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Women’s experience with myocardial infarction: a phenomenological approach Bowers, Michele J. 1996

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Women's Experience w i t h M y o c a r d i a l I n f a r c t i o n : A Phenomenological  Approach  by MICHELE J . BOWERS B.A., York U n i v e r s i t y , 1991 THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department  o f C o u n s e l l i n g Psychology)  We accept t h i s t h e s i s as conforming to the r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA 1996 January 199 6 ©Michele  J . Bowers, 1996  In  presenting  degree freely  at  the  available  copying  of  department publication  this  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his thesis  and  scholarly  or for  her  Department The University of British Columbia Vancouver, Canada  I  I further  purposes  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  permission.  DE-6 (2/88)  study.  of  be  It not  that  the  be  an  by  understood allowed  advanced  Library shall  permission for  granted  is  for  the that  without  make  it  extensive  head  of  copying my  my or  written  ii Abstract The purpose of t h i s study was t o examine the nature of women's experience of myocardial i n f a r c t i o n  (MI) from a  s u b j e c t i v e p e r s p e c t i v e i n order t o e x p l o r e and d e s c r i b e how women made meaning of t h i s p o t e n t i a l l y l i f e t h r e a t e n i n g event. A phenomenological  approach was used t o guide the data  and a n a l y s i s . Data were c o l l e c t e d through  in-depth  collection  semi-  s t r u c t u r e d i n t e r v i e w s with a v o l u n t e e r sample of 10 female cor e s e a r c h e r s h o s p i t a l i z e d with MI a t a l o c a l c i t y h o s p i t a l . The initial  i n t e r v i e w focused on o b t a i n i n g a d e s c r i p t i o n of co-  r e s e a r c h e r ' s experience and was conducted  a f t e r women were  t r a n s f e r r e d from the c r i t i c a l care u n i t t o the c a r d i a c ward. I conducted  v a l i d a t i o n i n t e r v i e w s w i t h c o - r e s e a r c h e r s s e v e r a l weeks  post h o s p i t a l d i s c h a r g e v i a telephone. The v a l i d a t i o n i n t e r v i e w p r o v i d e d c o - r e s e a r c h e r s with the o p p o r t u n i t y t o c o n f i r m o r c l a r i f y my understanding of t h e d e s c r i p t i o n of t h e i r MI experience, as w e l l as p r o v i d i n g any f u r t h e r i n f o r m a t i o n t h a t would c r y s t a l l i z e my understanding of t h e i r Audiotaped  story.  i n t e r v i e w s were t r a n s c r i b e d verbatim and analyzed  according to Giorgi's  (1975, 1985) method of  phenomenological  data a n a l y s i s . Nine common themes emerged from the data including:  (a) t h e experience of i l l n e s s awareness; (b) t h e  experience of f e e l i n g e m o t i o n a l l y overwhelmed; (c) the experience of  f e a r and worry; (d) the experience of l o s s ;  (e) d i f f i c u l t y  a s k i n g f o r help; ( f ) t h e experience of needing i n f o r m a t i o n ; (g) the experience of care and support;  (h) making sense of t h e MI  experience; and ( i ) t h e experience of p l a n n i n g f o r t h e f u t u r e .  iii e v i d e n t i n c o - r e s e a r c h e r accounts, t h e uniqueness was  of each woman  captured and r e f l e c t e d i n the v a r i a t i o n s i n which t h e themes  were expressed. The  i m p l i c a t i o n s of t h i s r e s e a r c h suggest t h e importance of  understanding women's experience of MI a t a s u b j e c t i v e l e v e l i n order t o f u l l y  understand  t h e extent and nature of women's i s s u e s  and concerns w i t h i n t h i s area. Thus c o u n s e l l i n g p s y c h o l o g i s t s should a c t as both  educators  and c o u n s e l l o r s i n order t o r a i s e the awareness of other h e a l t h p r o f e s s i o n a l s as t o the nature of women's experience of MI, t o a s s i s t i n t h e t e a c h i n g of s k i l l s t h a t would b e t t e r enable t h e implementation  of p a t i e n t - c e n t e r e d care, and t o p r o v i d e women a  forum through which they can r e c e i v e c o u n s e l l i n g r e l a t e d t o i s s u e s surrounding MI. Moreover, r e s u l t s of t h i s study p r o v i d e the b a s i s f o r f u t u r e r e s e a r c h , and i n h e l p i n g medical p r o f e s s i o n a l s implement the p r o v i s i o n of c a r d i a c care t h a t i s more germane t o women.  1  iv TABLE OF CONTENTS.  Abstract  i i  Table o f Contents  iv  Acknowledgements CHAPTER ONE:  v i i  INTRODUCTION  Background t o the Research  1  D e f i n i t i o n of Terms  4  CHAPTER TWO:  LITERATURE REVIEW  Introduction  6  Myocardial I n f a r c t i o n  6  Women and M y o c a r d i a l I n f a r c t i o n  8  Women and Recovery from M y o c a r d i a l I n f a r c t i o n  12  Meaning o f I l l n e s s  22  R e l a t e d Research.  25  Summary  27  CHAPTER THREE:  METHOD ,  Research Design  29  P e r s o n a l Assumptions  29  The Interview  ,  31  E t h i c a l Considerations  32  Selection  33  o f Co-Researchers  Data C o l l e c t i o n  35  Pilot  36  Interviews  Data C o l l e c t i o n  Interviews  . ...  36  Researcher's Impressions o f t h e Interviews  42  Data A n a l y s i s  44  Summary.  47  V  CHAPTER FOUR:  PRESENTATION OF THE FINDINGS  Introduction  49  Background of the Co-researchers Lydia  49  Kiko  51  Kaye  54  Roslynn  56  Penny  61  Hilda  64  Anne  68  Noreen  73  Brynn  79  Gina  84  D e s c r i p t i o n of the Themes  88  The Experience of I l l n e s s Awareness  89  The Experience of F e e l i n g E m o t i o n a l l y Overwhelmed  93  The Experience of Fear and Worry  97  The Experience of Loss  102  Having D i f f i c u l t y A s k i n g f o r or R e c e i v i n g Help from Others.... 106 The Experience of Needing Information  109  The Experience of Care and Support  115  Making Sense of the MI Experience  ....126  The Experience of P l a n n i n g f o r the F u t u r e .  133  Summary  137  CHAPTER FIVE:  DISCUSSION OF THE FINDINGS  Introduction I n t e g r a t i n g Current and Previous Previous Q u a l i t a t i v e Research  138 Research 139  vi C u r a t i v e versus C a r i n g  144  Importance of Communication  145  Importance of Information  147  S t r e s s o r s A s s o c i a t e d w i t h MI  150  A p p r a i s a l s and Coping  150  Developmental C o n s i d e r a t i o n s . . •  155  D e b r i e f i n g the MI Experience  157  M i s d i a g n o s i s or the D i s m i s s a l of Symptoms  159  B a r r i e r s t o Conducting the Study  160  Study L i m i t a t i o n s  162  *  Implications f o r Counselling Practice  164  Conclusion  168  References  170  Appendix A. Interview Format  179  Appendix B. Background Information Form  183  Appendix C. L e t t e r of Information  184  Appendix D. P a r t i c i p a n t Consent Form  186  Appendix E. Co-researcher Background Information  187  vii ACKNOWLEDGEMENTS I would l i k e t o acknowledge the members of my t h e s i s committee. My thanks goes t o B o n i t a Long f o r her endless enthusiasm, support, and p r o f e s s i o n a l i n t e g r i t y ; t o R i c h a r d Young f o r h i s i n t e r e s t and support, and f o r h i s p a t i e n c e d u r i n g my search f o r an e a s i e r way t o do q u a l i t a t i v e a n a l y s i s ; and t o I s a b e l Dyck f o r her i n t e r e s t and e x p e r t i s e . I wish t o express my deepest  a p p r e c i a t i o n f o r my co-  r e s e a r c h e r s f o r s h a r i n g t h e i r very p e r s o n a l s t o r i e s of myocardial infarction.  I f e l t p r i v i l e g e d t o have been witness t o t h e i r  t e l l i n g and very much a p p r e c i a t e t h e i r i n t e r e s t and w i l l i n g n e s s to p a r t i c i p a t e i n my p r o j e c t . A s p e c i a l thanks goes t o J a n i c e Conde, head nurse of t h e coronary care u n i t a t S t . Paul's H o s p i t a l , f o r her b r i l l i a n c e i n h e l p i n g t o g e t . t h i s p r o j e c t get o f f t h e ground. I would a l s o l i k e t o thank t h e r e s t of the CCU nurses a t S t . Paul's, whose t i r e l e s s work and d e d i c a t i o n t o n u r s i n g and wellness has been i n s p i r a t i o n a l . Thanks goes t o Sandy Barr, head nurse of 5A, f o r her e f f o r t s i n d e l i v e r i n g c o - r e s e a r c h e r s . Finally,  I would l i k e t o thank my f r i e n d s and f a m i l y f o r  t h e i r ongoing encouragement and support over t h e past s e v e r a l y e a r s . Thank you f o r g i v i n g me the space I needed t o do t h e j o b , f o r l i s t e n i n g t o my endless progress r e p o r t s , making me laugh and f o r c i n g me p l a y when I d i d n ' t know I needed t o , always b e l i e v i n g i n me, and j u s t b e i n g t h e r e . I c o u l d not have done t h i s a l l of you.  without  1  CHAPTER  ONE  Introduction Background to the Research Coronary heart d i s e a s e  (CHD)  of death among both women and men 1994)  and the U n i t e d  the c o n v e n t i o n a l  States  i s c u r r e n t l y the l e a d i n g cause i n Canada ( S t a t i s t i c s Canada,  (Packard,  1992). T h i s i s c o n t r a r y  b e l i e f t h a t heart d i s e a s e i s a s e r i o u s  concern f o r only middle-aged men.  Myocardial  infarction  to  health (MI),  the  major medical emergency of the c a r d i o v a s c u l a r system and most serious manifestation  of CHD,  accounts f o r the g r e a t e s t number of  these deaths. Whereas the i n c i d e n c e of MI men,  i s more p r e v a l e n t i n  s t a t i s t i c s confirm the magnitude of t h i s h e a l t h concern f o r  women. In 1991,  19,496 Canadian women d i e d as a r e s u l t of CHD.  these deaths, 9,844 were as a r e s u l t of acute MI Canada, 1994). Quite c l e a r l y , MI women as m o r t a l i t y r a t e s continue Despite  the prevalence  Of  (Statistics  i s a s e r i o u s h e a l t h concern f o r to i n c r e a s e .  r a t e s of CHD  f o r women, the  preponderance of i n f o r m a t i o n r e g a r d i n g the e t i o l o g y , i n c i d e n c e , management, p r o g n o s i s ,  and  r e h a b i l i t a t i o n of MI  p r i m a r i l y on s t u d i e s comprised of men Clarkson,  & T y r o l e r , 1986;  (Eaker,  Murdaugh, 1990;  i s based  Packard, Wenger,  Packard, 1992;  1989). Women have e i t h e r been excluded or are under  Wenger,  represented  i n c a r d i a c r e s e a r c h t o the p o i n t t h a t a gender comparison or separate (Eaker  a n a l y s i s of women's data i s d i f f i c u l t or  et a l . , 1986;  impossible  I s l e s , Hole, Hawthorne, & Lever,  1992;  Rodin  & I c k o v i c s , 1990). As a r e s u l t , many c l i n i c a l d e c i s i o n s i n v o l v i n g women and (Eaker  c a r d i a c h e a l t h are based on data obtained  et a l . , 1986;  I s l e s et a l . , 1992). The  little  from  men  research  2 t h a t has focused on o r i n c l u d e d women suggests  t h a t gender  d i f f e r e n c e s do e x i s t i n v a r i o u s c l i n i c a l f e a t u r e s of heart d i s e a s e such as m o r b i d i t y and m o r t a l i t y r a t e s , and t h a t d i s t i n c t i o n s across subgroups of women have a l s o been e s t a b l i s h e d (Eaker e t a l . , 1986; Young & Kahana, 1993). F o r example, Eaker e t al.  (1986) contends t h a t c a r d i o v a s c u l a r d i s e a s e m o r t a l i t y i s  twice as high amongst b l a c k women as i n white women, and s u b s t a n t i a l l y higher i n white women as compared t o women of other non-black groups. Although  there i s l i t t l e  an examination  c a r d i a c r e s e a r c h s o l e l y devoted t o  of women and MI, even fewer s t u d i e s have examined  the p s y c h o s o c i a l f a c t o r s r e l a t e d t o women's c a r d i a c h e a l t h o r t h e needs and responses of women i n c a r d i a c r e h a b i l i t a t i o n programmes (Eaker,  1989; P a r c h e r t & Creason, 1989). Eaker (1989) contends  t h a t when s t u d y i n g women and d i s e a s e , i t i s e s s e n t i a l t o c o n s i d e r f a c t o r s r e l a t e d t o t h e i r behavior, m i l i e u . Although socioeconomic  environment, and p s y c h o l o g i c a l  Eaker reviewed r e s e a r c h t h a t examined  s t a t u s , s o c i a l support,  and p e r s o n a l i t y v a r i a b l e s  i n r e l a t i o n t o women and heart d i s e a s e , none of these s t u d i e s examined women's experience  of MI i n terms of p e r s o n a l meanings.  In other words, these s t u d i e s have n e g l e c t e d t o e x p l o r e t h e nature of women's experience with c a r d i a c i l l n e s s from a s u b j e c t i v e o r p a t i e n t p e r s p e c t i v e . S i m i l a r l y , t h e r e has been no documented s t u d i e s examining the nature of men's experience MI  with  from a s u b j e c t i v e p e r s p e c t i v e . As a consequence, t h e r e i s a  l a c k of r e s e a r c h t h a t can guide a study of women's experience of MI. Conrad (1990) d e s c r i b e s a branch of s o c i a l r e s e a r c h t h a t  3 p l a c e s g r e a t e r emphasis on s t u d y i n g t h e s u b j e c t i v e experience of i n d i v i d u a l s w i t h i l l n e s s . T h i s r e s e a r c h emphasizes t h e person's p e r c e p t i o n s , b e h a v i o r s , and i l l n e s s experiences r a t h e r than t h e p h y s i o l o g i c a l p r o c e s s . Thus, an examination  of t h e meaning t h a t  people a t t r i b u t e t o t h e i r experience and how they make sense of what i s happening t o them i s c e n t r a l t o understanding the i l l n e s s experience. In a d d i t i o n , Benner and Wrubel (1989) suggest t h a t the meaning of an i l l n e s s i s d e r i v e d out of a t r a n s a c t i o n between an i n d i v i d u a l ' s c u l t u r a l h e r i t a g e and p e r s o n a l h i s t o r y , as w e l l as f e a t u r e s of t h e i l l n e s s  itself.  The purpose of t h i s study i s t o add an e x t e n s i v e d e s c r i p t i o n to the small e x i s t i n g body of l i t e r a t u r e on women and MI, and p r o v i d e an e x p l i c i t p o r t r a y a l of t h e experiences l i v e d by these women. I examined the nature of women's experience of MI from a s u b j e c t i v e p e r s p e c t i v e , i n order t o e x p l o r e and d e s c r i b e these experiences and t o understand Understanding  how women made sense of MI.  how women p e r c e i v e and make sense of t h e i r  i l l n e s s experience with MI may p r o v i d e t h e b a s i s f o r f u r t h e r understanding the nature of women's needs w i t h i n the realm of c a r d i a c c a r e . Moreover, t h i s i n f o r m a t i o n i s e s s e n t i a l i n h e l p i n g h e a l t h p r o f e s s i o n a l s implement the p r o v i s i o n of c a r d i a c care and r e h a b i l i t a t i o n s e r v i c e s t h a t are more germane t o women. Thus t h e s p e c i f i c q u e s t i o n s addressed  i n t h i s study were: (a) What a r e  women's experience of MI? (b) How do women make sense of t h i s illness  experience?  D e f i n i t i o n of Terms In order t o p r o v i d e a frame of r e f e r e n c e f o r t h e terms t o be  4 used i n t h i s study, the f o l l o w i n g d e f i n i t i o n s a r e p r o v i d e d : Coronary Heart Disease (CHD) - Heart a i l m e n t s caused by a narrowing of the coronary a r t e r i e s , and t h e r e f o r e , decreased blood supply t o the h e a r t (American Heart A s s o c i a t i o n , Myocardial I n f a r c t i o n  1980).  (MI) - A p o t e n t i a l l y l i f e t h r e a t e n i n g  m a n i f e s t a t i o n of CHD. More s p e c i f i c a l l y , the death of an area of heart muscle r e s u l t i n g from an inadequate oxygen supply t o t h a t area t h a t may r e s u l t i n d i s a b i l i t y or death of the i n d i v i d u a l , depending on the extent of h e a r t damage (American Heart A s s o c i a t i o n , 1980).  (The term h e a r t a t t a c k w i l l be used  i n t e r c h a n g e a b l y with MI, p a r t i c u l a r l y when i n t e r v i e w i n g coresearchers ) . Angina P e c t o r i s - Chest d i s c o m f o r t o r p a i n , b r i e f i n d u r a t i o n , which i s caused by a decrease i n b l o o d supply t o the heart (American Heart A s s o c i a t i o n ,  1980).  Angiogram - A d i a g n o s t i c x-ray procedure t h a t o u t l i n e s the a r t e r i e s of the heart and takes p i c t u r e s of them i n order t o determine the s e v e r i t y of o b s t r u c t i o n t o b l o o d flow t o the h e a r t . T h i s procedure i s i n s t r u m e n t a l i n d e t e r m i n i n g treatment o p t i o n s (American Heart A s s o c i a t i o n , Coronary Bypass  1980).  Surgery - A s u r g i c a l procedure t o improve the  blood supply t o the h e a r t muscle when narrowed  coronary a r t e r i e s  reduce the flow of oxygen-containing b l o o d which i s v i t a l t o the pumping h e a r t . (American Heart A s s o c i a t i o n ,  1981).  