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2005;14:285-293Am J Crit CareAnne G. Rosenfeld, Allison Lindauer and Blair G. DarneyInfarction: Descriptions of Decision-Making PatternsUnderstanding Treatment-Seeking Delay in Women with Acute Myocardial

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AMERICAN JOURNAL OF CRITICAL CARE,July 2005, Volume 14, No. 4 285

BACKGROUND Women delay seeking treatment for symptoms of acute myocardial infarction longer

than men delay. Womens delay time has not been thoroughly characterized.

OBJECTIVES To qualitatively describe the period between the onset of symptoms of myocardial infarc-

tion and enactment of the decision to seek care (decision time) and to identify common patterns of cogni-

tive, affective, and behavioral responses to the symptoms (decision trajectories). METHODS In this qualitative study, 52 women were asked in semistructured interviews to describe the

symptoms and related thoughts, decisions, and actions from the onset of symptoms of myocardial infarc-

tion to arrival at the hospital. Narrative analysis was used to examine the stories and to identify patterns

of decision-making behavior.

RESULTS Six common patterns of behavior during the decision time were identified: knowing and

going, knowing and letting someone take over, knowing and going on the patients own terms, knowing

and waiting, managing an alternative hypothesis, and minimizing. The patterns were further grouped as

knowing or managing. Women in the 2 groups (knowing and managing) differed primarily in their

awareness and interpretations of the symptoms and in their patterns of behavior in seeking treatment.

CONCLUSIONS Womens delay in seeking treatment for symptoms of myocardial infarction can be cate-

gorized into distinct patterns. Clinicians can use knowledge of these patterns to detect responses and sit-

uations that can decrease decision time in future cardiac events and to educate women about how to

respond to cardiac symptoms. (American Journal of Critical Care. 2005;14:285-293)

UNDERSTANDING TREATMENT-SEEKING DELAY INWOMEN WITH ACUTE MYOCARDIAL INFARCTION:

DESCRIPTIONS OF DECISION-MAKING PATTERNS

To purchase reprints, contact The InnoVision Group, 101 Columbia, AlisoViejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax,(949) 362-2049; e-mail, [email protected].

By Anne G. Rosenfeld,PhD, RN, CNS,Allison Lindauer,MSN, FNP, and Blair G. Darney,MPH.From School ofNursing, Oregon Health & Science University, Portland, Ore.

More women in the United States die of heartdisease than of any other cause, and one

form of heart disease, myocardial infarction,is responsible for the majority of these deaths. Moreover,

women who survive myocardial infarction are at high

risk for recurrent episodes of it and for heart failure.Several medical therapies are available to treat myocar-dial infarction and can greatly reduce the morbidity and

mortality associated with it. In order to be effective,these therapies must be delivered rapidly, within 2 hours

of the onset of symptoms.1,2Nevertheless, many patientsdelay several hours and sometimes days before seeking

care for their symptoms of myocardial infarction, and inmost studies,3-8 women delayed longer than men did.

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This period between the onset of symptoms andentry into the healthcare system is termed treatment-seeking delay, and it can be divided into 3 phases: (1)decision time, the interval from onset of acute symp-

toms to the decision to seek care and subsequent enact-ment of that decision (eg, calling 911); (2) transport

time, the period from the enactment of the decision to

seek care to arrival at the emergency department; and(3) therapy time, the period from arrival at the emer-gency department to initiation of medical treatment.

(We use this definition of therapy time because pre-hospital thrombolytic therapies are in very limited prac-

tice in the United States.) Although major advances intransport time and therapy time have been made in the

past 2 decades, little progress has been made in reducingpatients delay in seeking treatment, that is, in reducing

decision time. Reducing the time between the onset ofthe symptoms and entry into the healthcare system is

an important clinical and research priority.1,3,9,10

In our research, we focus on describing the deci-sion time in women, because women delay seekingtreatment longer and have worse outcomes from

myocardial infarction than do men. The long-termgoal is to develop an educational intervention to reduce

decision time and improve outcomes for women expe-riencing myocardial infarction.11

Understanding and addressing the decision time is

difficult because the target behavior takes place beforepatients enter the healthcare system. Most researchers

have measured decision time as a single outcome vari-able, documented in minutes and hours, but without any

description of what occurred during the decision time.

