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open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/PPA.S47120
exploring the information needs of patients with unexplained chest pain
ingrid Ølfarnes røysland1
elin Dysvik1
Bodil Furnes1
Febe Friberg1,2
1Department of health studies, Faculty of social sciences, University of stavanger, stavanger, norway; 2institute of health and care sciences, sahlgrenska Academy at göteborg University, göteborg, sweden
correspondence: ingrid Ølfarnes røysland Department of health studies, Faculty of social sciences, University of stavanger, n-4036 stavanger, norway Tel +47 5183 4133 Fax +47 5183 4150 email ingrid.roysland@uis.no
Background: Unexplained chest pain is a common condition. Despite negative findings, a large number of these patients will continue to suffer from chest pain after being investigated at cardiac
outpatient clinics. Unexplained chest pain covers many possible complaints, and diagnosing a
single cause for a patient’s pain is often described as difficult, as there are a number of possible
factors that can contribute to the condition. For health professionals to meet patients’ expecta-
tions, they must know more about the information needs of patients with unexplained chest pain.
The aim of this study was to describe information needs among patients with unexplained chest
pain and how those needs were met by health professionals during medical consultations.
Methods: A qualitative design was used. Data were collected by means of seven individual interviews with four women and three men, aged 21–62 years. The interviews were analyzed
by qualitative content analysis.
Results: The results are described in two subthemes, ie, “experiencing lack of focus on individual problems” and “experiencing unanswered questions”. These were further abstracted under the
main theme “experiencing unmet information needs”.
Conclusion: Existing models of consultations should be complemented to include a person- centered approach to meeting patients’ beliefs, perceptions, and expressions of feelings related
to experiencing unexplained chest pain. This is in line with a biopsychosocial model with active
patient participation, shared decision-making, and a multidisciplinary approach. Such an approach
is directly within the domain of nursing, and aims to take into account patient experience.
Keywords: information needs, qualitative research, unexplained chest pain
Introduction Many people will experience unexplained chest pain within their lifetime, although
the majority will not have it investigated.1 Bass and Mayou2 claim that noncardiac
chest pain is a common condition worldwide. Jonsbu et al3 indicate that the majority
of people referred to cardiac outpatient clinics for chest pain in Norway will be told
that their pain is not due to a cardiac condition. Unexplained chest pain covers many
possible complaints and diagnosing a single cause for a patient’s pain is often difficult
because there are a number of possible factors that can contribute to the condition.2
Common causes are described as esophageal disorders, musculoskeletal problems,
and pain referred from the thoracic spine, hyperventilation, and psychologic disorders.
However, the risk of death from coronary heart disease is not significantly different
to that in the general population,4 but there is substantial morbidity attached to unex-
plained chest pain, with work absenteeism rates around 29%.5http://www.dovepress.com/permissions.phphttp://creativecommons.org/licenses/by-nc/3.0/www.dovepress.comwww.dovepress.comwww.dovepress.comhttp://dx.doi.org/10.2147/PPA.S47120mailto:ingrid.roysland@uis.no
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According to research,3 people with unexplained chest
pain are often more anxious, with a higher prevalence of panic
disorder than people with heart disease, and a high percentage
continue to take cardiac drugs.6 Many have a similar level of
functional disability and use health services as frequently as
people with a positive diagnosis of heart disease. Persons with
unexplained chest pain experience fear and anxiety, feelings
of uncertainty, stress, and loss of strength.7 Fagring et al8 point
to the fact that men and women had more similarities than
variations in their descriptions of chest pain.
The traditional biomedical model has guided the assess-
ment and treatment of persistent pain for many years.9 As an
extension of this understanding, the biopsychosocial model,
including interaction of biological, psychologic, and social
factors causing noncardiac chest pain and subsequent dis-
ability, is suggested.2,10 According to this comprehensive
model, all diseases have biopsychosocial components that
contribute to the experience of unexplained chest pain and
the response to treatment.
Thus, there are a variety of challenges related to the
complexity of living with unexplained chest pain, which
presumably indicates a need for more knowledge and under-
standing in order to handle everyday life. Information needs
is defined by Knowles11 as the gap existing between specific
competencies and the ability of the learner to achieve these
specific competencies at present. According to Timmins,12
it is difficult to extrapolate from the literature an exact
definition of information needs for acute coronary syndrome
patients because no clear definitions or consensus upon ter-
minology is found. There are few studies about information
needs from the perspective of persons with unexplained chest
pain. However, in a qualitative study, Price et al13 aimed to
understand the needs and experiences of attendees at a rapid
access chest pain clinic and to determine the acceptability and
effectiveness of the procedural changes. Changes in proce-
dures helped patients to understand their pain, practice self-
management, and consider altering their lifestyle. Another
interesting aspect which points to the need to explicate
knowledge needs further is the deviation between patients’
actual needs and health care workers’ expectations of those
needs, as documented for coronary syndrome patients.12,14
The studies indicate that participants focused on stress and
symptom management rather than modifying health habits.
