The spiritual dimension of perceived life satisfaction in heart attack

This descriptive exploratory study was conducted in Malta in the local acute general hospital. The spiritual dimension of life satisfaction was explored twice by audio-taped face to face interviews on patients, aged > 65 years old with heart attack across the first three months (Time 1: n = 63; Time 2: n = 51) following onset of myocardial infarction. The study was guided by the theory: hierarchy of human needs. The findings identified two main themes namely: positive and negative spiritual influencing factors. The positive spiritual enhancing factors included family relationships, achievement of life goals and helping others. The spiritual negative influencing factors consisted of unfinished business and unachieved goals in life. The spiritual dimension was oriented towards finding meaning and purpose in life and turning to God for empowerment to cope with their holistic needs. Similarities were found between the findings of both data collection. While acknowledging


Introduction
Life satisfaction is a state of perceived well-being derived from the degree of achieving personal aspired goals in life (STURESSON;BRANHOLM, 2000).Research on life satisfaction has been integrated into the concept of quality of life (QOL) (ROEBUCK; FURZE; THOMPSON, 2001).Quality of Life (QOL) is a holistic concept incorporating the physical, psychological, social, spiritual and environmental domains (PILKINGTON; MITCHELL, 2004;GROENEVELD;SUE, MATTA, 2007;KALFOSS;LOW;MOLZAHN, 2008).Also, QOL is the individual's perceptions of one's life situation in the context of the respective cultural and value systems, related to the personal goals, expectations, standards and concerns in life (LUKKARINEN, 1998).Myocardial infarction (MI) is a life threatening illness which may affect the quality of life (SMELTZER et al., 2004) because of the experience of fear of death, uncertainties in life, social isolation and inability to return to one's lifestyle (PARK et al., 2006;LARSEN et al., 2006).The perceived severity of MI may trigger existential questions, the search for meaning and purpose in life and evaluation of personal life values (HUTTON;PERKINS, 2008;MURRAY et al., 2004).Research has been criticised for excluding the spiritual dimension from the concepts of life satisfaction/QOL (WHO-QOL GROUP 1995; KALFOSS; LOW; MOLZAHN, 2008;CASSAR;BALDACCHINO, 2012a, b).Thus, this study attempts to fill in this research gap by shedding light on how spirituality may contribute towards life satisfaction of Maltese patients with heart attack across the first three months of their recovery.

Aim
To explore the spiritual influencing factors on life satisfaction as perceived by Maltese patients across the first three months after the onset of MI.

Hierarchy of human needs
The hierarchy of human needs categorises the human needs which may be prioritised according to the individual's respective current life situations.The hierarchy encompasses the basic deficiency needs: physiological needs, safety and security needs, love and belonging needs; and the being needs: self-esteem and self-actualisation.Satisfaction of these needs may yield self-actualisation which may contribute towards life satisfaction.Therefore, in times of self-actualisation, individuals may still need to feel safe and secure in life to feel satisfied with their life holistically.Satisfied basic needs may enhance health and life satisfaction whilst unmet needs may generate unhealthy symptoms and lack of life satisfaction.Although this hierarchy is a closed circuit, it is argued that individuals might not reach full self-actualisation in life when faced by crisis situations such as, onset of a life threatening illness (BALDACCHINO, 2011) which might impair their life satisfaction.
Acquisition of needs in myocardial infarction may be influenced by various factors as proposed by the Theory of the Holy (OTTO, 1950) and the Theory of Logotherapy and Existential Analysis (FRANKL, 1984).Since myocardial infarction is a life threatening illness, patients might feel the numinous experience whereby patients tend to experience feelings of nothingness accompanied by eagerness to reach a higher power for security reasons (OTTO, 1950).MI triggers evaluation of personal life values with the result of searching for meaning and purpose in life which may help them to prioritise life values and change to healthy lifestyle.Eventually, acquisition of human needs may change from basic physical needs to higher levels of human needs, such as love and belongingness.This shift in priorities in life is activated by the individual's spirit in coordination with the body and mind (FRANKL, 1984) which may contribute towards higher levels of life satisfaction and self-actualisation.