Time is an important variable because of its relationshipto morbidity and mortality associated with myocardial

infarction, but decision time has been a deceptively sim-ple measure of a complex number of decisions, symp-

toms, and behaviors that occur during the decision time.

A description of the course of the symptoms and theresponses that make up that complex time span may bemore useful in understanding the phenomenon of delay

in seeking treatment, and such a description could laythe foundation for developing an intervention to reduce

the delay in women experiencing myocardial infarction.Women respond to the symptoms of myocardial

infarction in a variety of ways, but these responses havenot been well characterized. The purpose of this study

was to identify and describe the patterns of cognitive,affective, and behavioral responses of women from the

onset of symptoms of myocardial infarction to thedecision to obtain medical care to the action of seek-

ing care and entry into the medical system. We callthese patterns decision trajectories. Researchers haveused various theoretical frameworks to study the delay

in seeking treatment12

and have documented character-istics of the decision time phase,12-14but we still do nothave a good understanding of what happenedwhat

women were doing and experiencingduring thedecision time. We used inductive, qualitative strategies

to describe this period.Decision trajectories (ie, patterns of decision-making

behavior) in women who delay seeking treatment for

myocardial infarction are dynamic and can be shaped bya number of intrapersonal and social influences.15 A

range of decision times has been documented,4,12,16-19 andmanifestations of symptoms and courses differ among

women and between women and men.20-22 Therefore, wethought that women experiencing myocardial infarction

might follow varied decision trajectories. We conductedfocused semistructured interviews to elicit individual

stories and then used narrative analysis techniques toidentify common patterns of behavior that occurred dur-

ing the delay in seeking treatment.

MethodsWe recruited women who were hospitalized for

their first myocardial infarction, and we chose the

acute care setting to learn their stories soon after thestories occurred. All 52 participants were given the

option of completing the protocol in 2 sessions to

reduce the burden of taking part in the study, but nowoman chose to do so. This study was approved by

the appropriate institutional review board.Each woman was asked, in a focused semistruc-

tured interview format, to describe the events that

occurred from the onset of symptoms of the myocardialinfarction to the time of her arrival at the hospital. Thewomen were asked to describe not only their symptoms

but also their related thoughts, feelings, decisions, andactions. We probed for the womens interpretations of

these events and for the exact times of the onset ofsymptoms and the decision to seek care. Each inter-

view led to a complete story of the womans pattern ofdecision-making behavior, her decision trajectory.

286 AMERICAN JOURNAL OF CRITICAL CARE,July 2005, Volume 14, No. 4

Women delay seeking treatmentlonger and have worse outcomes frommyocardial infarction than do men.

Little progress has been made in reducingpatients delay in seeking treatment.



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Using the benchmarking technique of Alonzo,23

we determined a decision time for each woman. In this

approach, women who could not remember exact timeswere asked to time the onset of symptoms by relating

the onset to routine daily events, such as a favorite tele-vision program. Because we were interested in the pat-

tern of responses, we did not establish a priori categories

based on time frames. Interviews were tape-recordedand were transcribed for analysis.We used narrative analysis to examine the stories and

to identify decision trajectories. A narrative is defined asa story about a specific past event.24Narrative analysis

describes a meaning structure that rather than merelylisting a contextual sequence of events organizes the

story as a whole. By meaning structure, we mean thatthe researcher listens to the story and seeks to identify

the organizing structure and the meaning for the story-

teller. In this narrative analysis, we focused on the corenarrative of each womans decision making to identify

her decision trajectory.Narrative analysis has 2 goals: to identify the orga-

nizing structure of each narrative, the pattern thatholds it together, and to categorize common themes of

behavior across stories. In this study, these themesdescribe common decision trajectories. To achieve the

first goal, we used the structural approach of Labov.24

The 6 elements of this approach are as follows:

1. the abstract, which is a summary of the narrative;2. the orientation, including the time, place, set-

ting, and individuals present;3. the actions or the sequence of events;

4. the evaluation, which is the assessment of the

significance and meaning of the actions;5. the resolution, which is what finally happened;

and

6. the coda, or the returning from the narrative tothe present.

