The study had an explorative and descriptive design based on qualitative content analysis [31]. The interviews were carried out between April and December 2010 at 10 different hospitals (4 university, 3 county and 3 district hospitals) in Sweden. The heads of the cardiology departments were contacted and asked to give permission for cardiac rehabilitation nurses to participate in the study. All 10 Heads gave their approval and forwarded the names of the CRNs who met the inclusion criteria.

The inclusion criteria were CRNs, who were actively working with comprehensive CRPs in which physical training, education, risk factor modification, medical checks-ups, pharmacological treatment, psychological support and counseling, as well as vocational rehabilitation were included. The CRNs also had to be members of a multidisciplinary cardiac rehabilitation team (e.g. cardiologist, nurse, and physiotherapist) and fully understand, read and speak Swedish. Twenty-one CRNs were informed and asked to participate by the main author (IW), only one declined; due to time constraints. All CRNs were females and ages ranged between 28 and 65. The time having worked in cardiac care was between 4 and 25 years and between 2 and 23 years within cardiac rehabilitation.

Data was collected through interviews conducted and recorded by the main author (IW). The main author phoned the CRNs and asked them to choose a place and time for the interview. All interviews were conducted at the informants’ work place. Four pilot interviews were conducted, which then were included in the analysis. The interviews started with an open main question: “What do you think about women’s recovery after a first myocardial infarction?” In order to reach depth in data follow up questions such as “What do you think when you say…?” and “Can you explain more about…?” were asked. The interviews lasted between 35 and 75 minutes. All the interviews were transcribed verbatim.

Data was processed by the main author, in collaboration with the co-authors, using qualitative content analysis which consists of several analysis steps as described by Graneheim and Lundman [32]. The interviews were read through several times to become familiar with the text. Meaning units that were related to the aim of the study were placed in an analytical matrix. These meaning units were then condensed without losing the core of the content. In the next analysis step, the condensed meaning units were abbreviated to codes. These codes were compared, based on differences and similarities, and 12 subcategories were created forming 4 categories at a manifest level. Based on the content of these categories an overall theme emerged, which expressed the latent meaning of the content (Figure 1) [32].

The ethical principles of the study were according to the requirements of the world medical association declaration of Helsinki [33] and the heads of the cardiology departments have approved the study. After the participants were fully informed, both verbally and in writing, of the aim of the study and the voluntary nature of participation, as well as the possibility of withdrawing, an informed consent was obtained.

This category described that CRNs’ experiences that women’s opportunities to receiving support could either help or hinder the women’s recovery process. A major requirement for recovery was access to a good social network, where family, relatives, peers and friends had a supportive attitude, as well as support from health care and workplace.

The newly found situation involved not only the woman, but the whole family so therefore it was important how the support from the family was. The women, who had a functioning family life, where they felt safe and harmonious, generally recovered more easily. “The family, home, and how they have it at home, has an impact” ... (n3). It was important that the female’s partner was actively involved in the recovery process, as well as a well-functioning dialogue between family members. Interaction with children and grandchildren could distract the women from having negative thoughts. In cases where the children helped with practical things also created better possibilities for the women to recover. Likewise, when the family took into account, that it is not always the woman, the mother, who has to do everything in the

family, this influenced the woman’s recovery in a positive way. However, the women’s recovery was negatively influenced when they lacked support from their families as well as unsympathetic partners and family members who, neither understood, nor took into account the new situation. Many women, I’ve heard this many times by women who say that “Yes, but you were in hospital for four days, now you’re all right. What is wrong with you”? (n1). The families did not take time to listen, but instead, perceived the women as somewhat whining. Furthermore, they wanted everything to work in the home as before and desired the traditional female role. The women had more difficulty to implement the necessary recommended lifestyle changes. However, women became passive, especially in cases where women were overprotected by their family and were not allowed to do any daily work or exercise at all; which did not help the recovery process.

Support from work where the women were given possibilities to participate in various rehabilitation groups during working hours affected their recovery positively. “…, it all depends on... what they are working with. Large companies often let them go, but small, private companies, where they often do not have many employees, therefore more dependent upon staff, where it is a little harder to take one afternoon off a week ...” (n3). The women’s recovery was facilitated when employers arranged more regular working hours and less planned overtime.

Regarding support from people with the same experience, it emerged that women usually experienced great gains when they met others in the same situation in the rehabilitation groups. “I’ve heard women say that really, to meet other women in the same situation is better than the entire health care! So it is of great importance” (n2). Friendships developed, for example at the exercise training during the months the group members met, which led the women to continue to meet and exercise together, share experiences and support each other, after the initial group training period had come to an end. The women emphasized the importance of meeting people who understood their situation which was perceived as an additional support, something that made them realize that they were not alone.