Literature review
Life threatening illnesses such as, myocardial infarction (MI) may render individuals to become aware of their own spirituality (PRINCE-PAUL, 2008).Spirituality is defined as the power within a person which motivates the person to find meaning, purpose and fulfilment in life; suffering and death; and fosters hope to one's will to live (RENETZKY, 1979).Spirituality is a subjective and personally defined concept which may or may not be expressed through religiosity (MCSHERRY, 2006).Thus, spirituality may generate subjective perceptions of life satisfaction (CASSAR; BALDACCHINO, 2012a, b).
Research suggests that perceived life satisfaction may enhance wellness and QOL (KONSTANTINA;DOKOUTSIDOU, 2009).However, research on QOL/life satisfaction tends to focus mainly on the physical function abilities rather than on the holistic perspective of patients (CASSAR; BALDACCHINO, 2012a, b).Thus, various bio-psycho-social and spiritual factors may enhance or inhibit life satisfaction, such as, optimism, spiritual coping strategies and adaptation (BALDACCHINO et al., 2013a, b).
The onset of MI triggers reflective evaluation of one's entire life which may yield amelioration of one's lifestyle, re-organisation of their life goals and prioritisation of life values (BALDACCHINO, 2011;FRANKL, 1984).Optimism in life may generate a positive view of life and fosters acceptance of illness and adaptation to the new situation (BALDACCHINO; AGIUS; GAUCI, 2010).Finding meaning and purpose in life may enhance perceptions of health and life satisfaction (BALDACCHINO, 2011).Religious practice was found positively related to life satisfaction whereby patients who used religious practices, such as prayer, experienced higher levels of life satisfaction (BERGAN;McCONATHA, 2000).In contrast, negative religiosity such as, interpreting MI as a punishment from God may generate life dissatisfaction (BALDACCHINO, 2010;MURRAY;CIARROCHI, 2007).
During the first year of myocardial infarction, patients tend to score lower levels of life satisfaction due to anxieties and uncertainties in life (WHITE; HUNTER; HOLTTUM, 2007); and their efforts to accept and adapt themselves to the new situation by modifying life goals (KRISTOFFERZON; LÖFMARK; CARLSSON, 2007).Conversely, perceived higher levels of life satisfaction may be due to the spiritual dimension of recovery whereby the incidence of MI is considered as a spiritual encounter which may yield spiritual growth and positive view of life (KEATON;PIERCE, 2000).
Participation in rehabilitation programmes were found to be positively related to increased perceived life satisfaction/QOL (WANG et al., 2007).This may be due to the help received from the inter-disciplinary team and the group support following sharing of experiences of their attempts to shift to a healthy lifestyle and prioritisation of life values (BRINK; KARLSON;HALLBERG, 2006).Support from family, neighbours and friends; financial stability; and resolved physical pain were found to enhance recovery from illness and life satisfaction/QOL (LINDQVIST, 2000).Perceived personal control over one's life tends to generate a higher level of life satisfaction/QOL more than a belief of being controlled by luck or destiny.This may be because perceived self-control over illness may generate empowerment and hope which may enhance the healing process and life satisfaction (MARTENSSON; KARLSSON;FRIDLUND,1998). Participation in socio-religious activities such as church attendance and support groups was positively related to life satisfaction (STURESSON;BRANHOLM, 2000).
The impact of demographic characteristics on life satisfaction like age and gender is inconsistent in research.For example, older women were found to score higher levels of life satisfaction (STURESSON; BRANHOLM, 2000) while female patients with cardiac ailments were found to experience poorer life satisfaction/QOL (WESTIN et al., 1999).Culture may generate different perceptions, beliefs and life values which may influence society, individual's living environment and the nature of coping strategies (UTSEY et al., 2007).Spirituality may not always correlate positively with health (KING; SPECK; THOMAS, 1999).For example alignment with the will of God may render the individual to become passive which lessens individual's efforts for self care with slower rehabilitation outcomes.In contrast, prayer and having a purpose in life may foster wellness and perceived life-satisfaction (WRIGHT; SAYRE-ADAMS, 2000).

Participants
A systematic sampling technique was adopted whereby every second Maltese speaking patients with confirmed MI, and able to participate in a face to face interview, were recruited in the Coronary Care Unit (CCU) in the acute local general hospital in Malta.Patients who developed cardiac complications and/or those who underwent cardiac surgical interventions were excluded from the study yielding a sample of 63 in Time 1 (males: n = 40; females: n = 23; Mean age: 61.5 years) and 51 in Time 2 (males: n = 33; females: n = 18; Mean age: 61.8 years) (Table 1).