I l l n e s s Experience - Reactions t o d i s e a s e o r d i s c o m f o r t based on p e r s o n a l , i n t e r p e r s o n a l , and c u l t u r a l f a c t o r s  (Kleinman,  Meaning of I l l n e s s - The p e r s o n a l and s u b j e c t i v e r e l a t e d t o a person's i l l n e s s  (Lipowski, 1969).  1988).  significance  5 CHAPTER TWO Review of R e l a t e d L i t e r a t u r e Introduction What i s the nature of women's experience with MI, and how do women make sense of t h i s i l l n e s s experience? T h i s s p e c i f i c  issue  has not been adequately addressed i n the l i t e r a t u r e t h a t examines women and c a r d i a c h e a l t h . A review of r e s e a r c h r e l a t e d t o MI and women, women and r e c o v e r y from MI, as w e l l as a b r i e f of the meaning of the i l l n e s s experience, p r o v i d e s i n f o r m a t i o n r e l a t e d t o the nature of t h i s Myocardial  examination  background  issue.  Infarction  Developing p h y s i c a l i l l n e s s symptoms and undergoing medical treatment can be a h i g h l y s t r e s s f u l experience, e s p e c i a l l y i n the case of a p o t e n t i a l l y l i f e t h r e a t e n i n g event. The experience of MI i s t y p i c a l l y sudden, f r e q u e n t l y without forewarning, u s u a l l y d i s t r e s s i n g , and almost always  life-threatening  (Byrne, 1987b).  MI occurs when an o b s t r u c t i o n i n one of the coronary a r t e r i e s prevents s u f f i c i e n t oxygen t o supply the h e a r t r e s u l t i n g i n the death of a p o r t i o n of the h e a r t muscle.  Symptoms may be non-  e x i s t e n t , m i l d , o r severe, and may i n c l u d e chest p a i n (which may r a d i a t e t o the shoulder, arm, neck o r jaw), nausea,  c o l d sweat,  and shortness of b r e a t h . Although symptoms may be v a r i e d , i n d i v i d u a l s f r e q u e n t l y d e s c r i b e t h e i r p a i n as b e i n g heavy, c r u s h i n g , o r squeezing, and many r e p o r t a sense of impending or imminent death  doom  (American Heart A s s o c i a t i o n , 1980). The extent  to which the h e a r t i s damaged w i l l d i r e c t l y determine t h e l i k e l i h o o d of death o r the degree of d i s a b i l i t y a f t e r r e c o v e r y (American Heart A s s o c i a t i o n ,  1980).  6  Although women and men who develop CHD t y p i c a l l y p r e s e n t with s i m i l a r symptoms, r e g a r d l e s s of r i s k f a c t o r s , demographics, and age  (Coglianese, S o l l a n o , & B i l o d e a u , 1992), women tend t o  experience chest p a i n as t h e i r c h i e f symptom more f r e q u e n t l y than men  (Kannel & Abbott, In  1987).  g e n e r a l , p h y s i c a l i l l n e s s i s c o n s i d e r e d t o be an extremely  potent s t r e s s o r as i t may extend over a long p e r i o d of time and l e a d t o permanent changes i n the person and p o t e n t i a l l y changes in  t h e i r f a m i l y (Moos, 1979). The s t r e s s o r s a s s o c i a t e d w i t h MI  are d i v e r s e and may v a r y depending on t h e i r meaningfulness i n d i v i d u a l . These p h y s i c a l and emotional p o t e n t i a l threat, t o one's l i f e ,  t o the  stressors include the  bodily integrity,  functional  s t a t u s , s e l f - c o n c e p t , values and b e l i e f systems, s o c i a l and o c c u p a t i o n a l f u n c t i o n i n g , commitments and f u t u r e p l a n s , and emotional e q u i l i b r i u m  (Cohen & Lazarus,  1979; King, 1985;  Kleinman, 1988). The experience of the h o s p i t a l environment can a l s o be h i g h l y s t r e s s f u l g i v e n the constant reminders and m o r t a l i t y , d i s t r e s s i n g procedures,  of.illness  and t h e frequent sense of  u n f a m i l i a r i t y , boredom, o r l o s s of autonomy (Cohen & Lazarus, 1979). In MI  a d d i t i o n t o t h e p h y s i c a l trauma of MI, t h e experience o f  i s c o n s i d e r e d t o be a major l i f e  c r i s i s f o r most i n d i v i d u a l s ,  and t y p i c a l l y r e s u l t s i n v a r i o u s forms of emotional d i s t r e s s . The most common and expected  emotional consequences f o l l o w i n g MI a r e  d e p r e s s i o n and a n x i e t y (Byrne,  1987b, 1990; Croog, 1983; Hackett  & Cassem, 1984; Mayou, 1984; Stern, P a s c a l e , & McLoone, 1976, 1977). Most p s y c h o s o c i a l r e s e a r c h i n t h i s area however, i s comprised  of s t u d i e s sampling predominantly  men, and have not  7 adequately i d e n t i f i e d o r e x p l o r e d women's e x p e r i e n c e s . Byrne (1990) suggests t h a t v a r i o u s f a c t o r s may a f f e c t an i n d i v i d u a l ' s a f f e c t i v e and b e h a v i o r a l responses t o MI, thereby i n f l u e n c i n g t h e i r immediate medical and long-term r e c o v e r y . These i n c l u d e past experience w i t h MI e i t h e r p e r s o n a l o r i n d i r e c t , the amount of i n f o r m a t i o n communicated by the p h y s i c i a n r e g a r d i n g the nature of the i l l n e s s , p a t t e r n s of p e r s o n a l i t y , e x p e c t a t i o n s of MI, l e v e l s of l i f e Women and M y o c a r d i a l  sociocultural  s t r e s s , and s o c i a l  support.  Infarction  Most of t h e e x i s t i n g l i t e r a t u r e w i t h i n the area of women and MI i s e p i d e m i o l o g i c a l i n nature. F o r example, t h e Framingham study, t h e l o n g e s t ongoing i n v e s t i g a t i o n of CHD r i s k f a c t o r s , has generated a wealth of data as r e s e a r c h e r s have c o l l e c t e d and evaluated a wide assortment  of i n f o r m a t i o n r e l a t e d t o the  c h a r a c t e r i s t i c s found i n persons f r e e of c a r d i o v a s c u l a r d i s e a s e compared t o those who l a t e r developed the d i s e a s e (Kannel & Gordon, 1973). The Framingham study has been one of few p r o j e c t s t h a t has p r o v i d e d l o n g i t u d i n a l data r e l a t e d t o women, and i s f r e q u e n t l y c i t e d i n the c a r d i a c l i t e r a t u r e . Although a f u l l review of t h i s m a t e r i a l i s beyond the scope of t h i s study, an overview of the l i m i t e d and r e l e v a n t m a t e r i a l s p e c i f i c a l l y examining women i s e x p l o r e d . In  g e n e r a l , CHD d i f f e r s s i g n i f i c a n t l y i n women than i n men.  The Framingham data suggests t h a t MI as t h e i n i t i a l m a n i f e s t a t i o n of  CHD i s l e s s common i n women than i n men, and occurs almost 20  years l a t e r  (Kannel, as c i t e d i n Packard,  women p r e s e n t i n i t i a l l y Packard,  1992). More t y p i c a l l y ,  with angina p e c t o r i s  1992; Peberdy & Ornato,  (Eaker e t a l . , 1986;  1992; Rankin,  1990; Wenger,  8 1992). The Framingham data a l s o suggests t h a t MI i s more l i k e l y to  be f a t a l among women, and t h a t m o r t a l i t y r a t e s i n t h e f i r s t  month and the f i r s t year a f t e r MI a r e l i k e l y t o be h i g h e r (Kannel, as c i t e d i n Packard,  1992). As w e l l , post-MI m o r b i d i t y ,  and r a t e s o f r e - i n f a r c t i o n appear t o be h i g h e r among women (Eaker et  al.,  1986; Murdaugh, 1990; Wenger, 1989, 1992). Data from t h e  Framingham study a l s o r e v e a l e d t h a t except f o r the e l d e r l y , t h e p r o p o r t i o n of unrecognized o r s i l e n t i n f a r c t i o n s were g r e a t e r i n women (Kannel, 1990). Although the major r i s k f a c t o r s f o r CHD i n women a r e s i m i l a r to  those found i n men and i n c l u d e age,  high b l o o d p r e s s u r e , high  blood c h o l e s t e r o l , c i g a r e t t e smoking, d i a b e t e s , and high protein 1992;  lipo-  (Eaker e t a l . , 1986; Murdaugh, 19 90; Peberdy & Ornato,  Rosenberg e t a l . , 1983), gender d i f f e r e n c e s appear t o e x i s t  i n terms of the e x p r e s s i o n of these r i s k f a c t o r s Ornato,  (Peberdy &  1992). F o r example, Peberdy and Ornato (1992) suggest  t h a t the p r e v a l e n c e of h y p e r t e n s i o n i n women with CHD i s s i g n i f i c a n t l y higher than i n men with CHD, w h i l e d i a b e t e s i n c r e a s e s t h e r i s k of CHD s i g n i f i c a n t l y i n women and p l a c e s e f f e c t e d i n d i v i d u a l s a t the same r i s k l e v e l as age-matched nond i a b e t i c men. Moreover, more women than men have d i a b e t e s a t t h e time of t h e i r f i r s t MI. Although t h e a s s o c i a t i o n between smoking and MI i s e q u a l l y as s t r o n g i n women and men, t h e d e t r i m e n t a l c a r d i o v a s c u l a r e f f e c t s of smoking i n women a r e dose r e l a t e d and b e l i e v e d t o occur both b e f o r e and a f t e r menopause. The r i s k of acute MI however, i s b e l i e v e d t o be s i g n i f i c a n t l y g r e a t e r i n premenopausal women who smoke compared t o those who do not smoke (Slone e t a l . ,  1978; Rosenberg e t a l . ,  1983). With r e s p e c t t o  9  c h o l e s t e r o l , women have an advantage  over men as t h e f r a c t i o n of  p r o t e c t i v e high d e n s i t y l i p o p r o t e i n s i n young and middle  aged  women a r e h i g h e r than i n age-matched men. Nonetheless, t h i s p r o t e c t i v e advantage  e v e n t u a l l y decreases with age a t a r a t e  f a s t e r i n women than i n men and r e f l e c t s the dramatic i n c r e a s e i n women's r i s k of d e v e l o p i n g MI a f t e r menopause (Stampfer e t a l . , 1991). Other r i s k f a c t o r s a f f e c t i n g women i n c l u d e sedentary lifestyle,  o b e s i t y , p r e v i o u s f a m i l y h i s t o r y of MI o r s t r o k e , high  t r i g l y c e r i d e s , and s t r e s s  (Dustan, 1990; Eaker e t a l . , 1986;  Peberdy & Ornato, 1992). Female s p e c i f i c r i s k f a c t o r s f o r CHD, such as t h e c u r r e n t use of o r a l c o n t r a c e p t i v e s , have r a i s e d s e r i o u s concerns, e s p e c i a l l y i n the presence of c i g a r e t t e smoking. The r e l a t i o n s h i p of menopause t o t h e r i s k of CHD i s not fully  c o n c l u s i v e (Parchert & Creason, 1989; Slone e t a l . , 1981;  Stampfer  et a l . ,  1991). Eaker, Packard, and Thom (1989) suggest  that i t i s d i f f i c u l t  t o i s o l a t e the e f f e c t s of aging.  Type A o r coronary-prone b e h a v i o r p a t t e r n has presented an ongoing c o n t r o v e r s y i n i t s a s s o c i a t i o n with MI (see Bass & Wade, 1982;  Byrne,  1987a; Friedman  & Rosenman, 1974; Haynes, F e i n l i b , &  Kannel, 1980; Scherwitz, McKelvain, & Laman, 1983; Thoresen & Low,  1990). Much of what we know about t h e Type A c o n s t r u c t  remains p r i m a r i l y l i m i t e d t o m i d d l e - c l a s s a d u l t white men. Type A i s c h a r a c t e r i z e d by s e v e r a l l o o s e l y r e l a t e d a t t r i b u t e s  including  i n t e n s i v e s t r i v i n g f o r achievement,  e a s i l y provoked impatience,  urgent sense of time, and h o s t i l i t y  (Byrne, 1987a).  In a  l i t e r a t u r e review examining Type A and women, Thoresen and Low (1990) suggest t h a t a d e f i n i t i v e coronary-prone b e h a v i o r p a t t e r n  10 f o r women has y e t t o be i d e n t i f i e d and confirmed v i a m e t h o d o l o g i c a l l y sound r e s e a r c h . They suggest t h a t Type A i s r e l a t e d t o some but not a l l CHD markers, although no evidence c u r r e n t l y l i n k s Type A t o MI i n women. Furthermore,  Thoresen and  Low (1990) suggest t h a t t h e l i m i t e d r e s e a r c h concerning Type A and women has been plagued by inadequate Haynes & F e i n l i b ,  assessment ( a l s o see  1980).  A c c o r d i n g t o t h e Framingham 14-year follow-up data, education l e v e l i s s i g n i f i c a n t l y a s s o c i a t e d with CHD i n women (Eaker e t a l . ,  1989). Women with 8 years of education o r l e s s ,  demonstrated almost  f o u r times the r i s k of d e v e l o p i n g CHD over  the 14 year follow-up p e r i o d as compared t o women w i t h 12 years or more of education. When r e g r e s s i o n a n a l y s i s was performed c o n t r o l l i n g f o r f a c t o r s such as age, c h o l e s t e r o l , smoking, blood p r e s s u r e , r e l a t i v e weight,  and blood sugar l e v e l s , low education  remained a s i g n i f i c a n t p r e d i c t o r of CHD. In g e n e r a l , i t i s l i k e l y t h a t a woman's experience and p e r c e p t i o n of t h e world w i l l be i n f l u e n c e d by her l i f e s t y l e and a s s o c i a t e d r i s k f a c t o r s . F o r example, t h e h i g h l y educated menopausal c a r e e r women who works long days,  smokes e x c e s s i v e l y ,  and has an e x t e n s i v e f a m i l y h i s t o r y of CHD, may t h r i v e on s t r e s s as an i d e a l context i n which t o work and l i v e f o r a moderate number of y e a r s . In c o n t r a s t , the homemaker who maintains a s t r i c t d i e t , e x e r c i s e s , and p r a c t i c e s yoga d a i l y , may experience the world as an a c t i v e and h e a l t h y i n d i v i d u a l with t h e i n t e n t i o n to l i v e l i f e  f u l l y and f o r as long as p o s s i b l e .  Although women's s o c i a l r o l e s and l i f e s t y l e s have changed and continue t o change over t h e years, Eaker e t a l . (1986) suggest  11  t h a t we do not y e t have enough a v a i l a b l e i n f o r m a t i o n t o r e l a t e these changes t o women's experience Women and Recovery from Myocardial  of MI. Infarction  I t i s i n a p p r o p r i a t e t o assume t h a t women's experience  post-  i n f a r c t i o n i s s i m i l a r t o t h a t of middle-aged men (Conn, T a y l o r , & Abele,  1991; Johansson, Vedin,  & Wilhelmsson, 1983; Johnson &  Morse, 1990; Rankin, 1995; Sharp, C l a r k , & Janz,  1991).  Although  t h e r e has been a p l e t h o r a of l i t e r a t u r e examining t h e aftermath of MI amongst men (see Burgess e t a l . , 1987; Mayou, 1984; Mayou, F o s t e r , & Williamson,  1978; M i l l e r , Wikoff,  G a r r e t t , McMahon, &  Smith, 1990; O l d r i d g e , 1988), minimal r e s e a r c h has examined women's experience  or s p e c i a l needs a f t e r i n f a r c t i o n or d u r i n g  the process of r e h a b i l i t a t i o n Abele,  (Boogard, 1985; Conn, T a y l o r , &  1991).  Conventional  r e h a b i l i t a t i o n goals o f t e n do not r e f l e c t t h e  goals of t h e MI p a t i e n t (Godin, V a l o i s , J o b i n , & Ross, 1991; Johnson & Morse, 1990). To i l l u s t r a t e ,  " r e t u r n t o work," has l o n g  been t h e s t e a d f a s t and p e r v a s i v e outcome measure of MI adjustment (Byrne,  1987b, 1990; Croog, 1983; Smith, 1992; Stern, P a s c a l e , &  Ackerman, 1979) and r e i n f o r c e s the emphasis p l a c e d on male experience while p o t e n t i a l l y camouflaging experiences  the needs and  of women, e s p e c i a l l y those who a r e do not work a t  p a i d employment. Sharpe, e t a l . (1991) suggest  that t h i s  holds  p a r t i c u l a r l y t r u e f o r e l d e r l y women who a r e l e s s l i k e l y than men t o have worked o u t s i d e the home and do not r e t i r e i n t h e same formal sense. Not s u p r i s i n g l y , women's r e p r o d u c t i v e and c a r i n g labour has a l s o t r a d i t i o n a l l y not been viewed as work and has remained f o r the most p a r t absent  i n t h e MI recovery  literature.  12 Sharpe e t a l . (1991) a l s o suggests t h a t t h e r e t u r n t o work measure inadequately  captures the experience of d a i l y l i v i n g  that  i s not r e l a t e d t o p a i d employment, o r an i n d i v i d u a l ' s p e r c e p t i o n of  well-being. Rankin (1995) suggests t h a t because women a r e t y p i c a l l y  than men when they s u f f e r MI, t h i s has i m p l i c a t i o n s f o r and  older  recovery  r e h a b i l i t a t i o n from MI. F o r example, o l d e r women a r e more  l i k e l y t o be plagued with c o m o r b i d i t i e s orthopedic  such as a r t h r i t i s ,  impairment, o r v a s c u l a r d i s e a s e , which may impair  t h e i r a b i l i t y t o p a r t i c i p a t e i n c a r d i a c r e h a b i l i t a t i o n programs t h a t t y p i c a l l y emphasize e x e r c i s e p a r t i c i p a t i o n . C h i r i k o s and N i c k e l labour  (1984) examined gender d i f f e r e n c e s i n  f o r c e withdrawal a f t e r acute MI. Study r e s u l t s suggested  that a larger proportion  of p r e v i o u s l y working women withdrew  from employment a f t e r MI, compared with working men. C h i r i k o s and N i c k e l suggest t h a t t h i s f i n d i n g may be r e l a t e d t o women's way of responding t o the course of t h e d i s e a s e  and t o t h e l a c k of work  or f i n a n c i a l i n c e n t i v e s , as opposed t o d i s e a s e  severity or  concern about f u t u r e s u r v i v a l . The women i n t h i s study were i n f l u e n c e d more by t h e i r b e h a v i o r a l  response t o t h e i r  illness,  meaning t h e i r withdrawal from t h e market work f o r c e , r a t h e r than the s e v e r i t y of t h e i r d i s e a s e . was  In c o n t r a s t , men's r e t u r n t o work  s i g n i f i c a n t l y i n f l u e n c e d by f i n a n c i a l i n c e n t i v e s . Although r e t u r n t o sexual a c t i v i t y has a l s o been a w e l l  e s t a b l i s h e d i n d i c a t o r of recovery  from MI, o n l y a few s t u d i e s  have i n c l u d e d women i n t h i s area of r e s e a r c h 1987;  (Baggs & Karch,  Papadopoulos, Beaumont, S h e l l e y , & Larrimore,  One  1983).  