In order for health professionals to create person-centered
communication to meet patients’ expectations, there is a need
to know more about the information needs of patients with
unexplained chest pain. Person-centered communication
seeks to elicit and satisfy the needs, preferences, and values
that patients express themselves.15 Therefore, the aim of the
present study was to explore information needs and how
those needs were met by health professionals during medi-
cal consultations.
Materials and methods A qualitative design was used to gather indepth knowledge
about experiences16 related to the information needs of people
living with unexplained chest pain.
Participants The participants were selected from a cardiac outpatient clinic
at a university hospital in Norway. The inclusion criteria were
diagnosis of unexplained chest pain (a cardiologist should
have ascertained that patients’ symptoms had no apparent
organic cause), age at least 18 years, and ability to under-
stand and speak Norwegian. All eligible participants had a
symptom-limited bicycle test in the cardiac outpatient clinic,
and were given information about their test results. They also
received standard information about risk factors and lifestyle
factors related to the development of heart disease. Exclusion
criteria were the absence of chest pain symptoms and having
pathologic cardiac findings after the bicycle test. Patients who
met the inclusion criteria were consecutively invited to take
part in the study via a letter distributed by the head nurse
in the cardiac outpatient clinic. This consecutive selection
continued for a 6-month period. Those who were interested
in participating contacted the head nurse. Four women and
three men agreed to participate. The men were aged between
58–62 years and the women were aged 21–60 years. Five
participants had also been assessed for chest pain once or
twice before, in this or another cardiac outpatient clinic, and
were told that their chest pain was unexplained.
Two participants had an academic qualification, one was
studying to obtain an academic qualification, and four had a
vocational qualification. Three were working full-time, two
were working half-time, and two were receiving disability
compensation. Two of the participants’ jobs involved physi-
cal work. Five participants lived in cities and two lived in
rural areas.
ethical approval The persons who agreed to participate received both verbal
and written information about the study, and were assured
that the data would be treated confidentially and that they
were free to withdraw at any time. They were asked to sign
a written informed consent at study entry. Approval was
sought from the regional ethics committee (2009/2243-7),www.dovepress.comwww.dovepress.comwww.dovepress.com
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information needs of patients with unexplained chest pain
and the investigation conformed to the principles outlined
in the Declaration of Helsinki.
Data collection Data were collected from semistructured individual inter-
views using an interview guide (Table 1). The interviews
were narrative in form and were conducted as a conversa-
tion in which the informant was encouraged to talk freely.16
The interviews were carried out by the first author under the
same conditions in accordance with patient preference in an
undisturbed room in either the cardiac outpatient clinic or in
a room at the university. All interviews lasted for approxi-
mately one hour.
Data analysis Interview texts were analyzed using qualitative content
analysis, which included identifying meaning units, catego-
ries, subthemes, and theme,17 to provide new knowledge and
insights into the topic under investigation (Table 2). The
analysis followed several distinct steps, from the interview
situation to the validation of findings (Table 3): audiotap-
ing and transcribing the interviews; reading the text several
times; performing content analysis;17 selecting quotes; and
validation.
Results A main theme of “experiencing unmet information needs”
was formulated. This illustrates the latent content.17 To
retain the authenticity of the participants’ experiences, direct
quotations from the interviews were selected to illustrate the
most commonly reported aspects of each category or varia-
tion within the subthemes (Table 3). The two subthemes of
“experiencing lack of focus on individual problems” and
“experiencing unanswered questions” form the subheadings
in the following presentation of results.
experiencing lack of focus on individual problems not being seen as a person The participants attended the cardiac outpatient clinic with
uncertainties regarding their chest pain. They wondered how
it would affect them in the future, and what treatment was
needed. Most were positive towards the health professionals,
but wanted them to focus on their individual problems. The
majority of the participants perceived that the information
was very general. One participant stated:
“[…] they don’t think that every person has individual questions and things they would like to know.” (Woman,
21 years)
The bicycle test was perceived to be rather generic as
well. They were not reassured by a negative result. The tests
were not found to be tailored to them and their particular
problems.
“That bicycle test for me is like, I did not get breathless or
tired […] I bike so much [usually] that I did not feel any of that […] but they [the health professionals] are doing their program, even when they don’t get anything out of it.