Research instrument
The semi-structured interview schedule consisted of one main question: Considering your own life experiences, what are the spiritual factors which may contribute towards your life satisfaction?Probing questions were based on the Hierarchy of Human Needs (MASLOW, 1999).It is noted that the concept of spirituality had been explored earlier at the beginning of the longitudinal study (BALDACCHINO, 2002).

Research Ethics
The study was approved by the University of Malta Research Ethics Board and the hospital medical authorities.On recruitment, patients' autonomy was respected by providing them with verbal and written information about the aims of the study; they were free to take part and were free to refuse or withdraw from the study without any influence on their care.Participants signed an informed consent for the face to face audio-taped recorded interview by the main author (Time 1 + Time 2).Confidentiality was maintained by keeping the coded list of names sealed in an envelope under lock and key and the tapes were erased following transcription.Codes were used (M = male; F = female and age) against the direct quotations in publications by the author to prevent identification of patients.Privacy was maintained by interviewing patients in the manager's office on the ward (Time 1) and at home (Time 2).Since these interviews were a reminder of their MI, patients were offered counselling services by the hospital psychologist or hospital chaplain as deemed necessary.

Data collection
A pilot study was conducted on seven patients and the evenings and afternoons were found to the best time for data collection in hospital and at home respectively.Data were collected by a face to face audio-taped semistructured interview on transfer to the medical ward from CCU (Time 1: n = 63) and on the 13 th week post discharge (Time 2: n = 51).The interviews were conducted in Maltese for better expressions of experiences.The first interview transcripts were all validated by the patients and during the second interview, patients discussed further the findings which emerged from the first interview.Patients agreed on the first findings and added further explanation of their retrospective experiences during the three months following discharge.The quotations used for publications underwent a translation process into English by two linguistic professionals and the author.

Data analysis
The qualitative data underwent thematic analysis, guided by the Qualitative Content Analysis Framework (BURNARD, 1991) and the Hierarchy of Human Needs Theory (MASLOW, 1999).To enhance trustworthiness of data, the interviews were transcribed verbatim by the author and validated by all patients in Time 1 (100%) and by 45 patients in Time 2 (88%).The transcripts were read several times and coded manually along the text which were then categorised into two main themes namely, positive and negative spiritual factors contributing towards life satisfaction.A random sample of 15 interviews were analysed concurrently by a Maltese nurse researcher in spirituality which achieved (85-90%) agreement.

Findings
Two main themes were generated from the interview data which explain the positive and negative spiritual influencing factors on patients' life satisfaction across the first three months following the onset of MI.

Discussion
The findings are compared with research and Maslow's hierarchy of human needs, supported by the spiritual dimension in life satisfaction/ QOL analysed in the literature review.

Positive spiritual factors enhancing life satisfaction
The positive spiritual factors were oriented towards family relationships, achievements in life and helping others.

Family relationships
Life satisfaction was based on family relationships oriented towards a peaceful unified family, good relationship with spouse and children and contented with their children's achievements in life.Close relationship with family is a characteristic of the Maltese society which may be due to the small geography of Malta and heritage from the ancestors.The importance of a sound family relationship was consistently emphasised as a priority.
Rev. Pistis Prax., Teol.Pastor., Curitiba, v. 6, n. 1, p. 67-88, jan./abr.2014 The spiritual dimension of perceived life satisfaction in heart attack 75 Now that I suffered this heart attack, I feel I have a greater purpose to stay alive.It had never passed through m mind before.Now I can understand and appreciate much more the well-knit family we have.This is a great blessing for us.My wife and I are very proud of this.Thanks to God all the family respect us.Therefore I can safely say that I reached my goal in life because I have succeeded Respect, family unity and children's achievements, following the parents' efforts and hard work to invest in their education, were reported to increase life satisfaction.Research shows that connectedness with family and friends may help individuals to life harmoniously in times of distress (CHIU et al., 2004;MURRAY et al., 2004;NARAYANASAMY, 2003).
Patients' degree of life satisfaction tends to assess the extent to which their main goal in life was accomplished.Achievements in life may enhance self-esteem, empowerment and increased self-confidence (MASLOW, 1999).The experience of heart attack which is a life threatening illness appeared to make them aware of the help of God which has sustained them during their life and during the illness.This infers that patients' relationship with the family seemed to be encircled by their relationship with God as a resource of help.