We included symptoms as a subcategory of actionsbecause they were crucial to our interpretation of the

narratives. We read each transcript and coded clausesor sections for structural elements. Additional codes

were added as the analysis revealed important featuresor themes, such as reluctance to call 911. After this cod-

ing, we wrote a summary of the core narrative, or skele-

ton plot, for each story. Polkinghorne25 defines plot asthe organizing theme that identifies the significanceand the role of the individual events. Accomplish-

ment of this first goal provides within-subject analysis;that is, the cognitive, affective, and behavioral responses

in each womans story.We then used these organizing themes to develop a

decision trajectory for each story and labeled the trajec-tories. Examples of labels we developed include knowing

and waiting and managing an alternative hypothesis. Foreach story, in addition to writing the core narrative, we

developed a large matrix26 containing descriptive informa-tion. These matrices were used for both within- and

across-case analyses,27 and their components includedsymptoms, clinical characteristics (eg, prior heart dis-

ease), intrapersonal influences (eg, affective, cognitive,

and behavioral responses), sociostructural influences (eg,presence of others), and triggers to action.To achieve the second goal of narrative analysis, to

identify common themes across cases, we used con-stant comparison28 to compare the individual themes

and patterns. Two of us, the principal investigator (AGR)and the senior research assistant (AL), independently

categorized each individual pattern into one of the emerg-

ing categories of decision trajectories; we discussed anydiscrepancies until we reached an agreement or identi-

fied a need to further develop the categories. As the cat-egories were developed, we returned to earlier cases and

compared the organizing structure of those stories withthe current categories. At the conclusion, of the 52 nar-

ratives in our sample, each of 48 narratives was classifiedinto 1 of 6 types of decision trajectories, and descriptions

of each type were finalized. Four narratives could not beclassified as 1 of the 6 types; these we termed ambigu-

ous.29 The software program N530 was used to organizeanalysis of the qualitative data.

Techniques to ensure validity of the findings includedkeeping detailed accounts of the procedures followed and

reviewing findings with 4 participants in a focus groupformat. In the focus group discussions, descriptions of the

patterns of decision-making behavior were presented for

evaluation of the truthfulness of the descriptions. Thewomen enthusiastically endorsed the descriptions andgave only minor suggestions for changes.31

ResultsStudy participants were 38 to 87 years old (mean

67.4, SD 12.7), had a mean of 13.1 (SD 2.3) years of

education, and were predominantly white, insured, mar-ried, and unemployed, retired, or housewives.

We found 6 types of decision trajectories. Each typewas composed of individual stories that shared common

cognitive, affective, and behavioral responses. All trajec-

tories shared narrative elements, such as awareness andinterpretation of symptoms, triggers to action, and therole of others, that varied across the patterns. Although

the 6 trajectories were unique enough to be separate, 4had commonalities in the evaluation element and were

further grouped as knowing. The 2 remaining trajectoriesshared a common course of action and were grouped as

managing (see Table). The women in the 2 groups dif-fered primarily in their awareness and interpretations of




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symptoms of myocardial infarction and in their patternsof decisions about whether and how they sought treat-

ment. Women who told stories of managing delayedseeking treatment for their symptoms longer than did

those who told stories of knowing.

Knowing Group

The knowing group encompassed women whoknew that they would seek care for their symptoms or

who knew that they needed help, although this classifi-cation does not mean that women knew that they were

having a heart attack. All the women in the knowing

group had the common defining characteristic of mak-ing a decision early; women said they needed to seekhelp or told someone about their symptoms. This group

consisted of 4 trajectories: knowing and going, know-ing and letting someone take over, knowing and going

on the patients own terms, and knowing and waiting.Most of the fast-track patterns appeared in the

knowing group. The fast track is the desired pattern:recognizing symptoms as serious and entering the emer-

gency medical system in less than 1 hour from onset ofsymptoms. Ideally, women experiencing symptoms of

myocardial infarction call 911 within 15 minutes ofthe onset of the symptoms; indeed, recent guidelines32

call for the public to respond within 5 minutes. Fast-track responses to symptoms are a model of desired

behavior to minimize decision time.