So to have gotten a result, I should have cycled properly.”
(Man, 58 years)
Some indicated that they did not feel that the professionals
listened to their individual history of pain. The participants
regarded their perceived information needs as individual
ones and expected the health professionals to look into their
daily life. They wanted the physician to prescribe a more
facilitating job situation, for example, including breaks,
reduced working hours, and avoidance of night shift work
with increasing age. One participant said she would have
asked more questions if she felt there was room for this. The
participants also said that they wanted to understand their
chest pain. Some were confused after seeing the cardiologist
and were no closer to understanding their problems after
the consultation. However, one of the participants said the
information was very useful.
lack of time for asking questions Some participants became confused because of the short
consultation session.
“I didn’t [have time to] ask any questions or anything like
that. They told me I could ask, but in a way, yes, it went like
quick, quick, quick. So, it’s obvious, they do it [consulta-
tions] many times.” (Woman, 21 years)
Table 1 The interview guide
Interview sequence with topics or questions asked
Opening interviewer introduction information regarding the purpose of the interview
Main question can you tell me something about the information you received at the cardiac outpatient clinic?
closing Are there other important issues related to the information that we have not discussed, and that we should take into consideration when giving information to patients? summary of main topics with the most important remarkswww.dovepress.comwww.dovepress.comwww.dovepress.com
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The participants felt unable to think things over and to
ask appropriate questions within the time frame. Limited
opportunities to discuss the diagnosis, particular worries, and
further management were reported. One of the participants
suggested that a website about chest pain should be set up
so she could get more answers to her questions.
Alone with their problems Most of the participants felt they were alone with their prob-
lems. Some felt that social contacts were difficult to maintain
because the pain was bothering them so much.
“So often you just loaf about at home, you don’t go out
to a single thing, as crazy it may be. It’s terribly wrong, I
know myself. You have to pull yourself together, but it isn’t
always easy. It’s not.” (Woman, 55 years)
They also talked about the pain causing depression. One
participant said:
“Because of that [the pain], I think it is very easy to get
depressed, and it [the situation] feels as heavy as stones.”
(Man, 62 years)
The pain situation was a troublesome burden. This par-
ticipant also blamed himself for the situation because he had
been working too hard for too long. He thought it would be
easier to deal with if he had someone in the same situation
with whom he could talk. Further investigation and refer-
ral to a cardiologist every second year were suggested as a
follow-up preference by the participants. In such follow-up
consultations, they could be investigated with the opportunity
to share experiences of pain on a continuous basis.
experiencing unanswered questions Uncertain about how to formulate questions The participants reported that it was difficult to ask questions
when they did not know why they were in pain, and could
not find any pattern to the level or intensity of the pain. They
wanted the staff to inform them about what was important
to know.
“Because I am of the opinion that when you come to a doc-
tor, then he knows what to do […] if he is good at informing,
he just explains from the investigations.” (Man, 56 years)
Several participants wanted the health professionals to
inform them without first asking questions. Due to difficul-
ties in formulating their questions, the participants wanted
the professionals to be alert to both verbal and nonverbal
Table 2 examples from the qualitative content analysis process showing abstraction from condensed meaning units, categories, subthemes, and theme
Condensed meaning unit Category Subtheme Theme
They don’t think of each person as having individual questions when giving information The examination in the clinic which found unexplained chest pain, gave me many questions, but he (cardiologist) would not listen to my history
not being seen as a person experiencing lack of focus on individual problems
Didn’t have time to ask questions They said you could ask, but there was no room for it
lack of time for asking questions
People don’t talk about it (unexplained chest pain) strange that they don’t get (together) those who have the problems to talk with others
Alone with the problems experiencing unmet information needs
no pattern for when getting pain, that is why i do not know what to ask about not getting an answer why i feel this (chest pain) When cardiologist gives information, i do not ask Expect the doctors inform, based on their qualifications They found nothing wrong, but there is something, i feel pain need an explanation, why i have chest pain
Uncertain about how to formulate questions still uncertain of the cause of pain
experiencing unanswered questions
When problems with the heart, it makes me frightened of exercise The pain is so bad, i have to hold on to continue (exercising) The pain comes and goes (during exercise)
Uncertain about how to exercise in a safe way
The pain can come when i am eating i don’t know why the pain comes when i eat. it’s a mystery Wondering about if special food is causing pain i am careful with what i am eating, because i am unsure about the connection to chest pain
Uncertain if food is causing painwww.dovepress.comwww.dovepress.comwww.dovepress.com
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information needs of patients with unexplained chest pain
indicators of information needs. They wanted the health
professionals to impart information using appropriate
everyday words so that they could understand what had been
communicated.
still uncertain of the cause of pain The participants’ most frequently mentioned need was to
know what was causing the chest pain, and all of them
considered this to be important. All but one of the participants
thought they had a cardiac disease, even though their cardi-
ologist told them that the test results were negative.