Achievements in life
Personal job satisfaction and self-achievements in life were associated with enhanced life satisfaction as described by a young patient saying,

Up to now I can say that my wife and I had a dream and that we have succeeded that is, to buy a bungalow and live happily as we are now. Looking at myself, I was very lucky as I achieved a lot in my career. I'm a General Manager in a Company. I still have two young children to look after. I want to be with them (M44, 40 yrs).
Accomplishment of personal goals in life, oriented towards the patient's high rank career, appears to be superseded by the extent of life satisfaction derived from the personal goals associated with the family.Thus, the pending goal of fulfilling the role as a father to his two young children appeared to lessen life satisfaction.Thus, caring for the family is reconfirmed as a priority in life.The caring altruistic phenomenon was also related to the place of work, Rev. Pistis Prax., Teol.Pastor., Curitiba, v. 6, n. 1, p. 67-88, jan./abr.2014 The spiritual dimension of perceived life satisfaction in heart attack 77 I work as a manager.At work I've got many friends as I always tried to deal in peace.I always had good relationships at work.When the workers used to have problems, they used to come to me often for advices.Also they used to come to me to confide in me (M30, 57 yrs).
Respect, caring and friendship at work appeared to contribute towards job satisfaction and life satisfaction (RAD;DEMORAES, 2009).Being available to others is a characteristic of altruism which contributes towards life satisfaction.Individuals demonstrate their reciprocal love by giving and receiving in a trustful relationship.Eventually, love may minimize fear and fosters a feeling of understanding and acceptance (MASLOW, 1999).

Helping others
Altruism was oriented towards maintaining a peaceful family unity and helping others, especially their family.Following the heart attack, patients appeared to find time to reflect on their past life and became aware of their hardships in life and the lack of gratitude received from the recipients of their help.

You can never reach your aim in life 100%. You can always do your best. Always, by the help of God. I emigrated to Australia and had lots of experiences, I started working for my family at 11. I had to earn a living for my brothers and sisters because my father was dead... I can say I brought them up. They all succeeded in life... I'm the only not to have a profession. I wasn't lucky to have good schooling. But I made a great altruistic act and God will surely reward me. He has already done it because my wife and children show me great respect… As I have already told you, my only disappointment is that my brothers and sisters gave me a cold shoulder on my return to Malta (crying) (M42, 55yrs).
Following the experience of a heart attack, patients were found to acknowledge their limitations in the extent of achieving their life goals.Patients counted their blessings in life for example, acknowledging the preciousness of their life and the respectful reciprocal relationship with their family which appeared to help them overcome their suffering derived from receiving ingratitude in life.However, patients believed that God was grateful to them by being rewarded by the respect received from their family.Hence, the patients' trustful relationship with God seemed to help them forgive others with a peaceful outcome.Altruism in life may foster a meaningful life (FRANKL, 1984).However, individuals might still struggle to forgive others who responded to their help with actions of ingratitude.The healing effect of forgiveness may render individuals to live harmoniously with their interrelationships which may enhance life satisfaction (KOUTSOS; WERTHEIM; KORNBLUM, 2008;McCULLOUGH;WORTHINGTON, 1994).
Institutionalisation of older persons is on the increase in Malta due to the great demand for their children to work full time.Family support to an old parent living in the community is therefore an act of solidarity and altruism.
I brought up a family and my husband is as good as gold.I brought my elderly father to live with us instead of sending him into a retirement home.I feel a great satisfaction in having kept him with us and enjoyed his company till his final days.He deserved such treatment.I brought up my children in a Christian environment and they are extremely good mannered and are now well set up with their families.My last wish is to see my daughter become a mother (F27, 59 yrs).
Life satisfaction was found related to acts of generosity especially with vulnerable persons, which contributed towards life satisfaction.Priorities in life like the upbringing of their children and pending issues such as, an expectation of a newborn were consistently associated with needs to be met by their family.Thus, following a heart attack, the needs of their family were reported as the greatest priority in life.Achievement of life goals across past, present and future life seemed to contribute towards the extent of life satisfaction.