study t h a t d i d examine t h e e f f e c t s of MI on the sexual  13 a c t i v i t y of women i n c l u d e d 130 female c a r d i a c p a t i e n t s (Papadopoulos, Beaumont/ S h e l l e y , & Larrimore,  1983). Through  i n t e r v i e w s women were asked t o r e p o r t on t h e resumption and frequency  of sexual a c t i v i t y , and t o d e s c r i b e symptoms d u r i n g  sexual a c t i v i t y a f t e r MI. F i n d i n g s i n d i c a t e d t h a t MI had a negative impact on women's s e x u a l i t y . More s p e c i f i c a l l y , h a l f of the women t h a t were s e x u a l l y a c t i v e p r i o r t o MI, expressed  fears  of resuming sexual a c t i v i t y , while over a q u a r t e r of t h i s group f a i l e d t o resume any sexual a c t i v i t y . F i n d i n g s a l s o i n d i c a t e d t h a t l e s s than h a l f of these women r e c e i v e d some form of sexual c o u n s e l l i n g or i n s t r u c t i o n p r i o r t o h o s p i t a l In t h e Papadopoulos e t a l . (1983) study,  discharge. o n l y women under t h e  age of 65 were i n t e r v i e w e d , which may have i n f l u e n c e d t h e number of women t h a t were s e x u a l l y a c t i v e p r i o r t o MI. Whether t h i s sample i s r e p r e s e n t a t i v e of a l l women post MI i s q u e s t i o n a b l e . Moreover, t h e study f a i l e d t o c l o s e l y examine t h e women's s u b j e c t i v e experiences  of s e x u a l i t y a f t e r MI.  In a r e c e n t study, Rankin (1995) examined t h e recovery process  of women from MI w i t h i n t h e framework of l i f e - s p a n  development as compared t o t h a t of men. Rankin suggested  that  normative age-graded f a c t o r s as w e l l as normative h i s t o r y - g r a d e d f a c t o r s should be c o n s i d e r e d as i n f l u e n t i a l components e f f e c t i n g women's recovery from MI. More s p e c i f i c a l l y , Rankin argued t h a t the cohort of women most v u l n e r a b l e t o t h e e f f e c t s of heart d i s e a s e and MI, as a r e s u l t of normative age-graded f a c t o r s , a r e o l d e r when they have Mis, more l i k e l y t o experience com o r b i d i t i e s t h a t i n f l u e n c e d i f f e r e n t aspects of recovery, and l e s s l i k e l y than men t o have support,  p a r t i c u l a r y spousal  support  14 as a r e s u l t of widowhood, d u r i n g the MI recovery  period.  Results  from Sharpe e t a l . (1991) study examining t h e impact and managment of heart d i s e a s e  i n o l d e r women a l s o confirm  these  findings. Normative h i s t o r y - g r a d e d  f a c t o r s such as a t t i t u d e s toward  h e a l t h promotion, h e a l t h r e s t o r a t i o n , and h e a l t h maintenance, a r e a l s o u s e f u l t o help e x p l a i n such r i s k f a c t o r s as smoking, d i e t a r y and  exercise patterns,  resources  and l a c k of adequate f i n a n c i a l and s o c i a l  o f t e n c h a r a c t e r i s t i c of t h i s o l d e r cohort  example, t h e o l d e r cohort  of women who a r e predominantly those  who experience heart d i s e a s e  and MI today, l i k e l y d i d not have  the b e n e f i t s of t h e i n f o r m a t i o n women r e g a r d i n g  of women. F o r  c u r r e n t l y a v a i l a b l e t o younger  t h e e f f e c t s of smoking, poor d i e t , and l a c k of  exercise. Rankin (1995) f u r t h e r argued t h a t other  sociohistorical  f a c t o r s r e l a t e d t o past work and m a r i t a l r o l e s a r e a l s o s i g n i f i c a n t f a c t o r s t h a t i n f l u e n c e women's recovery  from MI. F o r  example, low socioeconomic s t a t u s i s l i k e l y a g r e a t e r  source of  s t r e s s f o r more women than i t i s f o r men. T h i s i s e s p e c i a l l y t r u e f o r o l d e r women who a r e more l i k e l y t o be widowed, r e t i r e d , o r l i v i n g on a f i x e d income. One  i n t e r e s t i n g f i n d i n g i n Rankin's study was t h a t the women  were i d e n t i f i e d t o have twice as many s o c i a l support needs as compared t o a group of male c a r d i o l o g y p a t i e n t s . Subsequently, h e a l t h care p r o v i d e r s  should  not assume t h a t women have s i m i l a r  support needs as male c a r d i a c p a t i e n t s , o r t h a t women have t h e same degree of support and c a r e t a k i n g a s s i s t a n c e a v a i l a b l e t o them as do men.  15 I m p l i c a t i o n s of Rankin's (1995) r e s e a r c h r e l a t e t o i n c r e a s i n g h e a l t h care p r o f e s s i o n a l s awareness about t h e d i f f e r e n c e s between women's and men's experience of c a r d i a c i l l n e s s , importance  of c o n s i d e r i n g developmental  and t h e  context as i t r e l a t e s t o  the c h r o n i c i t y of heart d i s e a s e and how t h i s a f f e c t s women's r e c o v e r y from M l . In a seminal work, Boogard (1984) compared the r e h a b i l i t a t i o n of women and men post MI. U s i n g q u a l i t a t i v e methodology, t h e study demonstrated t h a t women's experience of r e h a b i l i t a t i o n d i f f e r e d s i g n i f i c a n t l y from men's i n terms of r e t u r n t o p h y s i c a l a c t i v i t y , p s y c h o s o c i a l a s p e c t s , and f a m i l y i n t e r r e l a t i o n s h i p s . U s i n g serai-structured i n t e r v i e w s , 20 c a r d i a c p a t i e n t s (10 women and  10 men) were i n t e r v i e w e d between 3 and 6 months a f t e r MI.  P a r t i c i p a n t s i n the study were between 25 and 55 years of age, mostly married, and from d i v e r s e s o c i a l economic backgrounds. W i t h i n 1 week of d i s c h a r g e from the h o s p i t a l , women r e p o r t e d engaging  i n higher l e v e l s of e x e r t i o n , i n c l u d i n g l i g h t housework.  Most of the women d i d not p e r c e i v e household  a c t i v i t y t o be work,  or c o n s i d e r t h i s work t o be p o t e n t i a l l y harmful. Women were more l i k e l y t o i n c r e a s e t h e i r l e v e l of housework than t o e n r o l i n a walking o r r e h a b i l i t a t i v e program. In c o n t r a s t , p o s t - d i s c h a r g e a c t i v i t i e s f o r men i n c l u d e d r e s t i n g , r e l a x i n g , and walking. Boogard (1984) r e p o r t e d t h a t women i n t h e study  also  experienced a d e l a y i n r e t u r n t o work and sexual a c t i v i t y . These f i n d i n g s a r e congruent  with other r e s e a r c h (Baggs & Karch, 1987;  Papadopoulos e t a l . , 1983). Although both women.and men r e p o r t e d f e e l i n g depressed d u r i n g t h e i r r e h a b i l i t a t i v e p e r i o d , o n l y women r e p o r t e d f e e l i n g s of g u i l t , p a r t i c u l a r l y when f a m i l y members  16 performed household tasks f o r them. As w e l l , these women were more l i k e l y t o r e s i s t r e c e i v i n g help from o t h e r s . Boogard (1985) concluded  t h a t h e a l t h p r o f e s s i o n a l s need t o be  s e n s i t i z e d t o t h e p o t e n t i a l d i f f i c u l t i e s of women f a c i n g c a r d i a c r e h a b i l i t a t i o n , and t o i n c o r p o r a t e t h e knowledge of women's needs i n t o e d u c a t i o n a l g u i d e l i n e s geared  to f a c i l i t a t e  optimal  r e h a b i l i t a t i o n i n women. Boogard's (1984, 1985) work was reviewed i n d e t a i l because i t i s m e t h o d o l o g i c a l l y conducive  t o understanding  t h e process of  women's recovery from MI, and i s one of t h e few documented s t u d i e s t h a t has examined p s y c h o s o c i a l aspects of women's experience. Although  i n f o m r a t i o n surrounding women's d e l a y i n  r e t u r n t o work and p r e v i o u s  l e v e l s of sexual a c t i v i t y c o u l d not  be determined, t h e study p r o v i d e s a u s e f u l model f o r f u t u r e research. Using a grounded theory approach, Johnson and Morse (1990) examined adjustment a f t e r MI i n a group of 7 women and 7 men. A l l but f o u r p a r t i c i p a n t s were i n t e r v i e w e d a few months post MI, as the remaining  i n t e r v i e w s took p l a c e between 10 and 45 months  a f t e r MI. Johnson and Morse suggest  t h a t adjustment t o MI  i n v o l v e s the p r o g r e s s i o n through f o u r major stages, i n c l u d i n g t h e i n i t i a l threatened  l o s s of c o n t r o l , coming t o terms with t h e MI,  r e e s t a b l i s h i n g c o n t r o l a f t e r MI, and recovery. As the fundamental t a s k i n each major stage i s r e g a i n i n g a sense of c o n t r o l , t h e r o l e of t h e i n d i v i d u a l ' s p e r c e p t i o n s i s c r i t i c a l  i n the  adjustment p r o c e s s . Subthemes, r e f l e c t i n g s t r a t e g i e s and responses d i r e c t e d towards r e g a i n i n g c o n t r o l , were a l s o d e l i n e a t e d from the f o u r major stages. Although  Johnson and  17 Morse's proposed  theory of adjustment  appears  t o be p l a u s i b l e , as  they emphasize t h e s u b j e c t i v e experience of t h e i n d i v i d u a l i n terms of r e g a i n i n g a sense of c o n t r o l , they do not present t h e p o s s i b i l i t y of an o v e r l a p o r i n t e g r a t i o n of stage p r o g r e s s i o n . Instead, they endorse  the b e l i e f t h a t adjustment  t o MI i s a  f a i r l y l i n e a r p r o c e s s . As w e l l , i t would be of i n t e r e s t and r e l e v a n c e t o i d e n t i f y whether gender d i f f e r e n c e s , demographics, or s o c i a l context i n f l u e n c e d t h e e x i s t e n c e of the emergent stages of themes. These i s s u e s d i d not appear t o be addressed by t h e researchers. A s i d e from these major f i n d i n g s , Johnson and Morse (1990) r e p o r t e d t h a t the women i n the study tended t o minimize  their  i l l n e s s symptoms and r e t u r n e d t o t h e i r homemaker r o l e s  sooner  than was deemed m e d i c a l l y s a f e . T h i s perpetuated the b e l i e f t h a t housework was not " r e a l " work. As w e l l , most of these women were p r o t e c t i v e of t h e i r homemaker and mothering uncomfortable  r o l e s , and f e l t  r e c e i v i n g support from f a m i l y members. Moreover,  these women were more l i k e l y t o make l i f e s t y l e  changes  independently, b e i n g c a r e f u l not t o i n t e r r u p t o r o f f s e t t h e f a m i l y r o u t i n e . These f i n d i n g s a r e s i m i l a r t o and p r o v i d e  support  f o r Boogard's (1984, 1985) and Dunn's (1985) e a r l i e r r e s e a r c h findings. Based on t h i s r e s e a r c h , Johnson and Morse (1990) developed a theory of adjustment  t h a t emphasized t h e importance  of p a t i e n t p e r c e p t i o n s i n the adjustment  of t h e r o l e  p r o c e s s . Although  their  study examined the i l l n e s s experience of women and men, i t p r o v i d e d l i m i t e d i n f o r m a t i o n about t h e p a r t i c i p a n t s  (e.g., s o c i a l  and c u l t u r a l c o n t e x t ) , and t h e process of data c o l l e c t i o n and  18 a n a l y s i s . Although t h e authors l i m i t e d t h e i r sample t o persons i n r e h a b i l i t a t i o n programs, t h e i r d e v e l o p i n g t h e o r y c o u l d have been strengthened by t h e a d d i t i o n of an a l t e r n a t i v e group t o t e s t t h e l i m i t s of g e n e r a l i z a b i l i t y . Dunn (1985) used a phenomenological  method t o examine women's  experience of MI between 2 and 14 weeks f o l l o w i n g h o s p i t a l discharge.  Through a s e r i e s of s e m i - s t r u c t u r e d i n t e r v i e w s , Dunn  e x p l o r e d t h e i l l n e s s experiences of e i g h t women. The core theme t h a t emerged from the data a n a l y s i s and captured t h e essence of the women's experience with MI was l o s s . Women r e p o r t e d m u l t i p l e l o s s e s i n c l u d i n g : the l o s s of a p h y s i c a l l y h e a l t h y s t a t e ; t h e l o s s of p r e d i c t a b i l i t y i n terms of e x p e r i e n c i n g a sudden s h i f t from h e a l t h t o i l l n e s s , and a sense of u n c e r t a i n t y towards t h e recovery process; the l o s s of s o c i a l support from t h e i r ( e s p e c i a l l y t h e i r husbands);  families  and a l o s s of power and c o n t r o l as  they experienced changes i n t h e i r u s u a l s o c i a l and homemaker r o l e s . Women i n the study a l s o r e p o r t e d f e e l i n g s of g u i l t i n r e l a t i o n t o g i v i n g over t h e i r household  r o l e s t o t h e i r husbands  and other f a m i l y members. As w e l l , Dunn (1985) r e p o r t e d t h a t t h e women had d i f f i c u l t y p u t t i n g themselves  f i r s t when c o n f l i c t  developed between the competing demands of t h e i r home and f a m i l y l i v e s , and t h e i r own h e a l t h s t a t u s and r e h a b i l i t a t i o n . Moreover, women i n t h e study d i d not i d e n t i f y p h y s i c a l r e h a b i l i t a t i o n , t h e p r e s c r i p t i o n of c h o i c e i n t h e c a r d i a c l i t e r a t u r e , as a means t o g a i n c o n t r o l over t h e i r p e r c e i v e d sense of l o s s e s . T h i s study demonstrated the uniqueness MI.  of women's i l l n e s s experience w i t h  Dunn's f i n d i n g s were s i m i l a r t o Johnson and Morse's (1990)  l a t e r r e s e a r c h f i n d i n g s and suggest t h a t the women r e t u r n i n g home  19 from h o s p i t a l i z a t i o n with MI were concerned about f a m i l y  and  r e l a t i o n a l i s s u e s , p a r t i c u l a r l y around the e f f e c t s of t h e i r i l l n e s s on t h e i r f a m i l y , and  i n terms of j u g g l i n g p e r s o n a l  and  f a m i l i a l needs. Dunn (19 85)  explored and d e s c r i b e d the meaning of women's  i l l n e s s experience Although it  of MI a f t e r b e i n g d i s c h a r g e d from h o s p i t a l .  the i n f o r m a t i o n d e r i v e d from t h i s study i s i n v a l u a b l e ,  i s e q u a l l y important  experiences  to explore and understand  of women w h i l e h o s p i t a l i z e d with  Although  the  illness  MI.  there i s l i m i t e d q u a l i t a t i v e research i n t h i s  area,  t h e r e are numerous q u a n t i t a t i v e s t u d i e s examining adjustment to MI v i a the measurement of m u l t i p l e c o n s t r u c t s i n c l u d i n g a n x i e t y , d e p r e s s i o n , coping, f u n c t i o n a l c a p a c i t y , s e l f esteem, s o c i a l support, Keckeisen  and  s o c i a l adjustment (see Ben-Sira  & Nyamathi, 1990;  & Eliezer,  1990;  Stern, P a s c a l e , & Ackerman,  1977;  W i n e f i e l d & M a r t i n , 1981). Although  these s t u d i e s y i e l d  q u a n t i f i a b l e data, they g e n e r a l l y do not examine the s o c i a l or c u l t u r a l contexts of the i n d i v i d u a l s b e i n g s t u d i e d . As women are t y p i c a l l y excluded  or under-represented  recovery l i t e r a t u r e , t h i s p r o v i d e s understanding  from much of the MI .  l i m i t e d i n f o r m a t i o n to a i d  of women's s u b j e c t i v e experience  In p r e v i o u s r e s e a r c h t h a t has i l l n e s s experience  of MI  of  MI.  s p e c i f i c a l l y examined women's  (Boogard, 1984,  1985;  Dunn,  Johnson & Morse, 1990), data c o l l e c t i o n took p l a c e p a r t i c i p a n t s had r e t u r n e d home f o l l o w i n g h o s p i t a l  1985;  after discharge.  