital discharge. Such strategies could include 1166 | CARTLEDGE ET AL . the use of technology, such as websites, mobile apps or texts to pro- vide education both during the inpatient stay and beyond. It is important to ensure patients and spouses receive adequate levels of information as this appeared to decrease negative emotions associ- ated with the event and increase feelings of control.

Including CPR training is an element of information this popu- lation would like included in patient education and it is important that this population be provided with opportunities to train in CPR while they are still engaged with both their own health and the health system. Participants demonstrated positive attitudes and intent towards learning CPR training if included in a cardiac rehabilitation program. Cardiac disease management education and discussions around CPR training should commence during the acute phase, linking concepts together and ensuring continuation of patient and family education throughout the continuum of cardiac care.

ACKNOWLEDGEMENTS The authors wish to thank all the voluntary participants for their time and willingness to participate in the study. We would also like to acknowledge the Clinical Pharmacology Department, Alfred Health, for providing the interview space.

CONFLICTS OF INTEREST SC is a first aid trainer and director of City to Surf First Aid.

AUTHOR CONTRIBUTIONS All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE [http://www.ic mje.org/recommendations/]):

1.substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2.drafting the article or revising it critically for important intellec- tual content.

ORCID Susie Cartledge http://orcid.org/0000-0002-6837-2244 REFERENCES Ajzen, I. (1991). The theory of planned behavior.Organizational Behavior and Human Decision Processes,50(2), 179–211. https://doi.org/10.

1016/0749-5978(91)90020-T Allen, S. M. (1994). Gender differences in spousal caregiving and unmet need for care.Journal of Gerontology,49(4), S187–S195. https://doi.

org/10.1093/geronj/49.4.S187 Ambulance Victoria. (2017).Victorian Ambulance Cardiac Arrest Registry 2015 - 2016 Annual Report. Doncaster, Victoria: Ambulance Victoria.Retrieved from http://s3-ap-southeast-2.amazonaws.com/prod.assets.

ambulance.vic.gov.au/wp-content/uploads/2017/03/VACAR-Annual- Report_2015-2016.pdf Astin, F., Closs, S. J., McLenachan, J., Hunter, S., & Priestley, C. (2009).

Primary angioplasty for heart attack: Mismatch between expectations and reality?Journal of Advanced Nursing,65(1), 72–83. https://doi.

org/10.1111/j.1365-2648.2008.04836.x Australian Institute of Health and Welfare. (2013).How many people have cardiovascular disease?Canberra: AIHW. Retrieved from http:// www.aihw.gov.au/cardiovascular-health/prevalence/ Australian Institute of Health and Welfare. (2014).Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Prevalence and incidence. (Cardiovascular, diabetes and chronic kidney disease series no. 2. No. Cat. no. CDK 2.). Canberra: AIHW. Retrieved from http:// www.aihw.gov.au/cardiovascular-health/prevalence/ Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., & Deo, R.,...On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2017).Heart disease and stroke statistics—2017 update: A Report From the American Heart Association.Circulation,135(10), e146–e603. https://doi.org/ 10.1161/cir.0000000000000485 Blair, J., Volpe, M., & Aggarwal, B. (2014). Challenges, needs and experi- ences of recently hospitalized cardiac patients and their informal caregivers.The Journal of Cardiovascular Nursing,29(1), 29–37.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 3726572/ Blewer, A. L., Putt, M. E., Becker, L. B., Riegel, B. J., Li, J., Leary, M.,...

Delany, S. (2016). Video-only cardiopulmonary resuscitation educa- tion for high-risk families before hospital discharge a multicenter pragmatic trial.Circulation: Cardiovascular Quality and Outcomes,9(6), 740–748.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.

Qualitative Research in Psychology,3(2), 77–101. https://doi.org/ http://dx.doi.org.ezproxy.lib.monash.edu.au/10.1191/1478088706qp 063oa Bray, J. E., Stub, D., Ngu, P., Cartledge, S., Straney, L., Stewart, M.,...