Knowing and Going. The 14 women with stories ofknowing and going knew almost immediately thatsomething was wrong; sometimes, but not always, they

knew or suspected they were having a heart attack. A

total of 9 of the 14 women with this pattern followed afast track for seeking care, calling for or obtaining help

within 1 hour of the onset of symptoms. The key featureof these stories was that women acknowledged some-

thing was wrong, made a decision to seek care, and

acted on their decision within a relatively short time.Fast-track knowing-and-going stories described

the sudden onset of severe symptoms or of symptoms

that soon became severe. A total of 7 women had symp-toms that occurred at home; 1 womans symptoms started

at home, but she then went out to eat; and 1 womanssymptoms occurred on the job. These 7 women paid

immediate attention to their symptoms, that is, theyacknowledged the presence of the symptoms. Many

noted that they didnt think too long about them,typically because the symptoms were so overwhelm-

ing: When youre in so much pain, you really dontthink too much, except to get rid of that pain. All but

2 called 911 (or asked someone present to call) within30 minutes, although this group was not uniformly

confident about using emergency medical services. As

1 woman with a story of fast-track behavior put it,What if it turned out to be gas again? Then Id feel like

an idiot. One woman drove herself within this time.Most of the women (n = 7) thought they were or

might be having a heart attack. Some just knew;others had learned the symptoms of a heart attack and

recognized them. Significantly, their stories indicatedthat their first thoughts were that something was not

right, but not that they were having a heart attack.Some of these women had other conditions, such as

diabetes or gastroesophageal reflux disease, and triedmedications or checked their blood glucose levels, but

they quickly dismissed these possibilities as the causeof their symptoms; this evaluation is central to classi-

fication of these stories as knowing and going. Manyof these women said they were scared during their

experience of the symptoms.Cognitive processes were key to the knowing-and-

going fast-track stories: a quick acknowledgment (per-haps because of the nature of the symptoms) and

minimal contemplation. Most women with knowing-and-going stories thought they were or might be having

a heart attack: Theres nothing else behind the leftbreast, 1 woman recalled. A key feature of this group is

that tellers of fast-track stories did not describe the rea-

sons for the delay in seeking treatment as others had.Physiology may also play a role here; that is, severesymptoms are hard to ignore. However, we also heard

stories from women with severe symptoms who did notpursue a fast track, so physiology does not entirely

explain their behavior.The knowing-and-going stories that did not describe

fast-track behavior were also similar; these women

knew something was wrong and decided early to seekcare; thus, their stories echoed fast-track stories, but

for various reasons these women did not call 911 orarrive at emergency care within 1 hour of the onset of

symptoms. One reason is that symptoms of myocardialinfarction are often hard for patients to interpret. For

example, 1 woman vomited bile and knew somethingwas wrong, but because she did not think her symp-

toms were those of a cardiac problem, she went to anurgent care clinic rather than calling 911. In these sto-

ries, the women sought care despite a lack of clarity.Another woman with this pattern had intermittent

chest pain for 2 days; she saw her physician, who told


Reluctance to call 911 was a majortheme in many stories regardless ofthe patterns of decision making.



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her the pain was gastrointestinal in nature but instructed

her to go to the emergency department if the symp-

toms came back and were not relieved by gastroin-testinal medications. When her symptoms recurred

later that evening, she followed this advice and hadher daughter drive her to the emergency department.