Concerning support from female friends, it became evident that women willingly spoke more to their friends than to their partners when it came to their innermost thoughts and their situation. “And then women have more than men, good friends who support each other, I am sure we can say ...” (n13). Since emotional support was important for the women with regard to recovery, it was important that there were female friends around when needed.

Support from healthcare professionals deals with counseling and support during the women’s recovery process. This involved: having an experienced nurse to turn to, having confidence and assurance in the nurse, as well as, continuity of care. The CRNs, as well as the team’s approach, were also important in regard to the women’s recovery. “The fact that we also provide support, that they can call us and get adequate and accurate answers to their, all the questions they have… that we have the expertise, that we have faith to give a correct answer. Both in medical terms, and to be able to encourage and help them when attempting to quit smoking...” (n11). The women’s recovery was also influenced when the nurses managed to get the women: motivated to exercise, to be aware of both their risk and health factors which resulted in the women feeling better and stronger after visiting the nurse. Even physical training, under supervision, gave the women security which stimulated them to do more physical exercise. Likewise, medical assistance was of great importance. Their recovery was also affected by them knowing that they were prescribed the appropriate medication, and that the physician spoke about what they should or should not do.

This category described the CRNs’ experiences of that the women’s recovery was influenced by their ability to cope with the stresses of life such as: concerns for themselves and returning to work, the fear of dying and not doing enough for the family. Furthermore, the CRNs described that women’s recovery was affected by whether the woman had: a socially vulnerable situation with high demands, lack of finances, additional diseases and intensive treatments, as well as, whether they had experienced previous severe life events.

Regarding the feeling that life is threatened, it became clear that the women’s recovery was affected by the fear of dying and of being inadequate. The women admitted to keeping a closer watch on their own physical and mental symptoms which contributed to them noticing everything that felt different within the body compared with before. “There are ... many who talk about ... that they have, indeed a fear that it will happen again.” (n3). These thoughts came in the evening when it was quiet; therefore, sleeping habits could be adversely affected. Not infrequently, women had difficulty formulating their concerns into words and they avoided any discussions that they had been close to death. Instead, they had a need to dwell upon what had happened, to digest their new situation, in order to be able go forward in the recovery process. The women also had concerns about sexuality, and there were women who did not dare to have sexual intercourse as they were afraid that something could happen to the heart. The concern could also be about the fear of being sexually inactive and that inactivity and loss of desire would be permanent. Furthermore, it was also found that women were concerned about how the family would manage, now that they had suffered from ill health and could not cope with everyday tasks in the same way as before. “But it also seems like there is much concern for ... for the family ... usually the first ... you could say the first three or four months” (n1). Even the thought of returning to work concerned the women. Work could be experienced as difficult, both physically and mentally. “Obstacles to recovery, that is, I often have the feeling, those who are working, they will have the same amount of stress, they often say, as before. What will happen?” (n7). Many times, the women wished to have a longer period of sick leave in order to have time to their recovery.

Coping with stresses in life was affected by whether the women had an exposed social situation. The women’s recovery was influenced by earlier completed traumatic life events, such as: abuse, divorce, serious illness within the family and death. “The fact that women have, quite often, experienced some rather severe life events which surface again when you have a heart attack. Yes, something from the past that you think you have got over, but it still pops up in your head, in connection with a heart attack. It can be anxiety, anguish; therefore, it becomes a tougher time before they recover.” (n14). Furthermore, it was also found that there were women who stated that they already had a reduced work capacity, due to illness, resulting in a partial or full disability pension. This could be an additional burden that affected their recovery after an MI. Previous mental illness, depression and the onset of depression during the recovery phase also contributed to the fact that some women often declined to participate in CRP. “If you have experienced a breakdown in the past or suffered from depression; you are, of course, more vulnerable” (n14). Another factor that affected the women’s recovery was which stage in life the women were in. The older women accepted, more easily, their illness, which they associated with age. They were not as easily affected by stress and often put more time and effort on lifestyle changes than younger women. Elderly women had more time and used it well, walking, as well as planning the purchase and cooking of healthy nutriatious food; which made the recovery easier. Younger women who worked and had young children did not have time to think and act this way.