A c c o r d i n g t o Byrne (1990), women's p e r c e p t i o n s of t h e i r i l l n e s s experience  are l i k e l y to be much d i f f e r e n t  while  h o s p i t a l i z e d with l i f e t h r e a t e n i n g symptoms than r e p o r t i n g  20 r e t r o s p e c t i v e l y a t s e v e r a l months p o s t - h o s p i t a l d i s c h a r g e . Byrne f u r t h e r suggests t h a t a n x i e t y l e v e l s of h o s p i t a l i z e d p a t i e n t s f l u c t u a t e over time depending on t h e p e r c e i v e d s e r i o u s n e s s of t h e c h a l l e n g e f a c e d a t d i f f e r e n t p o i n t s i n t h e i r i l l n e s s p r o c e s s . F o r example, a p a t i e n t ' s a n x i e t y l e v e l  will  l i k e l y be high soon a f t e r symptom onset when the t h r e a t t o l i f e i s t h e g r e a t e s t , and again p r i o r t o h o s p i t a l d i s c h a r g e when constant medical a t t e n t i o n must be r e l i n q u i s h e d . C a p t u r i n g women's i n i t i a l  experiences of MI, b e f o r e b e i n g  exposed t o the r e s p o n s i b i l i t i e s of t h e i r home l i f e , and e x p l o r i n g how women make sense of these experiences, i s t h e focus of t h e c u r r e n t r e s e a r c h . Consequently,  i t i s necessary t o document  women's experiences w h i l e c o - r e s e a r c h e r s a r e s t i l l  hospitalized  with MI. Meaning of I l l n e s s C e n t r a l t o understanding how women make sense of t h e i r p o t e n t i a l l y l i f e t h r e a t e n i n g experience w i t h MI, i s t h e p e r c e p t i o n of meaning a t t a c h e d t o a l l aspects of t h e i r  illness  events. T a y l o r (1983) suggests t h a t when i n d i v i d u a l s experience a p e r s o n a l l y t h r e a t e n i n g event or setback, the process of adjustment  involves c o g n i t i v e l y adaptive e f f o r t s i n v o l v i n g three  fundamental themes. These fundamental themes i n c l u d e a search f o r meaning w i t h i n t h e experience, an attempt  a t mastery over t h e  t h r e a t e n i n g event, and an e f f o r t t o r e s t o r e a sense of s e l f esteem d e s p i t e the experience of a p e r s o n a l setback. More s p e c i f i c a l l y , the search f o r meaning i s an attempt the event o c c u r r e d , and t o understand  t o e x p l a i n why  the p e r s o n a l impact and  s i g n i f i c a n c e of t h e t h r e a t e n i n g event. T a y l o r f u r t h e r  suggests  21 t h a t t h i s process of c o g n i t i v e adjustment to  may enable  individuals  " r e t u r n t o or exceed t h e i r p r e v i o u s l e v e l of p s y c h o l o g i c a l  f u n c t i o n i n g . " Although  T a y l o r ' s (1983) a d a p t a t i o n t h e o r y  appears  p l a u s i b l e i n terms of a model f o r c o g n i t i v e adjustment t o t h r e a t e n i n g events, t h e stages f a i l t o f u l l y i l l u m i n a t e aspects of  t h e whole person and subsequently  we can thoroughly understand responses  l i m i t s the extent t o which  and capture t h e nature of women's  t o MI. F o r example, t h e impact  c o g n i t i o n s i s dependent on t h a t person's  of an i n d i v i d u a l ' s life  story. I t i s within  t h i s e n t i r e context, t h a t we would more f u l l y comprehend women's response t o MI. Lipowski  (1969) suggests t h a t i l l n e s s meaning i s d e r i v e d from  the p e r s o n a l and s u b j e c t i v e s i g n i f i c a n c e of a l l i n f o r m a t i o n r e l a t e d t o an i n d i v i d u a l ' s i l l n e s s . Meaning i s t h e core of a person's p s y c h o l o g i c a l response t o i l l n e s s , and w i l l s t r o n g l y i n f l u e n c e t h e i r emotional and b e h a v i o r a l responses.  Multiple  f a c t o r s e f f e c t t h e c o n s t r u c t i o n of meaning and each component of the i l l n e s s experience i n c l u d i n g p e r s o n a l i t y , l i f e h i s t o r y and experience, i n t r a p s y c h i c aspects, s o c i a l . c o n t e x t and r e l a t i o n s h i p s , and the d i s e a s e process i t s e l f . Lipowski t h a t t o understand  an i n d i v i d u a l ' s i l l n e s s experience, i t i s  necessary t o understand  t h e i r s u b j e c t i v e i n t e r p r e t a t i o n of t h e  experience and the p e r s o n a l meaning a s s o c i a t e d with related  suggests  illness  events.  Kleinman (1988) suggests t h a t t h e i l l n e s s experience has s e v e r a l meanings. F o r example, c u l t u r a l v a l u e s and s o c i a l r e l a t i o n s tend t o shape how i n d i v i d u a l s p e r c e i v e and monitor t h e i r bodies, l a b e l and c a t e g o r i z e b o d i l y symptoms, and i n t e r p r e t  22 symptoms and complaints w i t h i n the context of t h e i r Kleinman endorses  lives.  the use of q u a l i t a t i v e methods v i a the  c o n s t r u c t i o n of a i l l n e s s n a r r a t i v e or l i f e  s t o r y , as a means f o r  i n d i v i d u a l s t o g i v e shape and meaning t o her or h i s i l l n e s s experience. An i n d i v i d u a l ' s l i f e  story contains personal  metaphors and r h e t o r i c t h a t enable others t o c r e a t e knowledge about the i n d i v i d u a l ' s p e r s o n a l and c u l t u r a l models f o r making meaning of the i l l n e s s experience, as w e l l as p r o v i d i n g a method f o r communicating those meanings. Furthermore, emphasizes the importance  Kleinman (1988)  of "empathic w i t n e s s i n g , " or the  commitment of h e l p i n g a s i c k person f a c i l i t a t e t h e i r t e l l i n g of their illness  s t o r y which enables them t o make and g i v e value t o  their illness  experience.  Benner and Wrubel (1989) draw on a phenomenological  approach  to working with i l l n e s s and h e a l t h , and suggest t h a t an i n d i v i d u a l ' s meaning of i l l n e s s i s d e r i v e d out of an  interaction  between p e r s o n a l and c u l t u r a l background meanings, and f e a t u r e s of the i l l n e s s  situation.  I t becomes e v i d e n t t h a t the ways i n which an  individual  construes her or h i s experience of i l l n e s s i s c l o s e l y r e l a t e d t o the p e r c e i v e d meaningfulness  or p e r s o n a l s i g n i f i c a n c e of the  experience. As w e l l , an i n d i v i d u a l ' s p e r s o n a l v a l u e s , b e l i e f s , and c u l t u r a l r e l a t i o n s i n f l u e n c e the meaning a t t a c h e d t o v a r i o u s aspects of the i l l n e s s experience. In terms of women's experience with MI,  understanding  women need t o t e l l t h e i r own  life  s t o r y or i l l n e s s n a r r a t i v e v i a q u a l i t a t i v e methods such as phenomenology, i n order t o f u l l y e x p l o r e and communicate the r i c h n e s s of t h e i r i l l n e s s  experience.  23 Related  Research  Although adjustment  l i t t l e r e s e a r c h has been done i n the area of women's  t o MI, Compas ( c i t e d i n Compas & Orosan, 1993), i n a  s i m i l a r undertaking, has e x p l o r e d the meaning of the d i a g n o s i s and treatment  of cancer f o r p a t i e n t s and t h e i r f a m i l i e s . The  c e n t r a l concern i n t h i s r e s e a r c h i s t o understand what aspects of the i n d i v i d u a l ' s v a l u e s , g o a l s , and commitments a r e a t stake i n a g i v e n s t r e s s f u l encounter,  i n order t o understand the  i n d i v i d u a l ' s meaning of t h a t encounter.  Compas attempts t o  s i t u a t e the p a t i e n t ' s experiences w i t h i n the framework of Lazarus and Folkman's.(1984) s t r e s s and coping model. A c c o r d i n g t o Lazarus and Folkman's (1984)  phenomenological  c o g n i t i v e - t r a n s a c t i o n a l t h e o r y of s t r e s s and coping,  individuals  and t h e i r environments r e c i p r o c a l l y a f f e c t each other i n a dynamic and c o n s t a n t l y changing r e l a t i o n s h i p . Moreover, p s y c h o l o g i c a l s t r e s s i s d e f i n e d as "a p a r t i c u l a r  relationship  between the person and the environment t h a t i s a p p r a i s e d by the person as t a x i n g or exceeding h i s or her resources and endangering  h i s or her w e l l - b e i n g " (Lazarus & Folkman, 1984, p.  19). Lazarus and Folkman (1984) d i s c u s s "perceptions of meaning o r s i g n i f i c a n c e " i n terms of p e r s o n a l stakes, o r what i s a t stake f o r the person i n a s t r e s s f u l encounter.  S i g n i f i c a n t t o Compas'  work i s the i d e a of p e r s o n a l s t a k e s . Stakes i n v o l v e those  aspects  of the person and t h e i r r e l a t i o n s h i p with the environment t h a t have been threatened, harmed, or c h a l l e n g e d i n a s t r e s s f u l encounter.  Understanding  a person's  a p p r a i s a l s of meaning (or  stakes) p r o v i d e s r e l e v a n t i n f o r m a t i o n f o r understanding why a  24 p a r t i c u l a r s i t u a t i o n i s a p p r a i s e d as s t r e s s f u l by an i n d i v i d u a l . C l e a r l y , t h i s i s u s e f u l i n examining response  to similar  individual differences i n  circumstances.  Compas and Orosan (1993) have designed a p r e l i m i n a r y 10category framework c o n s i s t i n g of v a r i o u s a p p r a i s a l s based on t h e meanings of s t r e s s f u l events. These i n c l u d e such c a t e g o r i e s as affiliation,  achievement-power, p e r s o n a l growth, p e r s o n a l h e a l t h ,  and p l e a s u r e seeking. Each p a t i e n t was asked t o d e s c r i b e aspects of  t h e i r i l l n e s s o r treatment  t h a t was p e r c e i v e d t o be most  s t r e s s f u l t o them. Compas and Orosan suggest t h a t t h e t h r e a t t o p e r s o n a l h e a l t h i s not always the most s t r e s s f u l aspect of one's i l l n e s s . P a t i e n t s f e l t t h a t having other areas of t h e i r  lives  threatened by i l l n e s s was o f t e n more s t r e s s f u l . Although  Compas's r e s e a r c h has focused on cancer p a t i e n t s ,  the n o t i o n of p e r s o n a l stakes i s d i s c u s s e d by Lazarus and Folkman (1984) w i t h r e s p e c t t o any s t r e s s f u l encounter.  In terms of  women's i l l n e s s experience with MI, t h e s t r e s s and coping model and the n o t i o n of p e r s o n a l stakes may be u s e f u l t o c o n s i d e r when contemplating'co-researcher  themes d u r i n g data a n a l y s i s . I t i s  c r u c i a l however, t h a t the d e s c r i p t i o n s and experiences of t h e cor e s e a r c h e r s i n f o r m the phenomenological to  data a n a l y s i s as opposed  c r e a t i n g c o n s t r u c t s t o inform t h e c o - r e s e a r c h e r ' s experience.  Summary D e s p i t e t h e dramatic p r e s e n t a t i o n of MI, and t h e extent and degree t o which MI impacts  on women, t h e r e i s a s c a r c i t y of  l i t e r a t u r e and r e f l e c t s the l a c k of knowledge surrounding  this  l i f e t h r e a t e n i n g event. Although  r e s e a r c h suggests t h a t women present and m a n i f e s t MI  25 symptomology and r i s k f a c t o r s d i f f e r e n t l y than do men, t h e m a j o r i t y of c a r d i a c s t u d i e s have e i t h e r excluded o r under r e p r e s e n t e d women i n t h e i r study samples. As w e l l , much of t h e c u r r e n t l i t e r a t u r e i s based on narrow c o n s t r u c t s , t h a t a r e not conducive t o an examination  of women's i l l n e s s experience from a  s u b j e c t i v e p e r s e p c t i v e . Subsequently,  a major l i m i t a t i o n t o much  of the a v a i l a b l e r e s e a r c h i s t h a t women a r e not b e i n g asked the nature of t h e i r  about  experiences.  Boogard (1984, 1985) and Dunn's (1985) work has f u r t h e r i l l u m i n a t e d the uniqueness  of women's i l l n e s s experience, and  emphasized the need f o r f u r t h e r q u a l i t a t i v e r e s e a r c h i n t h e area of women and MI. Q u a l i t a t i v e methodology p r o v i d e s a means f o r e x p l o r i n g and d e s c r i b i n g t h e r i c h n e s s of women's experience. F i n a l l y , r e s e a r c h on the meaning of i l l n e s s emphasizes the importance  of e x p l o r i n g the meanings t h a t women a t t r i b u t e t o a l l  aspects of t h e i r i l l n e s s experience. I t i s e v i d e n t t h a t a woman's p e r s o n a l and c u l t u r a l h i s t o r y i n f l u e n c e s what she deems as b e i n g meaningful. Current r e s e a r c h focuses on c o l l e c t i n g data p o s t - h o s p i t a l d i s c h a r g e . In order t o broaden our scope of knowledge w i t h i n t h i s area, i t i s necessary t o examine t h e experiences of women who a r e still  h o s p i t a l i z e d . In terms of an i l l n e s s time  line,  h o s p i t a l i z a t i o n r e p r e s e n t s the b e g i n n i n g of the treatment f o r MI and marks a s i g n i f i c a n t stage i n an i n d i v i d u a l ' s  process  illness  experience. The c u r r e n t study aims t o expand our scope of knowledge w i t h i n the area of women and MI, by u s i n g  phenomenological  methods t o explore.and d e s c r i b e the meaning t h a t h o s p i t a l i z e d  26 women a t t r i b u t e  to t h e i r i l l n e s s experience of  MI.  27  CHAPTER THREE Methodology Research  Design  The primary focus of t h i s study i s t o e x p l o r e how sense of t h e i r i l l n e s s experience of MI. A approach was method was  women make  phenomenological  used t o guide the data c o l l e c t i o n and a n a l y s i s . T h i s  s e l e c t e d as the most a p p r o p r i a t e means of d e s c r i b i n g  and understanding the meaning of women's i l l n e s s experience, from t h e i r own  frame of r e f e r e n c e and view of s o c i a l  (MacMillan & Schumacher, The phenomenological as people experience i t "  reality  1989). method attempts t o c o n t a c t "phenomenon (Colaizzi,  1978,  p.57), and i s concerned  with understanding human behavior i n g r e a t e r depth than i s p o s s i b l e w i t h other methods of i n v e s t i g a t i o n t h a t seek t o c o n t r o l or p r e d i c t b e h a v i o r (Knaack,  1984). G i o r g i  r i g o r and d i s c i p l i n e can be a p p l i e d without  (1975) suggests t h a t necessarily  t r a n s f o r m i n g data i n t o q u a n t i t a t i v e e x p r e s s i o n s . Giorgi  (1975, p.83)  d e f i n e s phenomenology as "the study of  the s t r u c t u r e , and the v a r i a t i o n s of s t r u c t u r e , of the consciousness t o which any t h i n g , event, or person  appears."  G i o r g i f u r t h e r suggests t h a t phenomenology i l l u m i n a t e s not o n l y the phenomena which appears, but a l s o the manner i n which the phenomena appears. Personal  Assumptions  A fundamental  p r i n c i p l e of phenomenology i s the r e s e a r c h e r ' s  p a r t i c i p a t i o n i n the f o r m u l a t i o n of the r e s e a r c h q u e s t i o n , the d e t e r m i n a t i o n of what c o n s t i t u t e s the data, and d e c i s i o n s data c o l l e c t i o n and a n a l y s i s  (Osbourne,  1990).  around  Subsequently,  the  28 r e s e a r c h e r ' s frame of r e f e r e n c e becomes an e x p l i c i t p a r t o f t h e research report. The primary  t a s k o f t h e r e s e a r c h e r i s t o r e v e a l t h e meaning  of t h e c o - r e s e a r c h e r ' s  experience,  t h e r e f o r e i t i s necessary  for  the r e s e a r c h e r t o make p e r s o n a l b i a s e s o r p r e d i s p o s i t i o n s as e x p l i c i t as p o s s i b l e ( G i o r g i , 1975). Through a process o f " r i g o r o u s s e l f - r e f l e c t i o n " known as b r a c k e t i n g (Osbourne, 1990), the r e s e a r c h e r attempts t o a r t i c u l a t e and t e m p o r a r i l y suspend p e r s o n a l b i a s e s and p r e d i s p o s i t i o n s , t h a t may otherwise  distort  or i n t e r f e r e with the e x p r e s s i o n o f t h e c o - r e s e a r c h e r ' s experience. B r a c k e t i n g enables  those r e a d i n g t h e r e s e a r c h r e p o r t  to c o n s i d e r t h e r e s e a r c h e r ' s p e r s p e c t i v e through which t h e cor e s e a r c h e r ' s d e s c r i p t i o n s and meanings a r e understood 1975;  (Giorgi,  Osbourne, 1990).  Based on my own l i f e experience,  i n c l u d i n g an e x t e n s i v e  background working as a c a r d i o l o g y t e c h n o l o g i s t i n s e v e r a l h o s p i t a l s and r e h a b i l i t a t i v e s e t t i n g s , I have i d e n t i f i e d s e v e r a l general and p e r s o n a l assumptions t h a t a r e of r e l e v a n c e t o t h i s study. The assumptions t h a t guided t h i s study  included:  (a) Women w i l l be a b l e t o d e s c r i b e t h e i r experiences  o f MI w h i l e  hospitalized. (b) Phenomenological methods w i l l p r o v i d e a means t o understand women's i l l n e s s experience  of MI.  (c) Women i n t e r v i e w e d post MI w i l l be w e l l enough t o p a r t i c i p a t e i n follow-up i n t e r v i e w s . (d) Health care p r o f e s s i o n a l s a r e concerned about b e t t e r understanding  women's i l l n e s s experience with MI.  My p e r s o n a l assumptions g u i d i n g t h i s study i n c l u d e :  29 (a) People are t h e i r own (b) The  best e x p e r t s .  experience of b e i n g h o s p i t a l i z e d  with MI  i s an  extremely  s t r e s s f u l experience f o r most people. (c) There i s d i v e r s i t y understanding  among i n d i v i d u a l s  of the s e r i o u s n e s s of t h e i r  i n terms of  their  illness.  (d) People have an urgent need to t e l l t h e i r s t o r y r e g a r d i n g the events  surrounding t h e i r MI and h o s p i t a l i z a t i o n ,  the o p p o r t u n i t y to be a b l e to t a l k about t h e i r (e) The  hospital  and  appreciate  experiences.  environment does not adequately p r o v i d e p a t i e n t s  with the o p p o r t u n i t y t o explore or v o i c e t h e i r emotional regarding t h e i r i l l n e s s  concerns  experience.  ( f ) P a t i e n t s are l i k e l y to d e s c r i b e t h e i r concerns of themes such as l o s s of c o n t r o l  more i n terms  or u n c e r t a i n t y , than i n terms  of p e r s o n a l meanings. (g) I n d i v i d u a l s t h a t have experienced MI particular  need t o a t t r i b u t e  a  cause or causes t o t h e i r i l l n e s s . When medical  p r o f e s s i o n a l s are unable t o p r o v i d e adequate i n f o r m a t i o n , p a t i e n t s are more l i k e l y to c r e a t e l a y t h e o r i e s i n order t o make sense of t h e i r The  experience.  Interview Phenomenological r e s e a r c h d i f f e r s from the  scientific  traditional  model i n the view of the s u b j e c t of r e s e a r c h as a co-  r e s e a r c h e r or p a r t i c i p a n t  (Osbourne, 1990). T h i s  distinction  emphasizes the c o - o p e r a t i v e and v o l u n t a r y nature of the qualitative scientific  r e s e a r c h approach (Osbourne, 1990), and c o n t r a s t s the model, where the experimenter  and s u b j e c t  relationship  i s c h a r a c t e r i z e d by an imbalance of power (von E c k a r t s b e r g , 1971). In phenomenology, the r e s e a r c h e r engages i n a c o o p e r a t i v e  30 d i a l o g u e with the c o - r e s e a r c h e r i n order t o e x p l o r e and  clarify  the meaning of her or h i s experience. To f a c i l i t a t e the d i a l o g a l r e l a t i o n s h i p , i t i s e s s e n t i a l t h a t the r e s e a r c h e r e s t a b l i s h a t r u s t i n g r e l a t i o n s h i p and r a p p o r t with the c o - r e s e a r c h e r (Osbourne, 1990). T h i s was  achieved by c r e a t i n g an atmosphere of  concern and r e s p e c t f o r the c o - r e s e a r c h e r , communicating an i n t e r e s t i n understanding the c o - r e s e a r c h e r ' s experience, and encouraging the c o - r e s e a r c h e r t o d e s c r i b e and express experience  (Osbourne, 1990;  As a graduate  by  this  von E c k a r t s b e r g , 1971).  student i n c o u n s e l l i n g psychology,  I have  gained e x t e n s i v e i n t e r v i e w i n g and c o u n s e l l i n g experience,  based  on the Egan (1990) model of t h e r a p e u t i c s k i l l s . As w e l l , I have thoroughly examined the work of phenomenological i n c l u d i n g G i o r g i o (1975, 1985)  and C o l a i z z i  researchers  (1978).  E t h i c a l Considerations Approval  f o r t h i s study was  granted from the U n i v e r s i t y of  B r i t i s h Columbia e t h i c s committee, St. Paul's H o s p i t a l r e s e a r c h and e t h i c s committee, and the d i r e c t o r of C a r d i o l o g y at St. Paul's h o s p i t a l i n Vancouver. P r i o r to p a r t i c i p a t i o n , p o t e n t i a l co-researchers received a p a t i e n t i n f o r m a t i o n l e t t e r b r i e f l y o u t l i n i n g the nature of the p r o j e c t and requirements consent was  of p a r t i c i p a t i o n  (Appendix  D). W r i t t e n  subsequently o b t a i n e d from each woman who  p a r t i c i p a t e i n the study Co-researcher's  (Appendix  agreed  to  C).  r i g h t s were p r o t e c t e d throughout  the  r e s e a r c h . C o n f i d e n t i a l i t y and anonymity of c o - r e s e a r c h e r s assured and r e s p e c t e d a t a l l times throughout  the  was  study.  Pseudonyms were used t o assure c o - r e s e a r c h e r anonymity, and  any  31  i d e n t i f y i n g i n f o r m a t i o n was omitted  from t r a n s c r i p t s and t h e  f i n a l r e p o r t . In a d d i t i o n , l i s t s of c o - r e s e a r c h e r s ,  their  pseudonyms, and t h e i r consent forms were kept separate audiotapes  from t h e  and t r a n s c r i p t s and were a c c e s s i b l e o n l y t o myself and  my immediate r e s e a r c h a d v i s o r a t the u n i v e r s i t y . were assured  t h a t the audiotapes,  be erased a f t e r completion  Co-researchers  used i n t h e i n t e r v i e w s , would  of the r e s e a r c h .  As w e l l , t h e f o l l o w i n g c o n s i d e r a t i o n s were emphasized t o cor e s e a r c h e r s p r i o r t o p a r t i c i p a t i o n i n t h e r e s e a r c h i n t e r v i e w . Coresearchers  c o u l d choose t o : (a) withdraw from t h e study a t any  time without  concern t h a t t h i s would j e o p a r d i z e c u r r e n t o r f u t u r e  h e a l t h care,  (b) r e f u s e t o answer any i n t e r v i e w q u e s t i o n s , (c)  and ask t o stop the audio-tape  a t any p o i n t d u r i n g the i n t e r v i e w .  S e l e c t i o n of Co-researchers Co-researchers  were r e c r u i t e d by the f o l l o w i n g process. F o r  purposes of c o n f i d e n t i a l i t y , p o t e n t i a l c o - r e s e a r c h e r s  were  i n i t i a l l y contacted by a nurse, w h i l e i n CCU, and p r o v i d e d with a patient information l e t t e r nature  (see Appendix D) b r i e f l y o u t l i n i n g t h e  of the r e s e a r c h p r o j e c t and requirements of p a r t i c i p a t i o n .  Nurses then asked these women f o r p e r m i s s i o n names t o t h e r e s e a r c h e r .  t o forward  their  I l a t e r contacted these women once they  were t r a n s f e r r e d qnto t h e c a r d i a c ward i n order t o determine t h e i r study  e l i g i b i l i t y and t o f u r t h e r d e s c r i b e t h e p r o j e c t . One  co-researcher  was not admitted  t o t h e CCU but t r a n s f e r r e d  d i r e c t l y t o t h e c a r d i a c ward from a small r u r a l h o s p i t a l . The head nurse of t h e c a r d i a c ward agreed t o d i s t r i b u t e t h e p a t i e n t i n f o r m a t i o n l e t t e r t o t h i s women and any other e l i g i b l e p a t i e n t s t h a t had not been f u l l y b r i e f e d about t h e r e s e a r c h i n t h e CCU.  32 The  study comprised  of 10 v o l u n t e e r women, between t h e ages  of 40 and 75, t h a t were diagnosed  and h o s p i t a l i z e d with MI i n a  c i t y h o s p i t a l l o c a t e d i n Vancouver's g r e a t e r mainland.  Recent  h o s p i t a l s t a t i s t i c s i n d i c a t e d t h a t 147 women had been  admitted  over the year with MI (R. H e r r i c k , p e r s o n a l communication, October  29, 1992). I t took approximately  and October,  to recruit  5 months, between June  10 c o - r e s e a r c h e r s f o r t h e study.  Co-researcher's met the f o l l o w i n g c r i t e r i a f o r study inclusion:  (a) were diagnosed with MI, (b) were a l e r t and  o r i e n t e d t o time, person, and p l a c e , (c) were a b l e t o speak and read E n g l i s h , the study,  (d) p r o v i d e d informed consent  for participation i n  (e) were w i l l i n g t o d i s c u s s t h e i r MI experience.  F i v e of the c o - r e s e a r c h e r s r e s i d e d i n Vancouver where they were h o s p i t a l i z e d , whereas t h e remaining f i v e women r e s i d e d r u r a l l y and were t r a n s f e r r e d from t h e i r l o c a l h o s p i t a l t o the city  hospital. F i v e of t h e women were married o r l i v i n g common law with  t h e i r p a r t n e r s , t h r e e were widows, one was d i v o r c e d , and one woman i d e n t i f i e d h e r s e l f as b e i n g s i n g l e . E i g h t of the 10 cor e s e a r c h e r s had c h i l d r e n ,  1 of whom was l i v i n g a t home.  A l l of t h e women i n t e r v i e w e d had r e c e n t l y been diagnosed MI.  with  F i v e of t h e c o - r e s e a r c h e r s had never experienced a c a r d i a c  event, w h i l e two of the c o - r e s e a r c h e r r e p o r t e d having p r e v i o u s Mis. Two other women d e s c r i b e d e x p e r i e n c i n g ongoing angina, and one woman had experienced a p r e v i o u s c a r d i a c event  requiring  treatment. Moreover, t h r e e of t h e c o - r e s e a r c h e r s r e q u i r e d coronary bypass surgery as a r e s u l t of t h e i r c u r r e n t MI, and two of the women had a l r e a d y undergone p r e v i o u s bypass surgery. None  33  of the c o - r e s e a r c h e r s terminated t h e i r p a r t i c i p a t i o n i n the study. Data C o l l e c t i o n The data were " d e s c r i p t i o n s of experience" and were c o l l e c t e d through  (Osbourne, 1990),  a s e r i e s of in-depth s e m i - s t r u c t u r e d  i n t e r v i e w s and v a l i d a t i o n i n t e r v i e w s . In a d d i t i o n , my  field  notes  supplemented the i n t e r v i e w data. The purpose of the i n t e r v i e w  was  "to gather d e s c r i p t i o n s of the l i f e - w o r l d of the i n t e r v i e w e e w i t h r e s p e c t to i n t e r p r e t a t i o n of the meaning of the d e s c r i b e d phenomena" (Kvale, 1983, Co-researchers  p.  174).  were i n t e r v i e w e d i n h o s p i t a l , soon a f t e r b e i n g  t r a n s f e r r e d from the CCU  t o the c a r d i a c ward. T y p i c a l l y ,  co-  r e s e a r c h e r s were t r a n s f e r r e d onto the c a r d i a c ward a few days a f t e r MI.  T h i s time frame v a r i e d between the women, and  dependant on MI  s e v e r i t y , symptom s t a b i l i z a t i o n and  was  medical  c o m p l i c a t i o n s , as w e l l - a s the a v a i l a b i l i t y of h o s p i t a l beds CCU  nurse, p e r s o n a l communication, January  Pilot Two  30,  (SPH  1994).  Interviews p i l o t i n t e r v i e w s were conducted  p r i o r to data  collection  i n order t o v e r i f y the s u i t a b i l i t y of the study questions i n t e r v i e w format.  and  T h i s p r o v i d e d me w i t h the o p p o r t u n i t y to a d j u s t  study questions or d e v i s e a d d i t i o n a l q u e s t i o n s as needed, t o determine whether p o t e n t i a l c o - r e s e a r c h e r s c l e a r l y understood wording and i n s t r u c t i o n s of the i n t e r v i e w s c r i p t , and t o  the  estimate  the l e n g t h of time r e q u i r e d f o r the i n t e r v i e w . Moreover, the p i l o t i n t e r v i e w s allowed me  to become more f a m i l i a r with  s c r i p t , the i n t e r v i e w p r o c e s s , and with my  the  r o l e as r e s e a r c h e r .  The p i l o t i n t e r v i e w s i n c l u d e d meetings w i t h a 40-year-old  CCU  34 nurse s e v e r a l months post MI, and an 85-year-old h o s p i t a l i z e d woman 1 week post MI. Although t h e i n t e r v i e w s were audiotaped, they were not t r a n s c r i b e d o r i n c l u d e d i n data a n a l y s i s . The f i r s t p i l o t i n t e r v i e w was reviewed by two members of t h e t h e s i s committee. No recommendations f o r improving t h e i n t e r v i e w process were made a t t h a t time. A f t e r t h e completion of the second i n t e r v i e w , o n l y nominal  changes were made t o t h e o r i g i n a l  i n t e r v i e w s c r i p t and study q u e s t i o n s . Data C o l l e c t i o n The  Interviews  study i n v o l v e d one p r e l i m i n a r y meeting,  and two  i n t e r v i e w s with c o - r e s e a r c h e r s . During t h e p r e l i m i n a r y meeting, I met w i t h p o t e n t i a l c o - r e s e a r c h e r s and i n t r o d u c e d t h e r e s e a r c h , I p r o v i d e d a statement  of purpose  and a consent form, and I  answered any q u e s t i o n s t h a t the women had. The f i r s t i n t e r v i e w i n c l u d e d the p r i n c i p a l serai-structured data c o l l e c t i o n i n t e r v i e w , whereas the second i n t e r v i e w i n v o l v e d a telephone  validation  i n t e r v i e w . A l l data c o l l e c t i o n and v a l i d a t i o n i n t e r v i e w s were audiotaped. P r e l i m i n a r y meetings took p l a c e with c o - r e s e a r c h e r s once they were t r a n s f e r r e d from the CCU t o t h e c a r d i a c ward. During these meetings,  I i n t r o d u c e d myself as a graduate  student i n the  C o u n s e l l i n g Psychology Department a t t h e U n i v e r s i t y of B r i t i s h Columbia,  and as a c a r d i o l o g y t e c h n o l o g i s t c u r r e n t l y working a t  the h o s p i t a l . I a l s o e x p l a i n e d t h e r a t i o n a l e f o r t h e study, requirements  of study p a r t i c i p a t i o n , c o n f i d e n t i a l i t y and  anonymity i s s u e s , and answered any q u e s t i o n s about  study  p a r t i c i p a t i o n . At t h i s time, I u s u a l l y l e f t t h e women w i t h t h e consent form  (see Appendix C) and arranged a time t o meet f o r t h e  35 f i r s t i n t e r v i e w . Research i n t e r v i e w s were always scheduled t o accommodate both t h e c o - r e s e a r c h e r and the h o s p i t a l s t a f f . The p r e l i m i n a r y meeting a l s o served as an important i n i t i a l r a p p o r t b u i l d i n g with The  opportunity f o r  co-researchers.  f i r s t i n t e r v i e w was conducted  a f t e r r e c e i v i n g consent t o  p a r t i c i p a t e i n the study. To ensure c o n f i d e n t i a l i t y , were conducted  interviews  e i t h e r i n a p r i v a t e room b e s i d e the n u r s i n g  s t a t i o n or i n the c o - r e s e a r c h e r ' s h o s p i t a l room. Co-researchers  were i n t e r v i e w e d u s i n g an in-depth semi-  s t r u c t u r e d i n t e r v i e w format. Although  the interview length  v a r i e d , t h e average l e n g t h of the i n t e r v i e w s was approximately 1 hour and 15 minutes. A l l c o - r e s e a r c h e r s f e l t w e l l enough t o complete t h e i n t e r v i e w i n a s i n g l e s e s s i o n . The a c t u a l time  spent  with c o - r e s e a r c h e r s was o f t e n much longer due t o c o n v e r s a t i o n b e f o r e and a f t e r t h e i n t e r v i e w . Initially,  I acquainted c o - r e s e a r c h e r s with t h e nature and  approximate d u r a t i o n of the i n t e r v i e w . As w e l l , I a d v i s e d each woman t o inform me i f she f e l t  ill,  and t h a t she c o u l d take a  break i f necessary. As w e l l , c o - r e s e a r c h e r s were a d v i s e d t h a t they c o u l d r e f r a i n from answering questions t h a t they uncomfortable  felt  with, and c o u l d a l s o ask t o have t h e audio-tape  turned o f f a t any time. The  f i r s t i n t e r v i e w was guided by the r e s e a r c h q u e s t i o n , "how  do you make sense of your MI experience?" Co-researchers encouraged t o d e s c r i b e t h e i r experiences with a beginning, a middle, White and Epston to  were  i n t h e form of a s t o r y ,  and an end (see Appendix A ) .  (1990) suggest  t h a t s t o r i e s p r o v i d e a means  express o u r s e l v e s and make sense of our l i v e s . Furthermore,  36  the experiences of p a s t , p r e s e n t , and what i s p r e d i c t e d t o occur i n t h e f u t u r e , must be connected  i n a l i n e a l sequence i n order t o  develop the s t o r i e d account. As a l l s t o r i e s have a beginning, a middle, and an ending, t h i s s t r u c t u r e p r o v i d e s a frame through which an i n d i v i d u a l can o r g a n i z e and make sense of t h e i r experience  (White & Epston,  1990).  T h i s s t o r i e d approach p r o v i d e d c o - r e s e a r c h e r s w i t h a means t o frame t h e i r experiences of MI w i t h i n t h e context of t h e i n t e r v i e w . Co-researchers were encouraged t o d e s c r i b e t h e i r  story  i n as much d e t a i l as p o s s i b l e , with a focus on any thoughts, f e e l i n g s , and behaviors t h a t surrounded  t h e i r experience. Open-  ended q u e s t i o n s aimed a t f a c i l i t a t i n g t h e d e s c r i p t i o n of t h e cor e s e a r c h e r ' s i l l n e s s experience were used  (see Appendix A ) . When  necessary, prompts were used t o help c o - r e s e a r c h e r s f u r t h e r a r t i c u l a t e , e l a b o r a t e , or c l a r i f y t h e i r responses  to questions.  Background i n f o r m a t i o n was a l s o c o l l e c t e d from each cor e s e a r c h e r a t the end of the i n t e r v i e w , and i n c l u d e d b r i e f demographic q u e s t i o n s r e l a t e d t o age, education, income, employment s t a t u s , e t h n i c i t y , m a r i t a l s t a t u s , number of c h i l d r e n , and p r e v i o u s h i s t o r y of i l l n e s s  (see Appendix B ) .  