We categorized this womans story as knowing andgoing because we focused on the episode of symp-

toms directly linked to her myocardial infarction. Itwas sometimes difficult to separate the early warning

or prodromal symptoms20 from the actual myocardialinfarction, but our focus was the womans decision

making for the symptoms of myocardial infarction.In summary, whether on the fast track or not,

women with knowing-and-going stories acknowl-edged that something was wrong and decided early to

seek medical care for their symptoms. They thendescribed acting on that decision.

Knowing and Letting Someone Take Over. The

stories of the 4 women with the pattern of knowingand letting someone take over suggested that women

did not always know or say that their symptoms wereheart related or even explain their symptoms. The key

feature of this group was that the stories followed apassive pattern: women told someone they had symp-

toms or admitted so when asked and were willing to

go along with recommendations to seek medical care;that is, they allowed someone to take over. Sometimes

this decision resulted in a fast track, but it is unclear

what would have happened if someone had not takenover. None of the women in this group stated that she

had other plans for dealing with her symptoms.For 2 of the 4 women, the symptoms started when

the women were out, 1 at church and 1 at work. The other2 women were at home; 1 woman related her symptoms

to her husband, and 1 woman called her daughter. Thewoman whose symptoms began at work had the sudden

onset of headache, jaw and neck pain, and a band ofpain and heaviness from armpit to armpit. She thought

something was definitely wrong but did not think she

was having a heart attack. She first suspected an air-borne toxic agent, but then she realized no one else in

the office was ill. A coworker came by and said thewoman did not look well. From this point in her story,

the woman used the pronoun we, saying, for example,We called the supervisor. The supervisor agreed the

woman did not look well and asked if she wanted some-one to call 911. Tellingly, the woman said, We agreed.

The woman arrived at the emergency department 1 hourafter her symptoms started. Knowing-and-letting-some-

one-take-over stories began similarly to stories in theknowing-and-going group, but then the women followed

a more passive pattern to reach medical care, allowingothers to take over decision making and enactment.

Knowing and Going on the Patients Own Terms.The 3 women classified as knowing and going on the

patients own terms recognized symptoms, but their sto-ries were different. Even when these women described

seeking advice, they did not always follow the advice,choosing to reach medical care in other ways. These

other ways involved driving to the hospital rather thancalling 911 and calling a primary care provider rather

than going to the hospital, all of which added time.One woman had pain where the head joins the

body as well as shoulder pain and a hot feeling in themiddle of her chest. When the symptoms got worse, she

decided to seek help. She called her physicians office;he was not in, but the nurse asked the woman to describe

what was wrong. The nurse relayed this information toanother physician, who got on the telephone and told

the patient she was having all the symptoms of a

myocardial infarction; she should call 911 immediately

and go to the emergency department. As we heard frommany women, this woman did not want to call 911 anddeal with all the attention produced by an ambulance.

So she called her family, but had to make several tele-phone calls and leave messages before she reached

someone. When a family member arrived, the womanasked to be driven to the hospital. On the way, they

encountered delays due to road construction. Theyfinally asked to be let through for a medical emergency.


Women with stories of knowing andgoing acknowledged that somethingwas wrong, decided to seek care, andacted on that decision within a relatively

short time.

Trajectories of responses to symptoms of myocardialinfarction (n =52)*

No. of

Group Trajectory women

*A total of 4 women had patterns that were ambiguous and couldnot be classified.

Knowing and going

Knowing and letting some-

one take over

Knowing and going on thepatients own terms

Knowing and waiting

Managing an alternative

hypothesis

Minimizing

14

4

3

4

11

12

Knowing

Managing



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All together, it was 5 hours between the onset of thesymptoms and arrival at the emergency department.

The stories these women told suggested that theywanted to remain in control and were not willing to let

others make decisions for them; the women openlyacknowledged that they did not like to ask others for

help. One womans daughter saw her in bed with

symptoms and strongly advised her to go to the hospi-tal, and the woman replied, No, I dont want to go tothe hospital. The woman acknowledged, I guess I

want to do everything myself.

Knowing and Waiting. The 4 women in the know-ing-and-waiting group decided that they needed help

but did not call during the night or on the weekend.Usually they delayed seeking treatment because they

did not want to disturb others; so they waited until themorning or Monday to seek help.