“The physician said he could not find anything wrong
with my heart, but there is something. There is something,
because I feel it.” (Woman, 58 years)
The participants still felt the same chest pain as before
the consultation, and were not reassured about the result of
the test.
“But I have something, somewhere in the cardiovascular
system. I have no doubt.” (Man, 58 years)
There were no connections found. The participants did not
find a pattern for their chest pain, which made them uncertain.
They wanted to understand their chest pain, why it fluctu-
ated over time, and why it changed without understandable
reasons. The participants wanted to be able to help themselves
and to know what to do.
“The only thing I missed [during the consultation in the
cardiac outpatient clinic] was basically, what is it [the chest
pain], and what can I do about it?” (Woman, 21 years)
Participants reflected over possible causes. Most of them
had someone in the family with heart disease and wondered if
their condition was related to heredity. They reflected on what
information their family members had received regarding the
cause of their pain, and wondered if their own chest pain was
caused by the same thing. Others wondered if there could be
psychologic causes. Even if they did not have problems like
anxiety or depression, some participants reflected over possible
psychologic causes. Causes in daily life were also reflected
upon, such as various stressful events and burdens.
Uncertain about how to exercise in a safe way Physical activity was emphasized by all participants. Advice
on an adequate level of activity was of interest, as was advice
on how to respond when the pain starts.
“I can sit normally, like I do now, and then lifting
100 kilograms here, and then down to the floor, quite a
number times. So I think I can use my chest and all this here
then. And then, there is no pain at all, there isn’t. I wonder
if I have been using my muscles incorrectly, even though
I don’t think so.” (Man, 60 years)
According to this participant, the pain comes and goes
and is not associated with exercise. Some participants were
confused by being told to exercise in spite of pain and
expressed anxiety about doing exercise. Some admitted
lack of physical strength and/or self-confidence in perform-
ing common daily activities. The physician in the cardiac
outpatient clinic told the patients that they had less chance
of developing heart disease if they were in good shape. Even
well trained participants said that they had intensified their
training after being told in the cardiac outpatient clinic that
physical training can help them to avoid chest pain. Only one
of the participants had limited exercise after the consultation
and was striving to “get started”.
Uncertain if food is causing pain Some of the participants wondered if their diet was causing
chest pain, but could not find a connection.
“But on the other hand, you can only think: why do some
get pain, and then I think; they can’t find anything [cause
of the chest pain]. So I’m not so sure of anything. But then
Table 3 stages of the qualitative content analysis
1 The interviews were taped and transcribed word for word.
2 The transcribed interviews were carefully read through as a whole several times to gain a contextual understanding of the patients’ information needs. important nuances were discovered by searching for common distinctive features, as well as variations.
3 Patterns in the data were identified by dividing into meaning units (eg, constellation of statements that relate to the same central meaning).
4 The meaning units were condensed, with the core preserved.
5 categories were created as groups of expressed manifest content with shared commonality, and subcategories (eg, sentences to be sorted and abstracted into a category).
6 subthemes and a main theme; the meaningful essences that run through the data were constructed and based on manifest and latent content.
7 selection of quotes. There was agreement regarding which quotes were to be selected to illustrate each category.
8 Validation of findings. The counsellors agreed with and acknowledged the relevance of the findings after each interview. They also highlighted other areas of importance that were included.www.dovepress.comwww.dovepress.comwww.dovepress.com
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I have to add: I’m not the world’s cleverest man when it
comes to food, I must admit. So I could certainly been more
careful with my diet. I could certainly have been more care-
ful about many things, and maybe it has something to do
with that, I don’t know.” (Man, 58 years)
Symptoms of heart burn were experienced. Four par-
ticipants had been referred to gastroenterologists to look
for esophageal sources of their pain. Two of them had gas-
troesophageal abnormalities. At that time, it was indicated
that this could be the cause of the chest pain. The partici-
pants nevertheless wondered what in their diet could give
chest pain.
“But I know at least that when I eat, it [chest pain] can
come […] I’ve felt it with egg sometimes, but I don’t know why. But it can be other things as well […] like bread, so it’s a mystery.” (Woman, 54 years)
Some were careful about what they ate, and suggested
that more information be given about ways of improving
their health by dietary changes.