Negative spiritual factors inhibiting life satisfaction
Patients admitted that life satisfaction cannot be fully achieved.The negative spiritual factors derived from the interview data addressed lack of achievement of goals and unfinished business in life.

Unachieved goals in life
Reflection time following a life threatening illness appeared to generate guilt feelings associated with non-compliance with treatment which might have induced the heart attack, impaired life values such as, giving poor quality time to their family, and their efforts to accept the reality of their unachievable life goals.
First I have to free myself of these guilt feelings.I will by God's help!I am determined to look after my health.Then I hope I go back to work and delegate more […] I also hope to be present with my family to compensate for my limited presence with my children when they were younger.Now that I came face to face with death, I thank God that I'm alive, because in such a situation I became very conscious of my life, my actions and mistakes.I am determined to prioritise my values in life: first priority is my health and family (M22, 58 yrs).
Life saving, recovery of their health and family relationships were rated consistently as a priority.Guilt feelings about their mistakes in life and about their impaired fulfilment of their roles in life, especially with their family such as, lack of quality time to their family, appeared to decrease the rating of their life satisfaction.However, patients were determined to correct their mistakes by for example, changing to a healthy life style.Determination to enhance their lifestyle appears to be the result of learning from own experiences which yields self-growth through the life threatening MI (RAHOLM, 2002;KEATON;PIERCE, 2000).Additionally, patients started to have a positive outlook towards their life, oriented towards prioritisation of their life commitments.Positiveness and active alignment with the will of God may facilitate adaptation to the new lifestyle with increased life satisfaction (BALDACCHINO et al., 2013a, b).
Disappointments in life such as, childlessness were reported to decrease their life satisfaction.When basic human needs are satisfied, that is regaining health during the recovery from MI, other needs surface such as, safety and security through a change to a healthy lifestyle.On meeting this need, new, higher needs appear until these are met such as, achievement of life goals which may yield self-actualisation (MASLOW, 1999).
I've been through some hard times in my life!I had to look after my mother, who suffered from Parkinson's disease, for 10 years.My wife has been of great respect and help to me.I've resigned myself to not having children.I'd have loved to have had children, but it's God Will.I entrust myself to God, I don't grumble about it, as the Lord's blessed me with a good wife (M10, 51 yrs).
On realising the severity of their illness and the preciousness of their life, patients were grateful to God for having saved their life.Although many patients were not practising their religiosity before the onset of their heart attack, they became aware of their own spirituality and turned to God for empowerment (PRINCE-PAUL, 2008;McSHERRY, 2006).Following the onset of their heart attack, disappointments in life were overcome by seeing the positive side of the situation which helped to feel satisfied with their life and learn to count their blessings in life.Also, life goals may be modified to make them possible to be achieved (BALDACCHINO; MUSCAT; STURGEON, 2012;SCHNEIDER, 2007).

Unfinished business in life
Pending issues in life may hinder achievement of individual's purpose in life, threatening wholeness and life satisfaction (BALDACCHINO et al., 2010).While acknowledging the respect from their spouse and family, patients were concerned about the hardship to change their life style like, smoking cessation and family issues such as, worrying about their young children who wished them to settle down in life before passing away.
There's still much to be achieved in my life for example, wanting to see my children grow up as they are still very young.Presently, they ignore any advice I try to give them for studying.They'll face a hard life in the future.This little one (sleeping by her) needs me dearly.There still much to be achieved in my life… I haven't managed as yet to stop smoking.I wish to stop completely but this morning I smoked one […] I couldn't resist the temptation.It's going to be very hard for me to stop smoking (F32, 40 yrs).
Patients could understand the importance of changing to a healthy lifestyle.However, they found themselves limited to face such a huge shift in their life.On meeting the physical need of smoking cessation, order and stability in life are sought to preserve safety and security in life.Lack of security in life renders individuals to perceive uncertainties in life and unforeseen circumstances beyond their coping abilities (MASLOW, 1999).Struggling to stop smoking was associated with life saving and so they felt committed to confront it.Having a purpose in life such as, the need to support young children until they are settled in life appeared to sustain their efforts to maintain their determination to live a meaningful life with their family (LINDQVIST, 2000).These findings demonstrated the nature of finding meaning and purpose in life which was mostly oriented towards the patients' altruistic aspect of caring for their family.Additionally, MI appeared to trigger awareness of their spirituality as a coping mechanism, a dimension which might have been practiced in their past life.Being Christians, patients' spirituality was expressed through religiosity such as, prayer while reaching out towards God's help.Hence, culture may play an important role in the spiritual dimension of life satisfaction (UTSEY et al., 2007;BERGAN;McCONATHA, 2000).