One woman, an 86-year-old widow living in anassisted living facility, first experienced symptoms while

she was getting ready for bed. The pain persisted allnight. In her story, the woman focused on her reasons

for not calling the facility manager or her children.She related that the residents were to contact the man-

ager when they had an emergency so that the managercould call 911. The woman said, I didnt want to wake

those people. She also listed the specific reasons shedecided not to call her children. Thus, she had decided

she needed help, but waited until 6 AM to call.

Summary. The common pattern that tied the 4knowing trajectories together lies in the evaluation ele-ment of each narrative: the recognition of the symptoms

as serious, although not necessarily as indicative of a

heart attack. The 4 knowing trajectories differed in theactions or sequence of events and symptoms and in theresolution, the various paths taken to seeking treatment.

Managing Group

Women in the managing group had a steady orsmooth pattern of decision making. Women with man-

aging stories decided on a course and followed it untila trigger prompted action. A common resolution in

this group was to wait to seek help until shes in trou-ble or admits somethings wrong. The managing group

includes 2 patterns: managing an alternative hypothe-

sis (often a gastrointestinal problem such as gastro-esophageal reflux disease) and minimizing.

Managing an Alternative Hypothesis. A total of 11women had stories that fit into the pattern described as

managing an alternative hypothesis; 7 of the 11 attributedthe cause of their symptoms to gastrointestinal prob-

lems. Many started their story by saying, I thought Ihad . . . Thus, these women had developed a working

hypothesis or explanation for their symptoms, result-

ing in the actions they took. These actions involvedtreating the presumed cause with products such asantacids, baking soda and water, food, and carbonated

beverages. Many of the women said they did not real-

ize that their symptoms were related to a cardiac prob-lem: Having a heart attack never once entered my

head, was a typical response. Others, however, activelyruled out myocardial infarction as the source of their

symptoms. One woman who had a family member inthe medical profession was told her symptoms could be

reflux or a heart attack; she said shed go with reflux.Although women with stories with other patterns

expressed similar thoughts, they moved on to seekhelp. The actions taken by women with managing sto-

ries were steady, in the sense that the women contin-ued to act on their explanation until their symptoms

became unbearable or changed. In many instances, thesymptoms were severe. Thus, as in the knowing group,

severity of symptoms did not always determine thepath of behavior.

One African-American woman attributed hersymptoms to gallstones. She said she had gas, pain,

and hurting in her chest and had been gasping for air.Her total decision time was 30 hours, during which

she tried several remedies, including baking soda and

water, 7-Up, beer, and food. The last night she vom-ited all night long and consulted with her mother, whohad had gallstones in the past. The woman then asked

a friend to drive her to the doctors office. The frienddecided to drive her to the hospital instead because of

the vomiting. This woman stated, So if I would haveknown it was my heart, I would have been in a long

time ago.Several women with stories of managing an alter-

native hypothesis spoke about worries related to call-

ing 911, a theme we heard in stories from women ofall trajectory types. One woman said, You feel half

afraid . . . theres nothing wrong and youre going tofeel like a fool. Another woman described her reluc-

tance to go to the emergency department for fear ofbeing told that she was wasting their [hospital staffs]

time. A third stated, I just thought it was serious indi-gestion, and they were going to laugh at me by the time

I got to the doctors office, a statement that describesboth her alternative hypothesis and her worry related to

seeking care.


Women with managing storiesdecided on one course and followedit until a trigger (eg, symptomsbecame unbearable) prompted action.



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Minimizing. A total of 12 women had stories thatwere categorized as minimizing. Women with these

stories tried to ignore their symptoms or hoped thesymptoms would go away. For example, 1 woman had

discomfort in the left side of her chest and in her leftarm when she got up in the morning, but she show-

ered, got dressed, and went to work, hoping maybe it

will go away. Most of the women with minimizingstories did not recognize that their symptoms wererelated to a cardiac problem. For example, 1 woman

with sharp, tight pain in her jaw, ears, and neck said,To me they did not typify a heart attack. Most of the

women reported that they sat in a chair or went to bed

for the time they waited, If I positioned myself a cer-tain way, it would ease the pain. So I managed that

way until the evening.