Discussion The aim of this study was to explore the information needs of
people with unexplained chest pain and how those needs were
met by health professionals during medical consultations. The
participants experienced that their information needs were
not adequately met. The two subthemes of “experiencing
lack of focus on individual problems” and “experiencing
unanswered questions” form the subheadings in the follow-
ing discussion.
experiencing lack of focus on individual problems The results of our study indicate that patients felt that they
did not receive attention for individual problems when
attending the cardiac outpatient clinic. This is supported by
Price et al13 who pointed out that patients wanted a definite
diagnosis, an understanding of the problem, and to learn
about self-management. Laburnèe et al18 argue that there are
no standardized rules and methods to deliver information and
education or to evaluate the results of therapeutic education.
This clearly points to the responsibility of health professionals
to identify patients’ information needs. In our study, all partic-
ipants had received general information about their condition
and risk factors for developing a cardiac condition. Timmins12
found in her study that a natural conflict existed between
nurse and patient priority of information needs among acute
coronary syndrome patients. According to Timmins,12 there
is agreement that cardiac patients should have individualized
teaching based on assessment of information needs, but there
is no clear explanation of precisely what this is. This is in line
with our findings, which indicate a conflict of needs priorities
in terms of what health professionals and patients value as
important information. Presumably, this may influence the
level of uncertainty, as described in the study.
In health care, the traditional biomedical model often
guides assessment and information in connection with medi-
cal consultations.19 One main focus is to evaluate whether
there is a physical condition present that may explain the
symptoms. It is important to diagnose and treat pathologic
pain conditions, because a diagnosis will indicate or guide
treatment options. All participants in our study said that
their chest pain was influenced by their own experiences
and was unique to them. This is also in accordance with the
biopsychosocial model2,10 which contributes to understand-
ing of psychosomatic and environmental components in
unexplained chest pain.
Participants expressed that it was not easy for them to
communicate with anyone about problems related to their
chest pain. Some also expressed anxiety and depression.
Van Ravensteijn et al20 point out that diagnostic testing
hardly impacts on the level of someone’s doubts and fears.
Jerlock et al7 suggest nurses could talk to patients to elicit
their illness narratives in order to have a deeper understanding
of the patients’ experiences. This was also shown in our study.
In a study by Price et al,13 communication problems were
identified and interpreted as related to failure of clinical pro-
cedures to meet patients’ needs. According to Dammen et al6
and Jonsbu et al,3 psychologic factors may play a role in the
pathogenesis of unexplained chest pain. It is indicated that
there is a higher proportion of panic disorder and major
depressive episodes among this group of patients. Depres-
sion and poor social support are significant risk factors for
coronary heart disease21 and panic disorder,22 while stress and
anxiety can trigger coronary events.22 It is also claimed that
people experiencing such psychosocial difficulties are more
likely to be physically inactive, which is also an independent
risk factor for cardiac heart disease. Robertson et al23 reported
that people with unexplained chest pain viewed their condi-
tions as significantly less controllable and less understandable
than those whose pain was cardiac in origin. As suggested
by Robertson et al,23 a multidisciplinary approach to meet
patients’ different information needs is required. In addi-
tion, a sympatric appreciation by the health professionals to
take psychologic factors into account in the communicationwww.dovepress.comwww.dovepress.comwww.dovepress.com
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information needs of patients with unexplained chest pain
with the patients is suggested. Such approaches presumably
promote active patient participation. They may reduce psy-
chologic and psychosocial difficulties and help the patients
to experience more control and understanding, and as such
reduce cardiac risk factors.
experiencing unanswered questions The participants were uncertain about how to formulate
questions and did not feel their questions were answered.
In the cardiac outpatient clinic, they were informed that the
results of the tests were negative but remained uncertain
about the cause of the pain. The participants were uncertain
about how to exercise in a safe way and about issues related
to their diet. A definition of uncertainty, which is valid across
disciplines, is proposed by Penrod,24 who indicates that
people who are uncertain have a perception of being unable
to assign possibilities for what to do or think. This was also
true of the participants in our study, who felt pain but had
no explanation for it. According to Penrod,24 this promotes a
discomforting, uneasy sensation that may be affected through
cognitive, emotive, or behavioral reactions, or by the time
and changes in perception of circumstances.