Before ending t h e i n t e r v i e w s e s s i o n , c o - r e s e a r c h e r s were given t h e o p p o r t u n i t y t o ask any q u e s t i o n s or d i s c u s s t h e i r experience of the i n t e r v i e w . I b r i e f l y e x p l a i n e d the forthcoming process of t r a n s c r i p t i o n and data a n a l y s i s . As w e l l ,  I made  arrangements t o c o n t a c t them f o l l o w i n g h o s p i t a l d i s c h a r g e f o r a second v a l i d a t i o n i n t e r v i e w . D e t a i l e d f i e l d notes were recorded immediately  f o l l o w i n g each  i n t e r v i e w i n order t o document c o - r e s e a r c h e r demeanour and  37  behavior  ( v e r b a l and n o n - v e r b a l ) , t h e emotional c l i m a t e of t h e  i n t e r v i e w , and any notable d i s t r a c t i o n s o r d i s r u p t i o n s t h a t took p l a c e . As w e l l ,  I recorded my s u b j e c t i v e impressions o f how I  f e l t t h e i n t e r v i e w proceeded,  i n c l u d i n g my r o l e as r e s e a r c h e r ,  impressions o r hunches about i n t e r v i e w content, p e r s o n a l b i a s e s t h a t arose, as w e l l as any other p e r s o n a l r e a c t i o n s o r "gut f e e l i n g s " that,would be h e l p f u l i n documenting the experience. Brief f i e l d  notes were a l s o recorded f o r a l l of the v a l i d a t i o n  interviews. In g e n e r a l , i t appeared  t h a t the c o - r e s e a r c h e r s enjoyed  being  i n t e r v i e w e d and welcomed t h e o p p o r t u n i t y t o t a l k about t h e i r experiences. S e v e r a l c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g  somewhat  r e l i e v e d t o t a l k about the course of events surrounding t h e i r MI experience, while other women acknowledged f e e l i n g more c l e a r about understanding t h e i r f e e l i n g s surrounding c e r t a i n aspects of their illness  and h o s p i t a l i z a t i o n . Other women, who i n i t i a l l y  claimed t o have l i t t l e t o d i s c u s s , expressed t h e i r s u r p r i s e a t having spoken e x t e n s i v e l y d u r i n g t h e course of the i n t e r v i e w . The  second v a l i d a t i o n i n t e r v i e w , was conducted  r e s e a r c h e r s v i a telephone approximately  with co-  4 t o 6 weeks post  h o s p i t a l d i s c h a r g e . The purpose of the v a l i d a t i o n i n t e r v i e w , was to present my understanding of the c o - r e s e a r c h e r s ' d e s c r i p t i o n s of  experience, and notable i s s u e s as r e v e a l e d d u r i n g t h e data  c o l l e c t i o n i n t e r v i e w . Co-researchers were encouraged t o c l a r i f y , f u r t h e r develop and v a l i d a t e the d e s c r i p t i o n s and t o ensure t h a t a l l prominent aspects of t h e i r experience were i n c l u d e d . P r i o r t o each v a l i d a t i o n i n t e r v i e w , t h e i n t e r v i e w s were reviewed v i a audiotape and then t r a n s c r i b e d . The t r a n s c r i p t s were  38 then reviewed  i n d e t a i l i n order t o g a i n a c l e a r e r sense Of t h e  women's d e s c r i p t i o n s , i s s u e s , and p o t e n t i a l emerging themes. Hycner (1985) acknowledges the v a l u e of t h e v a l i d a t i o n i n t e r v i e w , and suggests  t h a t i t p r o v i d e s c o - r e s e a r c h e r s with t h e  o p p o r t u n i t y t o c o n f i r m whether t h e r e s e a r c h e r has a c c u r a t e l y and f u l l y captured her experience, t o c l a r i f y any vague o r incomplete m a t e r i a l , and t o p r o v i d e f u r t h e r i n f o r m a t i o n t h a t may c r y s t a l l i z e the r e s e a r c h e r ' s understanding  of t h e i r experience.  Validation  i n t e r v i e w s a l s o serve t o f u l l y i n v o l v e the c o - r e s e a r c h e r i n the ongoing r e s e a r c h p r o c e s s . Hycner (1985) a l s o suggests  t h a t the p o t e n t i a l consequence of  r e t r o s p e c t i v e r e p o r t i s c o n f a b u l a t i o n . Although u n c o n s c i o u s l y , a c o - r e s e a r c h e r may f i l l respond  u s u a l l y done  i n gaps of memory, o r  i n a manner b e l i e v e d t o p l e a s e t h e r e s e a r c h e r .  As a r e s u l t of t h e v a l i d a t i o n i n t e r v i e w s , c o - r e s e a r c h e r s r e p o r t e d f e e l i n g as though I had a c c u r a t e l y captured the essence of t h e i r MI experiences. Furthermore, none of t h e women f e l t t h e need t o p r o v i d e f u r t h e r c l a r i f i c a t i o n o r i n f o r m a t i o n . S e v e r a l cor e s e a r c h e r s r e i t e r a t e d almost verbatim many of t h e i s s u e s they had d i s c u s s e d d u r i n g the i n i t i a l i d e n t i f i e d c u r r e n t concerns  i n t e r v i e w , whereas other women  s i n c e r e t u r n i n g home. Women a l s o  r e p o r t e d b e i n g a t d i f f e r e n t p l a c e s a l o n g t h e continuum of r e c o v e r y . Four of the women r e p o r t e d b e i n g readmitted t o h o s p i t a l f o r f u r t h e r a n g i n a l symptoms o r d i a g n o s t i c t e s t i n g . Common t o most of t h e v a l i d a t i o n i n t e r v i e w s was t h e sense of a p p r e c i a t i o n f o r having had t h e o p p o r t u n i t y t o c o n t r i b u t e t o r e s e a r c h concerning women's h e a l t h . As w e l l , most of t h e women v o i c e d t h e i r a p p r e c i a t i o n f o r t h e follow-up telephone  contact.  39  A l l of the c o - r e s e a r c h e r s agreed t o be contacted, i f necessary, if  further validation  Researcher's  or c l a r i f i c a t i o n of the data were needed.  Impressions  of the Interviews  The process of conducting phenomenological  interviews  r e p r e s e n t e d a c h a l l e n g i n g but rewarding l e a r n i n g experience. My background as a c a r d i o l o g y t e c h n o l o g i s t p r o v i d e d me a fundamental of h o s p i t a l  understanding of c a r d i a c i l l n e s s and treatment,  and  procedures and r o u t i n e . Having t h i s knowledge and  f a m i l i a r i t y of the i l l n e s s environment d u r i n g the i n t e r v i e w s . As a r e s u l t , a b l e t o understand t h e i r h o s p i t a l  was  were times where I was  particularly  useful  I f e l t as though I was  experience and f e l t t h a t  enabled me t o b e t t e r hear women's s t o r i e s .  better this  In a d d i t i o n , t h e r e  a b l e t o i d e n t i f y the name of a f o r g o t t e n  drug or procedure, or perhaps  ask a c o - r e s e a r c h e r j u s t the r i g h t  q u e s t i o n t o f a c i l i t a t e a moment of i n s i g h t  into their  understanding of t h e i r MI experience. I f e l t t h a t t h i s strengthened the sense of t r u s t and r a p p o r t t h a t between me  with  own presence  developed  and the women I i n t e r v i e w e d .  During the i n i t i a l  i n t e r v i e w s , I found myself  feeling  concerned t h a t although some women d i s c u s s e d t h e i r experiences as b e i n g deeply emotional, other women focused more on a c o g n i t i v e or symptomatic l e v e l . I t took o n l y a couple of i n t e r v i e w s b e f o r e I f e l t more comfortable with these d i f f e r e n c e s and acknowledged t h a t i n h e r e n t t o t h i s method are commonalities  as w e l l as  d i f f e r e n c e s as women d e s c r i b e d the meaning of t h e i r e x p e r i e n c e s . Moreover, I had t o examine t h i s i n i t i a l  r e a c t i o n and r e c o g n i z e  t h a t my u n d e r l y i n g b i a s i m p l i e d t h a t the c o n t r i b u t i o n of a woman who  e x p l o r e s e x i s t e n t i a l concerns  i s more v a l u a b l e than the  40  c o n t r i b u t i o n s of a c o - r e s e a r c h e r who does not. Once I was aware of  t h i s b i a s , I f e l t more a b l e t o s e t i t a s i d e . Adopting the r o l e of t h e r e s e a r c h e r was one of the'-most  c h a l l e n g i n g aspects of the i n t e r v i e w i n g p r o c e s s . At times, t h e boundaries  between i n t e r v i e w e r and c o u n s e l l o r f e l t u n c l e a r , and I  had d i f f i c u l t y making t h e switch between r o l e s . F o r example, when one of the women became, extremely emotional  experience, i t f e l t  t e a r f u l w h i l e r e c o u n t i n g an  i n a p p r o p r i a t e and uncomfortable t o  remain i n the " n e u t r a l " r e s e a r c h e r r o l e . A f t e r a few data c o l l e c t i o n i n t e r v i e w s , I became i n c r e a s i n g l y aware of the importance of f i n d i n g a balance between t h e r o l e s of r e s e a r c h e r and c o u n s e l l o r . Oakley (1981) suggests t h a t t h e pretence of n e u t r a l i t y on t h e p a r t of t h e r e s e a r c h i n t e r v i e w e r i s c o u n t e r p r o d u c t i v e t o r e c e i v i n g the q u a l i t y and depth of the i n f o r m a t i o n given by c o - r e s e a r c h e r s . In most cases, the g o a l of f i n d i n g out about people through i n t e r v i e w i n g i s best achieved when t h e r e l a t i o n s h i p of i n t e r v i e w e r and i n t e r v i e w e e i s n o n - h i e r a r c h i a l and when t h e i n t e r v i e w e r i s prepared t o i n v e s t h i s o r her own p e r s o n a l i d e n t i t y i n the r e l a t i o n s h i p , (p. 42) For some of the i n t e r v i e w s , I f e l t more d i r e c t i v e than i n other i n t e r v i e w s where c o - r e s e a r c h e r s f e l t more comfortable i n the r o l e of s t o r y t e l l e r . Over t h e course of i n t e r v i e w s , I became much more aware of a sense of rhythm t h a t was e i t h e r present o r absent between me as r e s e a r c h e r and c o - r e s e a r c h e r s i n t h e interview process. I was a l s o s t r u c k with t h e extent t o which most women wanted to  t a l k about t h e i r e x p e r i e n c e s . The depth t o which most women  shared t h e i r s t o r i e s f u r t h e r r e i n f o r c e d t h e f a c t t h a t t h e r e i s l i t t l e o p p o r t u n i t y t o address  i n t r o s p e c t i v e concerns  during the  41  course of medical treatment. One p i l o t i n t e r v i e w e e d e s c r i b e d b e i n g i n t r i g u e d by the n o t i o n of framing her experience of MI i n terms of t e l l i n g a s t o r y . ...the s t o r y p a r t i s i n t r i g u i n g . . . c r e a t i n g a s t o r y out of i t r a t h e r than j u s t g i v i n g the f a c t s maam...which i s o f t e n what you get i n the h o s p i t a l . . . t h e k i n d of responses t h a t they j u s t want i n h o s p i t a l are j u s t f a c t s . . . a s opposed t o f e e l i n g s thoughts o r whatever and as opposed t o a story...how t h i n g s came about more than j u s t the symptoms. Data A n a l y s i s Data a n a l y s i s o c c u r r e d c o n c u r r e n t l y with data  collection.  F o l l o w i n g each i n t e r v i e w , audio-tapes were reviewed get an i n i t i a l  i n order t o  sense of the c o - r e s e a r c h e r ' s experience and t o  become more f a m i l i a r w i t h the content of the i n t e r v i e w . I then t r a n s c r i b e d the tapes verbatim T r a n s c r i p t s were reviewed  ( i n c l u d i n g a l l v e r b a l pauses).  again and analyzed a c c o r d i n g t o a  q u a l i t a t i v e method of a n a l y s i s . Giorgi's  (1975, .1985) phenomenological  data a n a l y s i s method  p r o v i d e d the means t o i d e n t i f y and e x t r a c t women's themes. T h i s process i n c l u d e d the f o l l o w i n g e s s e n t i a l steps ( G i o r g i , 1975, pp. 74-75). (a) The r e s e a r c h e r reads through the e n t i r e t e x t  (verbatim  t r a n s c r i p t i o n ) i n order t o get a g e n e r a l sense of the whole description. (b) The r e s e a r c h e r reads through the same d e s c r i p t i o n more thoroughly and as many times as necessary, i n order t o d e l i n e a t e each time a t r a n s i t i o n i n meaning i s p e r c e i v e d with r e s p e c t t o the phenomena b e i n g s t u d i e d . A s e r i e s of meaning u n i t s o r c o n s t i t u e n t s are o b t a i n e d through t h i s p r o c e s s . More simply, the e n t i r e t e x t cannot be analyzed s i m u l t a n e o u s l y , and t h e r e f o r e must  42 be broken down i n t o manageable (c)  units.  Once meaning u n i t s have been d e l i n e a t e d , any  are e l i m i n a t e d . The r e s e a r c h e r then c l a r i f i e s  redundancies  and e l a b o r a t e s on  the meaning of these c o n s t i t u e n t s , by r e l a t i n g them t o each o t h e r and t o the sense of the whole d e s c r i p t i o n . (d) The r e s e a r c h e r r e f l e c t s on the given meaning u n i t s t h a t are s t i l l  expressed i n the language of the c o - r e s e a r c h e r . Meaning  u n i t s are then transformed  from the language of the c o - r e s e a r c h e r  i n t o p s y c h o l o g i c a l language,  and examined f o r what they r e v e a l  about the phenomena i n q u e s t i o n , g i v e n the i n d i v i d u a l ' s s i t u a t i o n . I t i s d u r i n g t h i s stage t h a t the presence  of the  r e s e a r c h e r i s most e v i d e n t . (e) The r e s e a r c h e r s y n t h e s i z e s a l l of the i n s i g h t s d e r i v e d from the transformed meaning u n i t s i n t o a c o n s i s t e n t d e s c r i p t i o n of  the s t r u c t u r e of the c o - r e s e a r c h e r ' s experience. Although G i o r g i ' s  (1975, 1985) steps f o r  phenomenological  data a n a l y s i s were f o l l o w e d , t h e r e were numerous other common sense steps t h a t I c o n s t r u c t e d t h a t helped t o supplement G i o r g i ' s somewhat vague g u i d e l i n e s . F o l l o w i n g t r a n s c r i p t i o n , each t r a n s c r i p t was reviewed s e v e r a l times b e f o r e d e l i n e a t i n g meaning u n i t s . Meaning u n i t s were  then  h i g h l i g h t e d and numbered. Numbering the meaning u n i t s allowed to  me  e a s i l y r e t u r n t o the t e x t when necessary. Meaning u n i t s were  then paraphrased, language.  m a i n t a i n i n g the i n t e g r i t y of the c o - r e s e a r c h e r s  T h i s allowed me t o more f u l l y understand  the nature of  the woman's experience. The paraphrased  meaning u n i t s were then t r a n s l a t e d  p s y c h o l o g i c a l language,  and underwent an ongoing  into  iterative  43 process of r e v i s i o n u n t i l  I felt  c l e a r e r and c o n s i s t e n t about t h e  language I was u s i n g t o d e s c r i b e t h e i r e x p e r i e n c e s . In other words, i t was c l e a r l y important t h a t the same language was b e i n g used t o d e s c r i b e t h e same o r s i m i l a r experiences o r events. Initially,  I f o l l o w e d t h i s s t r a t e g y f o r the f i r s t t h r e e  t r a n s c r i p t s t o become f a m i l i a r i z e d with t h e p r o c e s s . The next t h r e e t r a n s c r i p t s were analyzed f o l l o w i n g the same s t r a t e g y , and then i n t e g r a t e d with the p r e v i o u s l y analyzed t r a n s c r i p t s . Once again, t h i s e n t a i l e d an ongoing  i t e r a t i v e process of comparison  and r e v i s i o n . At t h i s p o i n t , I had almost c r e a t e d a g u i d i n g framework t o analyse the remaining Once I had completed  transcripts.  the psychological t r a n s l a t i o n s ,  they  were catalogued and t h e i r frequency of occurrence was determined. At the same time, t h e corresponding meaning u n i t numbers were recorded. I c r e a t e d a l i s t  f o r each t r a n s c r i p t o u t l i n i n g t h e  t r a n s l a t i o n s and l o c a t i o n s of corresponding t e x t . Checking t h e frequency of these p r e l i m i n a r y themes served t o c o n f i r m my own sense about i t s r e l a t i v e importance.  F o r some of the women, more  than 50 p r e l i m i n a r y themes emerged from t h i s  analysis.  An ongoing process of c o l l a p s i n g these p r e l i m i n a r y themes i n t o s m a l l e r c a t e g o r i e s r e s u l t e d i n data t h a t were s i g n i f i c a n t l y more manageable. These p r e l i m i n a r y themes were then  further  c o l l a p s e d i n t o thematic groupings .from which nine common themes emerged. Before t r a n s l a t i n g meaning u n i t s i n t o p s y c h o l o g i c a l language,  I r e t u r n e d t o my own s u b j e c t i v e understanding o f t h e  c o - r e s e a r c h e r accounts  and recorded what each women i d e n t i f i e d ,  e i t h e r o v e r t l y o r c o v e r t l y , as b e i n g an important  issue or  44  concern. I repeated t h i s v e r i f i c a t i o n p r o c e s s , once the paraphrased meaning u n i t s were t r a n s l a t e d i n t o p s y c h o l o g i c a l language,  again r e c o r d i n g important i s s u e s o r concerns.  I n t e r e s t i n g l y , both of these r e c o r d s c l o s e l y resembled nine common themes t h a t emerged from completed T h i s thorough y e t tremendously  the f i n a l  data a n a l y s i s .  time consuming t a s k r e s u l t e d  i n t h e i d e n t i f i c a t i o n of commonalities  t h a t were e v i d e n t a c r o s s  c o - r e s e a r c h e r accounts. Some of themes may appear t o be more s i g n i f i c a n t t o some women than t o o t h e r s . As w e l l , t h e r e was c o n s i d e r a b l e v a r i a b i l i t y i n how c o - r e s e a r c h e r s experienced these themes.  .  .  .  