A married woman had pain in her neck and jaw,

under her arm, and down the arm and hard breathingfor a week. When her granddaughter asked whether

she should tell the womans husband, the womanresponded, No, honey. Im letting it pass. Im better

now. Finally, just after putting supper on the table, thewoman felt heaviness in her chest and was perspiring,

and she decided, Something is wrong. So she told

her husband she needed to go to the hospital rightaway, and he drove her. She had had a myocardialinfarction the week before and another one at the time

she went to the hospital.The stories in the minimizing group ended in 1 of 2

ways: the woman made the decision to seek helpbecause the symptoms worsened or she decided some-

thing was wrong, or a family member decided for her.The steady pattern leading up to the resolution of these

stories is what distinguishes stories of minimizing.

Summary. Womens stories in the 2 trajectorytypes in the managing group were distinguished by a

steady course of actions, or rather nonactions, thatinitially did not include obtaining outside help. Women

with stories of managing an alternative hypothesischose a noncardiac explanation and pursued its man-

agement. Several of these women had previously diag-nosed noncardiac conditions with similar symptoms,

perhaps adding to their difficulty in recognizing thecurrent symptoms as cardiac in origin. The minimiz-

ing stories differed from the managing-an-alternative-

hypothesis stories in that the women who told theminimizing stories did not acknowledge their symp-

toms until the symptoms became unbearable or some-one else decided to act on them.

DiscussionThe descriptions of womens patterns of cognitive,

affective, and behavioral responses from the time ofonset of the symptoms of myocardial infarction to entryinto the medical systemtheir decision trajectoriesrevealed common themes of behavior and action acrossindividual stories, which we categorized into 6 decision

trajectories. We also found common components (aware-ness and interpretation of symptoms, actions, role of oth-

ers) among the trajectory types. Our findings have

important implications for how nurses educate patientsabout how to respond to cardiac symptoms.

Our results suggest that educating women andtheir physicians about interpreting the symptoms of

myocardial infarction remains a significant obstacle inreducing decision time. Schoenberg et al33 described

womens confusion about the symptoms of myocardialinfarction as central to the womens delay in seeking

treatment, as did Finnegan et al,34 who studied sur-vivors of myocardial infarction and bystanders who

witnessed the infarctions. The interpretation of symp-toms posed challenges for many of the women in our

sample as well, and our findings lend context to thelonger delay times observed in women.4

I never thought it was a heart attack, was expressed

in stories with a variety of patterns. Even the know-ing-and-going fast-track stories described a lack of

clarity about symptoms (What if it turned out to begas again?). And although the stories categorized as

managing an alternative hypothesis did not describe

uncertainty, the women with these stories fixed onnoncardiac origins for their symptoms (I thought itwas just serious indigestion). McKinley et al35 found

that attributing symptoms to a noncardiac cause con-tributed to delay in seeking treatment.

Similarly, uncertainty about symptoms was evidentin stories of knowing and letting someone take over (1

woman thought she was suffering from some kind ofairborne toxic agent) and in stories of minimizing (I


Women with minimizing stories triedto ignore their symptoms or hoped theywould go away.

Educating women and their physiciansabout interpreting the symptoms ofmyocardial infarction remains a signifi-cant obstacle in reducing decision time.



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thought it was a toothache), but resolutions to the nar-ratives differed, partly because of the role of others. The

crucial difference is that those women with knowing-and-going stories decided that their symptoms were

serious despite uncertainty and took action, and thusthese stories may provide key information for teaching

women to act in the face of uncertainty.