The participants in our study had received information
that a pathologic cardiac condition did not explain their
chest pain, resulting in their uncertainty. However, their
experience of chest pain may have forced them to search
for alternative explanations which link chest pain with heart
disease. Following Leventhal et al,25 the chest pain compels
the individual to create a subjective perception of a heart
disease, which subsequently inspires a search for specific
bodily signs of cardiac pathology. These researchers point
to the importance of modeling patients’ subjective percep-
tions of the investigation, procedures they use to manage
their problems, questions they ask, and the criteria they
use to evaluate outcomes. According to research,25–28 it is
increasingly important to understand how the perceptions,
experiences, and impact of having pain might influence a
person’s interpretation and response, so that health profes-
sionals can, in turn, respond more appropriately. This is in
line with person-centered care,15 which is focused on the
patients’ narrative, partnership, and documentation of negoti-
ated care and decisions.
The majority of the participants in our study were not reas-
sured by the information that heart disease was not the cause
of their chest pain. Some of the participants described the pain
as “mysterious”. If the person’s pain beliefs are ignored, it
may complicate or entirely undermine the reassurance of hav-
ing negative findings of heart disease. This is in accordance
with reports by several other authors,29–31 who found that if
pain becomes persistent, patients may abandon previously
held cultural or personal beliefs about pain to form new pain
beliefs that are more consistent with their persistent pain
experience. Preparing patients by means of information for
negative test results is assumed and may make it easier for
them to accept simple reassurance from a cardiologist or car-
diac nurse.32
According to the results, the participants were uncertain
about how to exercise in a safe way. Thompson et al33 claim
that important information for the participants must focus
on the positive results of physical activity and that immo-
bility might be far more harmful for them. A study by Wil-
liams et al34 indicates that patients’ perceptions of their own
risks are often not a reflection of their true risks. The patients
in their study overestimated their risk factors compared with
an objective measure, regardless of whether they received
information or not. In relation to our study, the participants
did not receive explanations of cardiac origin for their chest
pain. They were still uncertain about how to exercise in a safe
way and expressed anxiety about doing physical exercise.
Some of the participants in our study expressed a lack of
physical strength for daily living. Wise and Patrick35 stress
that a modest increase in daily activities can improve health
and quality of life for persons with unexplained chest pain.
Jonsbu et al36 use the expression “noncardiac chest pain”. In
their study, patients with noncardiac chest pain were exposed
to physical activity as a part of a cognitive behavioral therapy
intervention. According to Mayou,10 patients with noncardiac
chest pain may have high levels of fear of body sensations,
and it is assumed that a reduction of this fear will lead to a
decrease in patient limitations, for example, with exercising.
In the study by Jonsbu et al,36 it was therefore assumed that
exposure to physical activity could be a useful element. When
exposed to physical activity, the treatment group in their
study showed significantly larger improvements in terms of
reduced avoidance of physical activity, fear of bodily sensa-
tions, depression, and some domains of health-related quality
of life. Some participants in our study expressed avoidance
of physical activity and fear of physical activity because of
the chest pain they felt.
Our participants also reported problems with digestion.
Hershcovici et al37 claim that gastroesophageal reflux disease
(GORD) is by far the most common cause of noncardiac chest
pain. Further, they say that esophageal dysmotility is rela-
tively uncommon among patients with non-GORD-related
noncardiac chest pain. They argue that it is still unclear if
longitudinal esophageal muscle contractions are a directwww.dovepress.comwww.dovepress.comwww.dovepress.com
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cause of chest pain or if they represent an epiphenomenon
that is associated with symptoms of such pain.
Some of the participants experienced anxiety and
depression. Lillestøl et al38 claim that anxiety and depres-
sion are common in patients with self-reported food
hypersensitivity. However, according to Lind et al,39 psy-
chologic factors were not major predictors of symptom
severity in patients with subjective food hypersensitivity.
The participants in our study had chest pain and no cause of
cardiac origin was found. They still believed they had a heart
disease, but also considered other explanations for their chest
pain. Notably, some were investigated for GORD.
implications for practice The results indicate that listening to patients’ beliefs, per-
ceptions, and expression of feelings related to experiencing
unexplained chest pain should be encouraged and acknowl-
edged by health professionals. The patient’s narrative is
thus a useful tool in the consultation when dealing with the
complexity of living with information needs and uncertainty
related to unexplained chest pain. Topics related to physical
activity and diet seem to be important content in conversation.
Dialoguing about pain as a normal and multifaceted phe-
nomenon in life is also suggested as important. A multidis-
ciplinary approach, such as team work among cardiologists,
dieticians, specialized nurses, and physiotherapists, with
a genuine focus on the patient perspective, and on shared
decision-making is proposed.