Moreover, women who have had Coronary Artery Bypass Surgery [CABG] had more often a longer and tougher recovery period than women who underwent Percutaneous Coronary Intervention (PCI) or any other intervention, in connection to their MI. This was the reason why they felt fatigued and could not face up to current situations in the same way as the women who had undergone PCI. Even certain drugs and their side effects affect the women’s daily life in a negative manner.

Furthermore, the women’s social situation with poor finances and a lack of time, regardless of age, contributed to the fact that they did not have the opportunity to focus on themselves and their own situation. This is a reason why the women did not participate in CRP, which also affect their recovery process. “You can be on low income, perhaps a single parent, you are struggling financially and you become sick too. Yes, things like that.” (n16). The women, intellectually, understood that CRP group meetings would be important to their recovery, but regardless of how hard they tried to plan their lives, there was a lack of time and money.

This category described the CRNs’ experiences of how the women’s recovery was influenced by their interest and desire to know how they, themselves, affect their new life situation and make sure that they prioritized themselves.

The women’s recovery was affected by their own interest of information with regard to the desire to know of risk and health factors, and understanding what exactly an MI was and what they should think about in the future. “The experience is that women are more interested in finding out, getting knowledge than men. They have more questions and concerns and it feels like they care more” (n4). They wanted to learn about the importance of diet and exercise in order to recover, how their prescribed drugs worked and about the body’s normal physical and mental reactions. When the women had many questions concerning their new life situation, the new-found knowledge gave them a certain security. CRPs, which lasted for four to five weeks, gave them the opportunity to take in the knowledge gradually. The more information the women took in, the higher was their chance to recover.

Through the women’s involvement in their care, the awareness of their own capacity was strengthened and led them not to see themselves only as “sick persons”. They realized that they should be in charge of their own lives; therefore, changing their present situation into something better, which also led to a part of their recovery, “That you gain an insight into your illness and that you can accept this and get an understanding of what it implies” (n12). Likewise, when the women did group physical training, they became aware of what they managed without getting chest pain. This meant that they became less worried about straining themselves physically when they were on their own.

Regarding willingness to change, it was described that many women were interested in getting help and support in order to change their lifestyles, and therefore, prioritizing participation in various CRPs. The women, who went to CRPs, were motivated to learn new things regarding: diet, exercise, medications, and just what research revealed concerning health factors; which helped in the recovery. “Women change their diet, exercise habits and weight” (n15). Women were particularly keen to change their diet. Those, who found it easy to get started with physical training, recovered more quickly. Women, who relatively quickly went back to work, possibly only part-time, and those who tried to change their work situation to prevent negative stress, generally recovered more quickly than women who continued to be on sickleave. To effectively implement the changes in life was easier for the women who lived a somewhat carefree life when they fell ill and had a supportive family.

This category highlighted the CRNs’ experiences of that women’s recovery was influenced by the way they related to themselves.

Regarding the feeling of shame and guilt, it emerged that there were women who expressed embarrassment over, both their smoking habits, and their overweight. They expressed an intention to stop smoking but they had relapsed and returned to their comforting smoking habits, which created a feeling of guilt. Not infrequently, they ended their participation in the CRPs which could affect their recovery adversely. Women also felt ashamed and guilty that they had fallen ill in the first place. “Women make themselves feel guilty ... I should not be doing this ... How did this happen? I should have foreseen” (n19). There were also women who felt guilty that their recovery took such a long time. These women needed to receive help to think through their life and work situation before they could continue their recovery.

The women’s approach to life could affect their recovery. The women who had a positive attitude experienced, in general, less anxiety than those with a pessimistic attitude. “It is individual how you recover. It depends on what kind of personality you have ...” (n13). Even women, who had to have total control over their home situation, and thought that everything would work as it always had done, otherwise their world around them would collapse, usually had difficulty in recovering. Having to be perfect was a common feature of these women. These women did not allow themselves to be sick and prioritized others before themselves; therefore, hampering their own recovery. “When it comes to women so maybe … they have to fix it by themselves … They must be the strong one in the family in some way, they do not have time to be sick and it could be the career. Such things influence” (n12). Furthermore, there were women who had difficulty accepting their illness. They had difficulty in seeing themselves as sick and did not understand the onset of the illness; despite the many risk factors. The women with a more positive outlook on life changed their lifestyles when they now had got a second chance. They expressed that they had been given a new lease of life; thanks to: a deeper understanding of their first MI, an altered diet, new exercise habits, and their letting go of certain everyday demands. However, there were women who reported finding it challenging to relax their demands on themselves regarding the performance of everyday tasks.