Finn, J. (2015). Mass media campaigns’ influence on prehospital behavior for acute coronary syndromes: An evaluation of the Aus- tralian heart foundation’s warning signs campaign.Journal of the American Heart Association,4(7), e001927. https://doi.org/10.1161/ JAHA.115.001927 Briffa, T. G., Hobbs, M. S., Tonkin, A., Sanfilippo, F. M., Hickling, S., Rid- out, S. C., & Knuiman, M. (2011). Population trends of recurrent coronary heart disease event rates remain high.Circulation: Cardiovas- cular Quality and Outcomes,4(1), 107–113.

Campbell, E. (2009). Nurse as educator: Principles of teaching and learn- ing for nursing practice.AORN Journal,90(6, Supplement), S122– S123. https://doi.org/10.1016/j.aorn.2009.11.012 Cartledge, S., Finn, J., Bray, J. E., Case, R., Barker, L., Missen, D., Shaw, J., & Stub, D. (2017). Incorporating cardiopulmonary resuscitation train- ing into a cardiac rehabilitation programme: A feasibility study.Eur- opean Journal of Cardiovascular Nursing. https://doi.org/10.1177/147 4515117721010 Cheng, Y. C. (1997). Targeted mass CPR training for families of cardiac patients–Experience in Taipei city.Tzu Chi Medical Journal,9(4), 273–278.

Chew, D. P., French, J., Briffa, T. G., Hammett, C. J., Ellis, C. J., Ranas- inghe, I.,...Bloomer, S. G. (2013). Acute coronary syndrome care across Australia and New Zealand: The SNAPSHOT ACS study.The Medical Journal of Australia,199(3), 185–191. https://doi.org/10.

5694/mja12.11854 Chew, D. P., Scott, I. A., Cullen, L., French, J. K., Briffa, T. G., Tideman, P.

A.,...Aylward, P. E. G. (2016). National Heart Foundation of Aus- tralia & Cardiac society of Australia and New Zealand: Australian CARTLEDGE ET AL . |1167 Clinical Guidelines for the Management of Acute Coronary Syn- dromes 2016.Heart, Lung and Circulation,25(9), 895–951. https:// doi.org/10.1016/j.hlc.2016.06.789 Chow, C. K., Redfern, J., Hillis, G. S., Thakkar, J., Santo, K., Hackett, M. L., ...Thiagalingam, A. (2015). Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: A randomized clinical trial.JAMA,314(12), 1255–1263. https://doi.org/ 10.1001/jama.2015.10945 Dracup, K., Heaney, D., Taylor, S., Guzy, P., & Breu, C. (1989). Can family members of high-risk cardiac patients learn cardiopulmonary resusci- tation?Archives of Internal Medicine,149(1), 61–64. https://doi.org/ 10.1001/archinte.1989.00390010079008 Esmaeili, M., Cheraghi, M. A., & Salsali, M. (2016). Cardiac patients’per- ception of patient-centred care: A qualitative study.Nursing in Critical Care,21(2), 97–104. https://doi.org/10.1111/nicc.12148 Fleury, J., & Moore, S. M. (1999). Family-centered care after acute myocardial infarction.Journal of Cardiovascular Nursing,13(3), 73–82.

https://doi.org/10.1097/00005082-199904000-00007 Fors, A., Dudas, K., & Ekman, I. (2014). Life is lived forwards and understood backwards–Experiences of being affected by acute coronary syndrome: A narrative analysis.International Journal of Nursing Studies,51(3), 430–437. https://doi.org/10.1016/j.ijnurstu.