Methodologic considerations Because few individuals agreed to participate, we acknowl-
edge that some data may be missing. However, the mate-
rial gives important answers to the research questions and
discloses both manifest and latent content. Although age
and gender varied in the sample, the data analysis revealed
only minor variations. To secure trustworthiness, several
aspects, including credibility and dependability, were
evaluated. Credibility was secured by ensuring that issues
related to the selection16 of the most suitable meaning
units, and how well categories and themes covered the data,
were critically discussed by all authors. The interviews
were audiotaped and transcribed verbatim. Both factors
of instability and the risk of inconsistency during the data
collection procedures were discussed by all coauthors.
The transferability of our findings can be considered by
taking into account the description of participant context,
data collection, and process of analysis.17 To strengthen
the credibility of the analysis, categories, subthemes, and
theme in the search for manifest and latent content were
identified and formulated in the course of the research
team’s discussion.
Conclusion This study reveals unmet information needs, specifically
a lack of focus on individual problems and unanswered
questions during medical consultations as experienced by
people with unexplained chest pain. Existing models of
consultations should be complemented to include a person-
centered approach meeting patients’ beliefs, perceptions, and
expression of feelings related to experiencing unexplained
chest pain. This is in line with a biopsychosocial model with
active patient participation, shared decision-making, and a
multidisciplinary approach. Such an approach is directly
within the domain of nursing, and aims to take into account
the patient’s experience of their condition.
Acknowledgments This study was supported by the Norwegian Nurses
Association. The authors are especially grateful to all the par-
ticipants in the study, and to Anne Marie Skaara (head nurse),
Cordt von Brandis (Cardiologist), and the rest of the staff
of the cardiologic outpatient clinic at Stavanger University
Hospital for their support. The authors also thank Anita
Shenoi, who revised the manuscript for English language.
Disclosure The authors report no conflicts of interest in this work.
References 1. Wong WM, Lam KF, Cheng C, et al. Population based study of non-
cardiac chest pain in southern Chinese: prevalence, psychosocial factors and health care utilization. World J Gastroenterol. 2004;10:707–712.
2. Bass C, Mayou R. Chest pain. BMJ. 2002;325:588–591. 3. Jonsbu E, Dammen T, Morken G, Lied A, Vik-Mo H, Martinsen EW.
Cardiac and psychiatric diagnoses among patients referred for chest pain and palpitations. Scand Cardiovasc J. 2009;43:256–259.
4. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD. How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart. 2007;93: 458–463.
5. Eslick GD, Talley NJ. Non-cardiac chest pain: predictors of health care seeking, the types of health care professional consulted, work absen- teeism and interruption of daily activities. Aliment Pharmacol Ther. 2004;20(8):909–915.
6. Dammen T, Arnesen H, Ekeberg Ø, Friis S. Psychological factors, pain attribution and medical morbidity in chest-pain patients with and without coronary artery disease. Gen Hosp Psychiatry. 2004;26:463–469.
7. Jerlock M, Gaston-Johansson F, Danielson E. Living with unexplained chest pain. J Clin Nurs. 2005;14:956–964.
8. Fagring AJ, Gaston-Johansson F, Danielson E. Description of unex- plained chest pain and its influence on daily life in men and women. Eur J Cardiovasc Nurs. 2005;4:337–344.www.dovepress.comwww.dovepress.comwww.dovepress.com
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information needs of patients with unexplained chest pain
9. Turk DC, Monarch ES. Biopsychosocial perspective on chronic pain. In: Turk DC, Gatchel RJ, editors. Psychological Approaches to Pain Management: A Practitioner’s Handbook. 2nd ed. New York, NY: The Guildford Press; 2002.
10. Mayou R. Chest pain, palpitations and panic. J Psychosom Res.1998;44:53–70.
11. Knowles MS. The Adult Learner: A Neglected Species. 4th ed. Houston, TX: Gulf Publisher Co; 1990.
12. Timmins F. A review of the information needs of patients with acute coronary syndromes. Nurs Crit Care. 2005;10:174–183.
13. Price JR, Mayou RA, Bass CM, Hames RJ, Sprigings D, Birkhead JS. Developing a rapid access chest pain clinic: qualitative studies of patients’ needs and experiences. J Psychosom Res. 2005;59:237–246.
14. Pâquet M, Bolduc N, Xhignesse M, Vanasse A. Re-engineering cardiac rehabilitation programmes: considering the patient’s point of view. J Adv Nurs. 2005;51:567–576.
15. Ekman I, Swedberg K, Taft C, et al. Person-centered care – ready for prime time. Eur J Cardiovasc Nurs. 2011;10:248–251.
16. Kvale S, Brinkmann S. Interviews: Learning the Craft of Qualitative Research Interviewing. 2nd ed. Los Angeles, CA: Sage; 2009.
17. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–112.
18. Labrunèe M, Pathac A, Loscos M, Coudeyre E, Casillas J-M, Gremeaux V. Therapeutic education in cardiovascular diseases: state of the art and perspectives. Ann Phys Rehabil Med. 2012;55:322–341.
19. Dossey BM, Guzzetta CE. Holistic nursing practice. In: Dossey BM, Keegan L, Guzzetta CE, editors. Holistic Nursing: A Handbook for Practice. 4th ed. Sudbury, MA: Jones and Barlett; 2005.
20. van Ravesteijn H, van Dijk I, Darmon D, et al. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012;86:3–8.
21. Bunker SJ, Colquhoun DM, Esler MD, et al. “Stress” and coronary heart disease: psychosocial risk factors. Med J Aust. 2003;178(6):272–276.
22. Walters K, Rait G, Petersen I, Williams R, Nazareth I. Panic disorder and risk of new onset coronary heart disease, acute myocardial infarction, and cardiac mortality: cohort study using the general practice research database. Eur Heart J. 2008;29:2981–2988.
23. Robertson N, Javed N, Samani NJ, Khunti K. Psychological morbidity and illness appraisals of patients with cardiac and non-cardiac chest pain attending a rapid access chest pain clinic: a longitudinal cohort study. Heart. 2008;94:e12.
24. Penrod J. Refinement of the concept of uncertainty. J Adv Nurs. 2001;34:238–245.
25. Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cognit Ther Res. 1992;16:143–163.
26. Leventhal H, Benyamini Y, Brownlee S, et al. Illness representations: theoretical foundations. In: Petrie KJ, Weinman JA, editors. Perceptions of Health and Illness. 2nd ed. Amsterdam, The Netherlands: Harwood Academic Publishers; 1998.
27. Hagger MS, Orbell S. A meta-analytic review of the common-sense model of illness representations. Psychol Health. 2003;18:141–184.
28. Hansen BS, Rørtveit K, Leiknes I, et al. Patient experiences of uncertainty – a synthesis to guide nursing practice and research. J Nurs Manag. 2012;20:266–277.
29. Williams DA, Thorn BE. An empirical assessment of pain beliefs. Pain. 1989;36:351–358.
30. Williams DA, Robinson ME, Geisser ME. Pain beliefs: assessment and utility. Pain. 1994;59:71–78.
31. Cogan J, Ouimette MF, Vargas-Schaffer G, Yegin Z, Deschamps A, Denault A. Patient attitudes and beliefs regarding pain medication after cardiac surgery: barriers to adequate pain management. Pain Manag Nurs. Epub 2013 Feb 26.
32. Petrie KJ, Müller JT, Schirmbeck F, et al. Effect of providing information about normal test results on patients’ reassurance: randomised controlled trial. BMJ. 2007;334(7589):352.
33. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in prevention and treatment of atherosclerotic cardiovascular disease: a statement from the council on clinical cardiology (Subcommittee on exercise rehabilitation and prevention) and the council on nutrition physical activity and metabolism (Subcommittee on physical activity). Arterioscler Thromb Vasc Biol. 2013;23:e42–e49.
34. Williams A, Lindsell C, Rue L, Blomkalns A. Emergency department education improves patient knowledge of coronary artery disease risk factors but not the accuracy of their own risk perception. Prev Med. 2007;44:520–525.
35. Wise FM, Patrick JM. Resistance exercise in cardiac rehabilitation. Clin Rehabil. 2011;25:1059–1065.
36. Jonsbu E, Dammen T, Morken G, Moum T, Martinsen EW. Short-term cognitive behavioral therapy for non-cardiac chest pain and benign palpitations: a randomized controlled trial. J Psychosom Res. 2011;70: 117–123.
37. Hershcovici T, Navarro-Rodriguez T, Fass R. Non-cardiac chest pain: an update. CML – Gastroenterology. 2011;30:37–54.
38. Lillestøl K, Berstad A, Lind R, Florvaag E, Lied GA, Tangen T. Anxiety and depression in patients with self-reported food hypersensitivity. Gen Hosp Psychiatry. 2010;32:42–48.
39. Lind R, Lied GA, Lillestøl K, Valeur J, Berstad A. Do psychological factors predict symptom severety in patients with subjective food hypersensitivity? Scand J Gastroenterol. 2010;45:835–843.http://www.dovepress.com/patient-preference-and-adherence-journalhttp://www.dovepress.com/testimonials.phphttp://www.dovepress.com/testimonials.phpwww.dovepress.comwww.dovepress.comwww.dovepress.comwww.dovepress.com
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