Summary Q u a l i t a t i v e methodology, namely phenomenology, was used t o guide t h i s study. Co-researchers were s e l e c t e d on the b a s i s of r e c e n t MI d i a g n o s i s , informed consent, competency, a b i l i t y , and w i l l i n g n e s s t o d e s c r i b e t h e i r MI e x p e r i e n c e . Ten v o l u n t e e r female c o - r e s e a r c h e r s were i n t e r v i e w e d twice over a p e r i o d of 5 months. As w e l l , two p i l o t i n t e r v i e w s were conducted p r i o r t o data c o l l e c t i o n . Data comprised of t r a n s c r i b e d audio-tapes and f i e l d notes taken from c o - r e s e a r c h e r i n t e r v i e w s . Data a n a l y s i s was conducted a c c o r d i n g t o the phenomenological by G i o r g i  methods as o u t l i n e d  (1975, 1985). Completion of data a n a l y s i s r e s u l t e d i n  the d e s c r i p t i o n of c o - r e s e a r c h e r accounts and t h e i d e n t i f i c a t i o n of nine common themes.  45 , CHAPTER FOUR P r e s e n t a t i o n of the F i n d i n g s Introduction T h i s chapter p r e s e n t s the c o - r e s e a r c h e r s accounts  of t h e i r  experience with MI as w e l l as the common themes t h a t emerged from the i n t e r v i e w s u s i n g phenomenological  analysis.  In order t o g a i n a b e t t e r understanding of the women t h a t p a r t i c i p a t e d i n t h i s r e s e a r c h , as w e l l as t o p r o v i d e the b a s i s and context f o r f u r t h e r a n a l y s i s ,  I present a b r i e f background  f o r each c o - r e s e a r c h e r i n the f o l l o w i n g s e c t i o n . Pseudonyms have been used t o assure c o - r e s e a r c h e r anonymity. E x c e r p t s , verbatim, have been recorded i n a way  quoted  t h a t most a c c u r a t e l y  r e f l e c t s the c o - r e s e a r c h e r ' s a c t u a l c o n v e r s a t i o n . For a c o n c i s e summary of c o - r e s e a r c h e r ' s background i n f o r m a t i o n see Appendix E. Background of  Co-researchers  Lydia L y d i a i s a 73-year-old r e t i r e d nurse. She c u r r e n t l y alone and has remained unmarried from an upper-middle-class was  lives  without c h i l d r e n . L y d i a came  f a m i l y of medical p r o f e s s i o n a l s .  She  p r e v i o u s l y h o s p i t a l i z e d i n the e a r l y 1980s with b r e a s t cancer  and pulmonary f i b r o s i s . As w e l l , L y d i a r e p o r t e d having p r e v i o u s episode of angina s e v e r a l years L y d i a was  ago.  interviewed just p r i o r to being discharged  h o s p i t a l . She was  from  i n t e r e s t e d and w i l l i n g t o p a r t i c i p a t e i n the  study, y e t f e l t t h a t she was L y d i a was  one  "not going t o be very h e l p f u l . "  p l e a s a n t t o t a l k t o and presented her o p i n i o n s i n an  a r t i c u l a t e manner. She appeared  t o be s t r o n g l y independent  c l e a r about her needs. At one p o i n t , she c h a l l e n g e d my  own  and  4 6  thoughts  around how I would respond t o having an MI.  L y d i a ' s account began with a r e c o l l e c t i o n of having  unusual  chest pains t h a t her d o c t o r d i d not b e l i e v e t o be c a r d i a c r e l a t e d . A few weeks l a t e r ,  she r e t u r n e d home from an appointment  and experienced a chest p a i n t h a t she q u i c k l y assessed t o be c a r d i a c i n o r i g i n . Concerned about her v e h i c l e , L y d i a drove her car  home b e f o r e c a l l i n g f o r t h e ambulance. In r e t r o s p e c t , she  r e a l i z e d t h a t her d e c i s i o n t o d r i v e home was "not very b r i g h t . " L y d i a q u i c k l y a r r i v e d a t the h o s p i t a l where she was t r e a t e d i n emergency and admitted t o the CCU. While  i n emergency, L y d i a ' s  " c h i e f r e a c t i o n was i n t e r e s t t o see what they do now days." She had worked i n the h o s p i t a l ' s emergency department 30 years ago as a head nurse, and was f a m i l i a r w i t h the r o u t i n e . L y d i a f e l t t h a t t h i s f a m i l i a r i t y p r o v i d e d her with the a b i l i t y t o b e t t e r understand  and a n t i c i p a t e t h e events surrounding her MI.  L y d i a a l s o r e p o r t e d b e i n g "very impressed"  with the care t h a t  she r e c e i v e d while h o s p i t a l i z e d . She emphasized the importance of having r a p p o r t with one's d o c t o r s i n terms of f e e l i n g secure, and d e s c r i b e d f e e l i n g h i g h l y c o n f i d e n t with both her g e n e r a l p r a c t i t i o n e r and c a r d i o l o g i s t whom she had p r e v i o u s l y c o n s u l t e d as a p a t i e n t and worked a l o n g s i d e w h i l e nursing..."she all  instills  s o r t s of f a i t h and confidence i n me." L y d i a made s e v e r a l r e f e r e n c e s t o her l a c k of f e a r or  apprehension or  surrounding t h e process of g e t t i n g t o the h o s p i t a l  t o t h e n o t i o n of p o t e n t i a l l y not s u r v i v i n g ,  "the thought o f  maybe not s u r v i v i n g j u s t d i d n ' t bother me." She a t t r i b u t e d to  this  her s t r o n g C a t h o l i c f a i t h and t o her background i n n u r s i n g .  She a l s o r e v e a l e d having two s i s t e r s l i v i n g with Alzheimers and  47 felt  s t r o n g l y t h a t d y i n g was p r e f e r a b l e t o e x p e r i e n c i n g t h e  p r o g r e s s i v e degeneration i n h e r e n t t o the d i s e a s e . L y d i a recounted her experiences i n a r a t i o n a l and matter of f a c t manner, and r a r e l y d i s c u s s e d her MI i n terms of emotional a f f e c t . She d i d however, f r e q u e n t l y q u e s t i o n her own r e a c t i o n of not f e e l i n g more concerned about t h e course of events. When asked about the meaning of her MI experience, L y d i a responded  by d i s c u s s i n g the i n f o r m a t i o n she would o b t a i n from t h e  r e s u l t s of her angiogram t h a t was scheduled f o r t h e f o l l o w i n g week. T h i s suggested t h a t having concrete i n f o r m a t i o n was a s s o c i a t e d with the meaning of her experience. While h o s p i t a l i z e d , L y d i a f e l t concern" demonstrated  " a b s o l u t e l y overwhelmed by t h e  by her l a r g e s o c i a l network and d e s c r i b e d  her f r i e n d s as b e i n g p a r t i c u l a r l y important t o h e r . Although L y d i a exuded a s t r o n g aura of independence, her f r i e n d s and f a m i l y overrode her d e c i s i o n t o remain alone a f t e r b e i n g d i s c h a r g e d from t h e h o s p i t a l . She d i d not i d e n t i f y any apprehensions  about r e t u r n i n g home and i n s i s t e d t h a t having an MI  r e p r e s e n t e d " j u s t another day i n my  life."  Kiko Kiko i s a 65-year-old r e t i r e d Japanese woman. F o r s e v e r a l y e a r s , she had worked i n the f r u i t  and v e g e t a b l e wholesale  b u s i n e s s . She has 2 sons, 2 step daughters, and 3 g r a n d c h i l d r e n . Kiko i s widowed and i s c u r r e n t l y l i v i n g  with her o l d e s t son. She  has no p r e v i o u s c a r d i a c h i s t o r y , but was h o s p i t a l i z e d 10 years ago w i t h g a l l s t o n e s . Kiko was eager t o p a r t i c i p a t e i n t h e study. She appeared contemplative i n terms of d e s c r i b i n g her experience and f e e l i n g s ,  48 and o c c a s i o n a l l y became t e a r f u l w h i l e t a l k i n g about her f a m i l y . Kiko's words suggested t h a t she was  an independent  woman w i t h an a p p e t i t e f o r t r a v e l and adventure. an a c t i v e sense of humour throughout  She  spirited demonstrated  the i n t e r v i e w .  Kiko began her s t o r y by r e c a l l i n g a "cramping n i g h t on the way  and  feeling"  home from v i s i t i n g r e l a t i v e s . She  one  attributed  t h i s t o heartburn as i t disappeared l a t e r t h a t evening. A couple of  days l a t e r , Kiko experienced a sense of f e e l i n g immobilized  and d i z z y w h i l e t a k i n g a bath. S e v e r a l hours  l a t e r , her son  c a l l e d f o r an ambulance when Kiko's symptoms became more i n t e n s e and she was  unable t o get dressed. She was  h o s p i t a l where she was  diagnosed w i t h  taken t o a l o c a l  MI.  Kiko d e s c r i b e d h e r s e l f as f e e l i n g "immobilized by the p a i n . " A f t e r s e v e r a l doses of morphine, her chest p a i n r e s i d e d and was  admitted t o the CCU.  you y o u r s e l f  Kiko found i t " r e a l l y s u r p r i s i n g  [are t h e r e ] " t o see how  until  the "doctors and nurses work  t o g e t h e r . " She r e c a l l e d t h a t the emergency s t a f f speak E n g l i s h so they brought my  she  "thought  son i n t h e r e . " A f t e r  t h a t they were both E n g l i s h speaking, he was  I can't  realizing  asked t o wait  outside. Although Kiko f e l t as though she understood what the d o c t o r s and nurses were t a l k i n g about w h i l e she was  hospitalized,  she  expressed g r e a t concern f o r o l d e r A s i a n p a t i e n t s t h a t c o u l d not speak E n g l i s h . She i n q u i r e d as t o whether the h o s p i t a l p r o v i d e d i n t e r p r e t e r s e r v i c e s and f e l t t h a t p a t i e n t s t h a t d i d not have a sense of what was  happening  t o them were disadvantaged. Kiko a l s o  expressed the b e l i e f t h a t as a p a t i e n t them." She f e l t t h a t  "you r e a l l y have t o t r u s t  "when the nurses and d o c t o r s are t a l k i n g  49 i t ' s good I f i n d out e v e r y t h i n g . " During the i n t e r v i e w , Kiko d i s c u s s e d s e v e r a l experiences of other people's i l l n e s s e s i n c l u d i n g her husband's death; a g i r l f r i e n d ' s s t r o k e ; her s i s t e r ' s heart a t t a c k ; and her mother's experience with angina. She appeared  t o be deeply moved by a l l of  these e x p e r i e n c e s . Kiko a l s o t a l k e d e x t e n s i v e l y about her concerns r e g a r d i n g the p e r c e i v e d e f f e c t s of her i l l n e s s on her two  sons, and d e s c r i b e d  f e e l i n g more w o r r i e d about her f a m i l y i n terms of what they might go through i f she d i d not s u r v i v e her i l l n e s s . She recounted the events surrounding her husbands death and how  she f e l t  this  caused her sons a l o t of g r i e f . Kiko's comments suggested she d i d not want t o upset her sons i n the same way  that  or burden them  with having t o take care of her. Although Kiko was  l o o k i n g forward t o going home, she  expressed some apprehension  about what her r e c o v e r y was  look l i k e . She f e l t determined  going t o  t h a t she would get b e t t e r  and  looked forward t o b e i n g a b l e t o have c o n t a c t w i t h her f r i e n d s , pursue v o l u n t e e r work, and make plans t o t r a v e l . Although expressed a d e s i r e t o go home d i r e c t l y ,  she  she agreed t o stay w i t h  her s i s t e r ' s f a m i l y f o r a few days i n order t o appease her  sons.  Kiko d i s c u s s e d s e v e r a l p e r s o n a l r e a l i z a t i o n s when asked  about  the s i g n i f i c a n c e of having a heart a t t a c k . She f e l t t h a t she " l e a r n t a l e s s o n " by t h i n k i n g t h e r e was MI,  "no way"  she would have a  and f e l t t h a t i t would be wise t o d r a f t a w i l l . F e e l i n g  i n v u l n e r a b l e , Kiko f e l t as though she had been g i v e n a chance and t h a t i t was  had  her t u r n t o help o t h e r s . She  less  second  particularly  f e l t t h a t i t i s important t o teach young people the v a l u e of  50 l i f e . As w e l l , Kiko d i s c u s s e d the p r o s p e c t of more v o l u n t e e r work as w e l l as a d e s i r e t o do more  travelling.  Kaye Kaye i s a 75-year-old woman with a h i s t o r y of coronary a r t e r y d i s e a s e . She had her f i r s t heart a t t a c k 8 years ago and underwent coronary bypass surgery over 16 years ago. Over the past s e v e r a l years she has been plagued with i n c r e a s i n g back p a i n , of b r e a t h , and has been diagnosed c u r r e n t l y self-employed  shortness  w i t h h y p e r t e n s i o n . Kaye i s  as the manager of an income p r o p e r t y i n  which she owns and a l s o l i v e s . Her p r e v i o u s employment h i s t o r y i n c l u d e s r e t a i l management, and p r o p e r t y r e n t a l and management. A widow of many years, she has one son, and a young grandson. Her daughter-in-law  works as a nurse a t the l o c a l h o s p i t a l i n which  she was h o s p i t a l i z e d . Kaye was i n t e r v i e w e d s h o r t l y b e f o r e h o s p i t a l d i s c h a r g e and seemed t o a p p r e c i a t e the o p p o r t u n i t y t o v o i c e some of her concerns.  She was s t r o n g l y o p i n i o n a t e d and t a l k e d u n r e l e n t i n g l y  about her experiences. Kaye appeared t o be f i e r c e l y  independent  and d e s c r i b e d her plans f o r the f u t u r e w i t h an a i r of f e i s t y d e t e r m i n a t i o n . She f r e q u e n t l y used humour when responding t o emotional  content as w e l l as t o demonstrate her sense of  optimism. On s e v e r a l o c c a s i o n s d u r i n g the i n t e r v i e w , she appeared visibly restricted  by her shortness of b r e a t h .  Kaye began her s t o r y by d e s c r i b i n g an i n t e n s e r a d i a t i n g back p a i n t h a t she experienced one evening while a t home. Assuming t h i s was a f l a r e up of her c h r o n i c back p a i n , she put her hot water b o t t l e on her back i n hopes t o ease the p a i n . " N a t u r a l l y i t wouldn't dawn on me t h a t i t was my h e a r t . " As Kaye prepared t o  51 get ready f o r bed "severe"  and  she became very i l l .  She d e s c r i b e d her p a i n  f e l t t h a t "[she] c o u l d have climbed  S h o r t l y t h e r e a f t e r , she was  as  the w a l l s . "  taken t o the emergency department of  the l o c a l h o s p i t a l by her son who  had  c o i n c i d e n t a l l y dropped  by.  Kaye made s e v e r a l r e f e r e n c e s t o f e e l i n g concerned about not knowing what had happened to her i n the emergency department to  the f a c t t h a t she had  days of h o s p i t a l i z a t i o n ,  l o s t her memory f o r the f i r s t s e v e r a l "I don't what they did...and  suppose t h a t I ' l l ever know.,, . i t bugs me, one p o i n t , Kaye questioned about heart a t t a c k and f r e q u e n t l y expressed  I don't  I'd l i k e t o know." At  even having a MI,  "they're  talking  I d i d n ' t have no heart a t t a c k . "  She  f e e l i n g d i s s a t i s f i e d and angry with the  of i n f o r m a t i o n she had r e c e i v e d and  f e l t as though she had  her  adamant t h a t p a t i e n t s should be able t o  f r a n k l y d i s c u s s t h e i r h e a l t h with t h e i r d o c t o r s . she t a l k e d about s w i t c h i n g t o a d o c t o r who b e t t e r care of  lack  to  " f i g h t " with her doctor i n order to f i n d out the s t a t u s of c o n d i t i o n . Kaye was  due  Subsequently,  she f e l t would  take  her.  When asked-> about the meaning of her MI  experience,  Kaye  t a l k e d e x t e n s i v e l y about her concerns of t a k i n g care of f i n a n c i a l a f f a i r s . More s p e c i f i c a l l y , the p r e s s u r e s e l l i n g her income p r o p e r t y and  her  t h a t surrounds  s e t t l i n g i n t o a more s u i t a b l e  accommodation. "I've got to get out of there and  settled...and  then i f I d i e , I d i e . . . I have t o f e e l prepared...I've got t o get r i d of the p l a c e I've expressed  got and the worry of a l l the work."  f e e l i n g overwhelmed by the enormity of t h i s  Kaye a l s o d i s c u s s e d her f r u s t r a t i o n and  She  task.  embarrassment around  her d e t e r i o r a t i n g p h y s i c a l c o n d i t i o n . Although she  considers  52 h e r s e l f t o be "more a g i l e than a l o t of o l d e r people," she acknowledged t h a t her shortness of b r e a t h and back p a i n had i n c r e a s i n g l y r e s t r i c t e d her m o b i l i t y i n the p a s t few years .and had i n t e r r u p t e d the process of f i n d i n g a new home. When asked about r e t u r n i n g home, Kaye remarked "I can't wait t o get home...I can't wait t o get i n the door."  She t a l k e d  about  the p l e a s u r e s and f a m i l i a r i t y of her home, and t h e support of her neighbours  and her son.  