2013.06.012 Gentz, C. A. (2000). Perceived learning needs of the patient undergoing coronary angioplasty: An integrative review of the literature.Heart & Lung: The Journal of Acute and Critical Care,29(3), 161–172. https:// doi.org/10.1067/mhl.2000.106002 Godin, G., & Kok, G. (1996). The theory of planned behavior: A review of its applications to health-related behaviors.American Journal of Health Promotion,11(2), 87–98. https://doi.org/10.4278/0890-1171- 11.2.87 Goldberg, R. J. (1987). Physicians and CPR training in high-risk family members.American Journal of Public Health,77(6), 671–672. https:// doi.org/10.2105/AJPH.77.6.671 Grbich, C. (1999).Qualitative research in health. Crows Nest, NSW: Allen & Unwin.

Grbich, C. (2013).Qualitative data analysis: An introduction(2nd ed.). Lon- don, Thousand Oaks, Calif: SAGE Publications. Hamberg, K., Johansson, E., Lindgren, G., & Westman, G. (1994). Scien- tific rigour in qualitative research—examples from a study of women’s health in family practice.Family Practice,11(2), 176–181.

https://doi.org/10.1093/fampra/11.2.176 Hansen, E. C. (2006).Successful qualitative health research: A practical introduction. Crows Nest, NSW: Allen & Unwin.

Hanssen, T. A., Nordrehaug, J. E., & Hanestad, B. R. (2005). A qualitative study of the information needs of acute myocardial infarction patients and their preferences for follow-up contact after discharge.

European Journal of Cardiovascular Nursing,4(1), 37–44. https://doi.

org/10.1016/j.ejcnurse.2004.11.001 Hasankhani, H., Gholizadeh, L., Mohammadi, E., Zamanzadeh, V., Allah- bakhshian, A., Ghaffari, S., & Allahbakhshian, M. (2014). The lived experiences of patients post coronary angioplasty: A qualitative study.Journal of Vascular Nursing,32(4), 144–150. https://doi.org/10.

1016/j.jvn.2014.04.001 Haugk, M., Robak, O., Sterz, F., Uray, T., Kliegel, A., Losert, H.,...Doma- novits, H. (2006). High acceptance of a home AED programme by survivors of sudden cardiac arrest and their families.Resuscitation,70 (2), 263–274. https://doi.org/10.1016/j.resuscitation.2006.03.010 Hertz, R. (1997).Reflexivity and voice. Thousand Oaks, CA: SAGE Publica- tions Inc.

Hewitt, J. (2007). Ethical components of researcher—researched relation- ships in qualitative interviewing.Qualitative Health Research,17(8), 1149–1159. https://doi.org/10.1177/1049732307308305Hutchinson, S. A., Wilson, M. E., & Wilson, H. S. (1994). Benefits of par- ticipating in research interviews.Image: The Journal of Nursing Schol- arship,26(2), 161–166. https://doi.org/10.1111/j.1547-5069.1994.tb 00937.x LeCompte, M. D. (2000). Analyzing qualitative data.Theory Into Practice, 39(3), 146. https://doi.org/10.1207/s15430421tip3903_5 McKinley, S., Aitken, L. M., Marshall, A. P., Buckley, T., Baker, H., David- son, P. M., & Dracup, K. (2011). Delays in presentation with acute coronary syndrome in people with coronary artery disease in Aus- tralia and New Zealand.Emergency Medicine Australasia,23(2), 153– 161. https://doi.org/10.1111/j.1742-6723.2011.01385.x Moser, D. K., & Dracup, K. (2000). Impact of cardiopulmonary resuscita- tion training on perceived control in spouses of recovering cardiac patients.Research in Nursing & Health,23(4), 270–278. https://doi.

org/10.1002/(ISSN)1098-240X Moser, D. K., Dracup, K. A., & Marsden, C. (1993). Needs of recovering cardiac patients and their spouses: Compared views.International Journal of Nursing Studies,30(2), 105–114. https://doi.org/10.1016/ 0020-7489(93)90060-8 National Heart Foundation of Australia. (2015). My heart, my life.

Retrieved October 21, 2017, from https://www.heartfoundation.

org.au/images/uploads/publications/CON-141.v4_MHML2015_WEB.

