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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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røysland et al

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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røysland et al

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

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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.

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