In addition to uncertainties about the symptomsof myocardial infarction, reluctance to call 911 was amajor theme in stories across the patterns of decision

making. Previous investigators13,34,36 found that embar-rassment about calling 911 may lead to increased

delay in seeking treatment. Our results highlight thefact that even some women who told stories of fast-

track behavior, deciding to access care quickly and

acting on that decision, shared this feeling.As difficult as recognizing the symptoms and calling

911 were for women, we heard stories that suggestedthat these factors were not the only obstacle to overcom-

ing delays in seeking treatment. Individual characteristicsalso played an important role in womens treatment-seek-

ing decisions and actions. Some women told stories ofwanting to remain in control of decision making and

actions related to their symptoms, even in the face ofadvice from a doctor, nurse, or trusted family member.

This sort of behavior, rooted not in a lack of knowledgeor certainty but in personal characteristics and psychoso-

cial processes, may be difficult to change. Our findingssupport those of Dempsey et al,13 who identified control

as central to the treatment-seeking process, and add newinsight about the need to target educational messages.

We used an inductive approach to describe womens

patterns of decision making and thus did not use an apriori conceptual framework. However, other studiesin our program of research are designed on the basis

of social cognitive and self-efficacy theories.11 Wechose these approaches because of their potential to

provide guidelines for interventions to modify behavior.Many researchers12,37 have used Leventhals common-

sense model of self-regulation as a framework forstudying delays in seeking treatment. Our findings are

not inconsistent with this theory, which proposes thatpersons form hypotheses about the meaning of symp-

toms and then decide on coping actions. The success

of those actions is evaluated, and appraisals of theireffectiveness are formed. Community-based interven-tions partially based on Leventhals theory have not

been successful to date.17,38 Our findings suggest thatindividual, tailored interventions may have more suc-

cess in producing behavioral changes that wouldreduce delays in seeking treatment.

Our descriptions of the womens narratives havelimitations, including potential recall bias and the

homogeneity of the sample. We were not able to obtainall possible stories, specifically, stories of women who

did not survive a myocardial infarction. However, wewere able to obtain a range of narratives of women

who differed in their delay in seeking treatment, theirsymptoms, and their resolution of the problem. This

study provides useful descriptions of what occurs dur-

ing the decision time that can be used to develop edu-cational interventions to reduce treatment-seekingdelay that are based on womens experiences of the

symptoms of myocardial infarction. Such interven-tions may be more effective than interventions based on

content dictated by healthcare professionals because the

interventions are based on what women actually feel,think, and do in these situations.

Rather than trying to explain why women delayseeking treatment for the symptoms of myocardial

infarction, we sought to describe what happens duringthe decision delay period. Researchers to date have elu-

cidated sociodemographic and clinical factors associ-ated with delay in seeking treatment3,5,12,19,36 or have

focused on discrete aspects of the decision time, such asemotional arousal.39 In our qualitative descriptive study,

we used narrative analysis techniques to detect and cate-gorize commonalities in womens experience of the

entire decision time. We plan to use these descriptions todiscuss with women the kinds of situations, behaviors,

and responses that result in treatment-seeking delay andthus which paths to avoid with future cardiac events.

Despite all the resources devoted to reducingtransport time and therapy time for myocardial infarc-

tion, areas in which marked technological advances have

been made during the past 2 decades, little progress hasbeen made in reducing patients decision time, wheremost of the minutes, hours, or days of delay are con-

centrated.12,16 We hope that an individualized interven-tion tailored to womens experiences will be more

effective than previous community-based trials17 indecreasing decision time. Our narrative analysis of

womens own stories of decision time, resulting indescriptions of 6 decision trajectories (patterns of behav-

ior), describes the course of the myocardial infarctiondecision time. Our findings therefore provide knowl-

edge women can use to identify factors, responses, or

situations that can decrease decision time and ulti-mately improve womens cardiac health.

ACKNOWLEDGMENTSWe thank the nursing staffs of Providence St. Vincent Medical Center, ProvidencePortland Medical Center, and Oregon Health & Science University Hospital, Port-land, Ore; Kathleen Knafl; Judith Kendall; and Rachel Dresbeck.This research was supported by a grant (R01 NR05268) to Anne G. Rosenfeld,principal investigator, from the National Institute of Nursing Research.

Commentary by Mary Jo Grap (see shaded boxes).




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