PDF Pattenden, J., Watt, I., Lewin, R. J. P., & Stanford, N. (2002). Decision making processes in people with symptoms of acute myocardial infarction: Qualitative study.BMJ,324(7344), 1006. https://doi.org/ 10.1136/bmj.324.7344.1006 Rea, T. D., Pearce, R. M., Raghunathan, T. E., Lemaitre, R. N., Sotood- ehnia, N., Jouven, X., & Siscovick, D. S. (2004). Incidence of out-of- hospital cardiac arrest.The American Journal of Cardiology,93(12), 1455–1460. https://doi.org/10.1016/j.amjcard.2004.03.002 Redfern, J., Thiagalingam, A., Jan, S., Whittaker, R., Hackett, M., Mooney, J.,...Chow, C. (2014). Development of a set of mobile phone text messages designed for prevention of recurrent cardiovascular events.

European Journal of Preventive Cardiology,21(4), 492–499. https://doi.

org/10.1177/2047487312449416 Schneider, L., Sterz, F., Haugk, M., Eisenburger, P., Scheinecker, W., Klie- gel, A.,...Laggner, A. N. (2004). CPR courses and semi-automatic defibrillators—life saving in cardiac arrest?Resuscitation,63(3), 295– 303. https://doi.org/10.1016/j.resuscitation.2004.06.005 Schwandt, T. (2007).The SAGE dictionary of qualitative inquiry. Thousand Oaks, California, USA: SAGE Publications, Inc. https://doi.org/10.

4135/9781412986281 Soar, J., Mancini, M. E., Bhanji, F., Billi, J. E., Dennett, J., Finn, J.,...Mor- ley, P. T. (2010). Part 12: Education, implementation and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emer- gency Cardiovascular Care Science with Treatment Recommenda- tions.Resuscitation,81(1, Supplement), e288–e332. https://doi.org/ 10.1016/j.resuscitation.2010.08.030 Thompson, D. R., Ersser, S. J., & Webster, R. A. (1995). The experiences of patients and their partners 1 month after a heart attack*.Journal of Advanced Nursing,22(4), 707–714. https://doi.org/10.1046/j.1365- 2648.1995.22040707.x Vaillancourt, C., Charette, M., Kasaboski, A., Brehaut, J. C., Osmond, M., Wells, G. A.,...Grimshaw, J. (2014). Barriers and facilitators to CPR knowledge transfer in an older population most likely to witness cardiac arrest: A theory-informed interview approach.Emergency Medicine Journal,31(9), 700–705. https://doi.org/10.1136/emermed- 2012-202192 Valaker, I., Norekv al, T. M., R aholm, M.-B., Nordrehaug, J. E., Rotevatn, S., & Fridlund, B. (2017). Continuity of care after percutaneous coronary intervention: The patient’s perspective across secondary and primary care settings.European Journal of Cardiovascular 1168 | CARTLEDGE ET AL . Nursing,16(5), 444–452. https://doi.org/10.1177/147451511 7690298 Vosbergen, S., Janzen, J., Stappers, P. J., van Zwieten, M. C. B., Lacroix, J., Idema, K.,...Peek, N. (2013). A qualitative participatory study to identify experiences of coronary heart disease patients to support the development of online self-management services.International Journal of Medical Informatics,82(12), 1183–1194. https://doi.org/10.

1016/j.ijmedinf.2013.09.001 Wilkins, E., Wilson, L., Wickramasinghe, K., Bhatnagar, P., Leal, J., Luengo-Fernandex, R., & Townsend, N. (2017).European cardiovascu- lar disease statistics 2017 edition(pp. 1–192). Belgium: European Heart Network. SUPPORTING INFORMATION Additional Supporting Information may be found online in the sup- porting information tab for this article.

How to cite this article:Cartledge S, Feldman S, Bray JE, Stub D, Finn J. Understanding patients and spouses experiences of patient education following a cardiac event and eliciting attitudes and preferences towards incorporating cardiopulmonary resuscitation training: A qualitative study.

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