Limitations
This descriptive exploratory study collected in-depth data twice from patients across the first three months following the onset of MI.The findings of the Time 1 were reinforced and clarified further by data collection on the third month which contributes towards trustworthiness of data.A mixed method is suggested in further research to approach could have enhanced reliability and generalisation of the findings.However, the in-depth data sheds light on life satisfaction which has now been integrated with the concept of quality of life.Since all patients were Roman Catholics, this study applies only to patients with Christian religious affiliation.Therefore, further comparative trans-cultural longitudinal study is suggested, recruiting patients with diverse cultures and religious affiliations/atheists across the first year following MI.

Conclusion
The positive and negative spiritual factors identified in this study were oriented towards family relationships, achievement of life goals and altruistic actions.Similarities were found in the findings derived from Time 1 and Time 2. The negative spiritual factors consisted of impaired achievement of life goals and unfinished business in life which may inhibit life satisfaction.However, both the positive and negative spiritual factors may motivate individuals to utilise their full potential to enhance their capabilities to achieve their life goals (MASLOW, 1999).Although negative spiritual factors may interfere with achievement of goals, when individuals accept their limitations and disappointments in life, a high level of life satisfaction may result.The spiritual dimension identified in this study complements this outcome as patients were found to turn to God's help for empowerment, find meaning and purpose in life which may be modified accordingly to make them realistically achievable.Optimism in life such as, realising that they have survived MI, may help them to see the positive side of the situation and may help them to cope with and adapt to the new lifestyle.
Life satisfaction was highly oriented towards family relationships, considered as a beneficial resource of life satisfaction.Thus, the hospital management is recommended to modify the daily visiting time to a more flexible time to facilitate face to face communication with their family.Spirituality may enhance life satisfaction and so this concept should be integrated within the undergraduate and post-graduate nursing curricula.

Table 1 -
Demographic data & response rate of participants with heart attack Source: Research data.

Table 2 -
Themes and categories generated from the face to face interviews Theme 1: Positive spiritual factors enhancing life satisfaction 1.1.Family relationship I have brought up 4 children, all married and their children respect me also.I have 19 grand children.So I am a great-grand father.I have had great respect from my wife.We gave them the best education that we could give.They all occupy high posts in society.I'm very proud of them.I pray God to give me strength to enjoy my family for whom I worked a great deal (M02, 68 yrs).1.2.Achievements in life Through my capability as a hotel manager, I succeeded in bringing the X Hotel on its feet.Till this very day, all that I wished through sheer perseverance, hardship, strain and ability, I have been able to acquire (M57, 60 yrs).1.3.Helping others My wife and children respect me a lot and this is God's greatest gift to me in this world.We had a little trouble with my niece, because she got pregnant before getting married, but now I can't wait to see her baby.I wish to see the baby [...] I tried to keep calm.A mistake won't correct another mistake [...] I pray God for her to have a smooth pregnancy.I wish to see him, he will make me great grandfather before I die (crying) (M26, 81 yrs).keeping peace and unity in my family.Apart from this, I gave my children a good education, because as I had a hard bringing up, I didn't want my children to suffer the same fate (M07, 60 yrs).
Theme 2: Negative spiritual factors inhibiting life satisfaction 2.1.Unachieved goals in life 'Quite satisfactory with my life!There are still many things in my life to sort out.I'm happy to have two sons, one 18 years old and the other 10.But I'm feeling guilty, because although I work hard for them, but sometimes I don't give them a good example.There were times when they reproached me about my behaviour… I don't deserve to have such a respectful children [...] I wish to change my lifestyle [...] I need to stop smoking also as they ruined my health.However I wonder whether I'll be successful (35, 44 yrs).Rev. Pistis Prax., Teol.Pastor., Curitiba, v. 6, n. 1, p. 67-88, jan./abr.2014 BALDACCHINO, D. R. in