Roslynn Roslynn i s a 47-year-old p r o f e s s i o n a l engineer. She i s c u r r e n t l y employed and has worked e x t e n s i v e l y w i t h i n t h e f i e l d of e n g i n e e r i n g i n p o s i t i o n s such as shoreman engineer and g e o l o g i s t , u n i v e r s i t y l e c t u r e r , and e n g i n e e r i n g management c o n s u l t a n t . Roslynn r e c e n t l y r e l o c a t e d from overseas and i s p r e s e n t l y l i v i n g with her aging mother. She i s a d i v o r c e e of many y e a r s , and has 1 son, 1 daughter,  and 4 g r a n d c h i l d r e n . In terms of c a r d i a c  h i s t o r y , Roslynn had two Mis i n 1988, but has experienced few c a r d i a c symptoms d u r i n g t h e l a s t s e v e r a l y e a r s . She has been diagnosed with high c h o l e s t e r o l , and had a kidney stone removed i n 1993. Roslynn g l a d l y agreed t o p a r t i c i p a t e i n the study. She a r t i c u l a t e l y d i s c u s s e d her experiences and p h i l o s o p h i e s w i t h an a i r of honesty and s e l f r e f l e c t i o n . As w e l l , she appeared s t r o n g l y independent  t o be  and d e c i s i v e about her needs and plans f o r  the f u t u r e . I was s t r u c k by my sense of f a m i l i a r i t y and ease w i t h her d u r i n g the i n t e r v i e w , and by the profound sense t h a t we had met  before. Roslynn began her s t o r y with a d e t a i l e d account and  53 d e s c r i p t i o n of t h e events surrounding her f i r s t MI i n 1988. While at  work, she became i n c r e a s i n g symptomatic with angina. "I d i d n ' t  know what was happening  t o me...I d i d n ' t know i t was a heart  a t t a c k . . . I d i d n ' t know i t was a n g i n a . . . a l l I knew w a s . . . i t h u r t l i k e h e l l . " The r e c e p t i o n i s t c a l l e d f o r an ambulance and Roslynn was taken t o t h e h o s p i t a l and u l t i m a t e l y diagnosed with MI. A couple of days l a t e r she experienced her second MI w h i l e s t i l l i n hospital. F o l l o w i n g her f i r s t MI, Roslynn became determined c o n t r o l over her h e a l t h . Subsequently,  t o take  she made l i f e s t y l e changes  i n terms of d i e t , e x e r c i s e , c o n t r o l l i n g her c h o l e s t e r o l , as w e l l as an o v e r a l l mindfulness towards h e a l t h and w e l l n e s s . Roslynn d i s c u s s e d her r e c o v e r y from her f i r s t Mis i n terms of  r e h a b i l i t a t i o n , r e t u r n t o work, making sense of t h e  experience, and t h e subsequent  emotional and c o g n i t i v e process  f o l l o w i n g t h e i l l n e s s . F o r example, she t a l k e d e x t e n s i v e l y about the impact of memory l o s s post MI, and d e s c r i b e d her f e a r and f r u s t r a t i o n of f o r g e t t i n g i n f o r m a t i o n and student's names w h i l e t e a c h i n g a t the u n i v e r s i t y . Roslynn a l s o recounted,  "the s c a r y  p a r t was wondering how i s my body going t o cope with the emotions."  She d e s c r i b e d her process and experience w i t h  c l a r i t y u s i n g terms such as "acceptance syndrome," and " d e n i a l f a c t o r . "  factor,"  such  "regret  I t was as though Roslynn had  c o n s t r u c t e d a theory of p s y c h o l o g i c a l r e c o v e r y from MI based on her own experience and p e r s o n a l r e s e a r c h . Furthermore,  she t h e o r i z e d e x t e n s i v e l y about t h e d i f f e r e n c e s  between women and men i n terms of a t t r i b u t i o n s ,  self  reliance,  and s e l f c o n t r o l and how these f a c t o r s r e l a t e d t o MI. On numerous  54 o c c a s i o n s , she r e i t e r a t e d the importance  of women r e g a i n i n g a  sense of c o n t r o l of t h e i r bodies and t h e i r l i v e s . She a l s o explored the r e l a t i o n s h i p between mind c o n t r o l and MI, and suggested t h a t  "the c l e a n s i n g of the system s t a r t s w i t h a  c l e a n s i n g of your m i n d . . . c o r r e c t a l l of your problems... cure those problems and then you can cure your h e a r t a t t a c k . . . a n d then you can cure your h e a r t . " Roslynn's c u r r e n t MI o c c u r r e d approximately 5 months a f t e r r e l o c a t i n g from overseas. A f t e r e x p e r i e n c i n g a few episodes of angina over the course of s e v e r a l days, Roslynn was examined by her d o c t o r who gave her a c l e a n b i l l  of h e a l t h . Two n i g h t s l a t e r ,  she experienced angina b e f o r e going t o s l e e p , and l a t e r again t h a t n i g h t . Her symptoms continued i n t o the morning, when she r e a l i z e d t h a t she was having a heart a t t a c k . In a c a l c u l a t e d and s t r a t e g i c manner, she c a l l e d 911 and prepared h e r s e l f f o r t r a n s p o r t t o the h o s p i t a l . In the mean time, Roslynn's mother developed an arrhythmia as a r e s u l t of w i t n e s s i n g the a t t a c k and was taken t o the same h o s p i t a l i n a second ambulance. When the ambulance a r r i v e d , Roslynn t o l d the attendants "I've got t h i s bad angina [knowing] i t was a h e a r t a t t a c k , " and was q u i c k l y taken t o the l o c a l h o s p i t a l . all  "I f i n a l l y get there...I'm  s m i l e s . . . i t had p a s s e d . . . i t was done." While i n emergency,  Roslynn waited s e v e r a l hours b e f o r e s e e i n g a c a r d i o l o g i s t . "I knew I was i n good hands and a n y t h i n g I needed was t h e r e . . . I wasn't w o r r i e d but somebody e l s e c o u l d of r a i s e d a h e l l u v a f u s s because i t was not my f i r s t heart a t t a c k and I knew what I had." Roslynn had her f o u r t h MI l a t e r t h a t n i g h t i n the CCU. Subsequent angiography r e v e a l e d f u r t h e r o c c l u s i o n s and her  55 d o c t o r s recommended immediate bypass surgery. In response  to  these recommendations, Roslynn n e g o t i a t e d f o r time with her d o c t o r s and maintained t h a t she would have the surgery when she f e l t t h a t i t was my  life first."  the r i g h t t h i n g t o do..."I've got t o s t r a i g h t e n She a l s o suggested t h a t "nobody has g i v e n me  the  chance t o t r e a t myself y e t , and...I want the chance t o t r e a t myself  n a t u r a l l y b e f o r e the k n i f e i s going t o cut me  In terms of making sense of her c u r r e n t MI, t h a t "the f i r s t t h i n g I d i d wrong was I shouldn't have." She f a c t o r was  open."  Roslynn  suggested  i n d u l g i n g i n some food t h a t  suggested t h a t the second  contributing  the s t r e s s a s s o c i a t e d with her p e r c e i v e d l o s s of  freedom r e s u l t i n g from the r e s p o n s i b i l i t y of c a r e t a k i n g her aging mother. Roslynn made very l i t t l e mention of her experience of h o s p i t a l i z a t i o n or of the q u a l i t y of care t h a t she r e c e i v e d w h i l e hospitalized. With r e s p e c t t o r e t u r n i n g home, Roslynn was to having her daughter  l o o k i n g forward  v i s i t and spend time with her and  mother. Her comments suggested  her  t h a t r e t u r n i n g home r e p r e s e n t e d a  p o i n t of t r a n s i t i o n i n terms of making changes with r e s p e c t t o her c a r e t a k i n g r e s p o n s i b i l i t i e s f o r her mother. She d e s c r i b e d her p l a n t o arrange f o r an attendant t o take over the m a j o r i t y of these r e s p o n s i b i l i t i e s .  "That's the o n l y way  I ' l l r e g a i n my  freedom...when my mother t r a n s f e r s her r e l i a n c e onto somebody e l s e . . . o n l y a t t h a t time can I move i n t o my cure  c o n t r o l . . . i n order t o  myself." Roslynn a l s o d i s c u s s e d her v i s i o n t o c r e a t e a h e a l i n g c e n t e r  f o r people l i k e h e r s e l f who  are l i v i n g w i t h heart d i s e a s e .  She  56 e n v i s i o n e d i n t e g r a t i n g a more i n t u i t i v e or i n t r o s p e c t i v e component i n t o the c e n t e r i n c l u d i n g p r a c t i c e s such as She  suggested  meditation.  t h a t a c e n t r a l focus of the center would be to  encourage people  to r e g a i n a sense of p e r s o n a l c o n t r o l . Roslynn  acknowledged t h a t the center would a l s o serve as a v e h i c l e through which she c o u l d move away from her c u r r e n t c a r e e r t h a t "she  couldn't a c t i v e l y do any more." F i n a l l y , Roslynn made  r e f e r e n c e t o her experience  of t h i s l a s t heart a t t a c k  p i e c e s of a p u z z l e t h a t come and f a l l i n g i n t o p l a c e and  fall  into place." "Everything i s  l i k e t h i s heart a t t a c k b u s i n e s s . . . I don't  b e l i e v e i t j u s t happens, i t ' s got a medical philosophy  "like  i s t h a t i t may  cause but  my  happen because I need t o do  centre...maybe t h i s i s what I'm  this  here f o r . "  Penny Penny i s 40 years o l d and the youngest of the study's r e s e a r c h e r s . She has no previous c a r d i a c h i s t o r y or  co-  recognized  r i s k f a c t o r s , and r e p o r t e d having no p r e v i o u s i l l n e s s e s . She once h o s p i t a l i z e d with v e r t i g o s e v e r a l years ago. married without  c h i l d r e n and  Penny was  Penny i s  c u r r e n t l y works i n the  housing department of a l a r g e mortgage and housing  was  social firm.  eager t o p a r t i c i p a t e i n the study and appeared t o  a p p r e c i a t e the o p p o r t u n i t y to share her experience  of MI.  She  was  s o f t spoken and p l e a s a n t to t a l k t o , and became i n c r e a s i n g l y animated as the i n t e r v i e w progressed.  Penny p r o v i d e d a d e t a i l e d  and a r t i c u l a t e account of her experiences, r e a c t i o n s to  feelings,  and  events.  Penny recounted  b e i n g on v a c a t i o n with her husband  teenage nephew when she s t a r t e d to experience  and  i n t e r m i t t e n t chest  57 p a i n which she a t t r i b u t e d to i n d i g e s t i o n . A f t e r a few  nights,  Penny's symptoms worsened as her chest p a i n i n t e n s i f i e d and became i n c r e a s i n g l y i l l . anything  After deciding  she  "that t h i s wasn't  normal," her husband c a l l e d f o r an ambulance. "I knew  t h a t t h e r e was  something s e r i o u s l y enough wrong t h a t I had  to the h o s p i t a l . . . but  I still  had  no i d e a t h a t i t was  a  to  go  heart  a t t a c k . " Penny made a conscious e f f o r t t o pace h e r s e l f and  relax,  knowing t h a t the ambulance would take about 2 hours t o a r r i v e from the c l o s e s t town. Within  minutes of a r r i v i n g , the ambulance attendants  transported  Penny to the l o c a l h o s p i t a l where she  s e v e r a l r o u t i n e t e s t s and was d i s b e l i e f at having a MI. CCU  diagnosed with MI.  Penny was  f e e l i n g worried  c o n d i t i o n o n l y a f t e r she was pacemaker. She  the  days.  about the s e v e r i t y of  her  t o l d she r e q u i r e d a temporary  of the procedure and d i s p e l l e d her  a notions  surgery.  Penny noted s e v e r a l occasions  where she was  f a c t t h a t her experience i n the CCU everything  r e c a l l e d her  q u i c k l y f e l t r e l i e v e d a f t e r s t a f f provided  thorough e x p l a n a t i o n of major  She  q u i c k l y t r a n s f e r r e d to  where she mostly s l e p t f o r the f i r s t few Penny d e s c r i b e d  underwent  seemed t o go i n and  s u r p r i s e d at how  s u r p r i s e d by  the  "didn't seem t h a t bad...  come out very q u i c k l y . . . I  p a i n l e s s e v e r y t h i n g was... nothing  really  was hurt."  At the same time, she expressed a sense of r e l i e f at g e t t i n g r i d of the tubes and  l i n e s , and  r e g a i n i n g her m o b i l i t y ,  " i t made me  f e e l much b e t t e r t o know I d i d n ' t have to r e l y on a l l these things...my body was which was  a real  able t o do a l l these t h i n g s again by  relief."  itself  58 Although Penny " t r i e d not t o t h i n k about what had happened a lot  of the time," she admitted f e e l i n g a sense of uneasiness  at  n i g h t b e f o r e going t o s l e e p . She a t t r i b u t e d t h i s t o f e e l i n g f e a r f u l t h a t something might happen t o her w h i l e s l e e p i n g , "I guess a f t e r a few n i g h t of waking up every morning I kinda r e a l i z e d t h a t I was  going t o be...hoping  t o be okay."  Penny remained i n the l o c a l h o s p i t a l f o r about a week b e f o r e b e i n g t r a n s f e r r e d t o the c i t y c e n t e r f o r f u r t h e r i n v a s i v e t e s t i n g . She f e l t  "happy" t o be t r a n s f e r r e d , and b e l i e v e d the  angiogram would p r o v i d e more i n f o r m a t i o n about the s t a t u s of her h e a r t . She made a p o i n t of a s k i n g her c a r d i o l o g i s t f o r a p i c t u r e of  her angiogram and  h e r s e l f . She  " f e l t b e t t e r " when she c o u l d see i t f o r  l a t e r d e s c r i b e d the angiogram as b e i n g "a m i l e s t o n e "  i n terms of her h o s p i t a l experience. "I [ f e l t ] much more relaxed...much more comfortable about my  heart."  Penny d e s c r i b e d the care t h a t she r e c e i v e d both a t the r u r a l and c i t y h o s p i t a l as b e i n g " e x c e l l e n t , " and f e l t t h a t the had r e a l l y taken the time t o make her experience as  nurses  "comfortable"  as p o s s i b l e . When asked about the meaning of her MI suggested t h a t her MI was  experience, Penny  a "freak" event because of her age  and  l a c k of r i s k f a c t o r s . She d i d however, express some concern about making sure t h a t she d i d not have another  one.  Penny expressed her d e s i r e t o r e t u r n home a f t e r spending 2 weeks i n the h o s p i t a l . Her comments suggested  t h a t she would  maintain a s e n s i b l e approach t o recovery, and d i d not expect t o r e t u r n t o the same l e v e l of r e s p o n s i b i l i t y or a c t i v i t y u n t i l was  she  g i v e n c l e a r a n c e by her d o c t o r . Although Penny r e a s s u r e d her  59  husband t h a t she would f o l l o w d o c t o r ' s o r d e r s , she was t h a t he was  going to overextend  concerned  h i m s e l f once she r e t u r n e d home.  Consequently, she f e l t more "worried"  about her husband than  herself. Hilda H i l d a i s a 64-year-old and  r e t i r e d woman who  l i v i n g with her husband who  9 a d u l t c h i l d r e n and  i s c u r r e n t l y married  a l s o has a h i s t o r y of MI.  She  17 g r a n d c h i l d r e n . H i l d a r e p o r t e d having  has had  o c c a s i o n a l employment as a cook and baker i n l o c a l r e s t a u r a n t s , as w e l l as m a i n t a i n i n g e n t r e p r e n e u r i a l i n t e r e s t s with husband. Previous  i l l n e s s e s i n c l u d e d a p p e n d i c i t i s as a c h i l d .  a l s o r e p o r t e d having one previous episode of angina angiography s e v e r a l years ago, high blood  her She  and  and i s c u r r e n t l y on medication  for  pressure.  H i l d a was  interviewed s h o r t l y before h o s p i t a l discharge.  She  d e s c r i b e d f e e l i n g e n t h u s i a s t i c to p o t e n t i a l l y be a b l e to help other heart p a t i e n t s . H i l d a communicated her thoughts  and  f e e l i n g s i n a d i r e c t and t h o u g h t f u l manner. She p r o v i d e d d e s c r i p t i o n s of her experience comfortable was  of h o s p i t a l i z a t i o n and  d i s c u s s i n g the emotional  vivid  appeared  impact of these events.  I  s t r u c k with the ease at which the i n t e r v i e w t r a n s p i r e d , and  H i l d a ' s a b i l i t y t o e l o q u e n t l y summarize what s e v e r a l other r e s e a r c h e r s had  co-  discussed.  H i l d a ' s account began hours a f t e r r e t u r n i n g home from a c e l e b r a t i o n of her 45th wedding a n n i v e r s a r y . She awoke to "severe" chest p r e s s u r e t h a t r a d i a t e d i n t o her neck. As symptoms worsened, H i l d a ' s husband took H i l d a t o the hospital,  "he was  more concerned than  her  local  I was...I knew something  60 was going on but I never c o n s i d e r e d  a heart a t t a c k . . . I  didn't  t h i n k t h a t my c o n d i t i o n was s e r i o u s enough." A f t e r a s e r i e s of t e s t s , H i l d a was diagnosed with angina and admitted f o r o b s e r v a t i o n . t o experience  Over the next 6 days, H i l d a  i n t e r m i t t e n t p a i n . In a d d i t i o n , she had two more  angina a t t a c k s , i n c l u d i n g a severe event t h a t o c c u r r e d before  continued  she was t o be d i s c h a r g e d .  the n i g h t  Subsequently, H i l d a was  t r a n s f e r r e d t o the c i t y h o s p i t a l . By then she had developed pneumonia and was found t o be h i g h l y a l l e r g i c t o the blood t h i n n e r she had been given f o r the past s e v e r a l days. She continued  t o experience  angina symptoms and underwent angiography  a few days l a t e r . Test r e s u l t s confirmed a blocked  a r t e r y and  a n g i o p l a s t y was performed. The  next day, H i l d a experienced  had b e f o r e "  "another k i n d of p a i n I never  and promptly went i n t o c a r d i a c a r r e s t . Although she  was s u c c e s s f u l l y r e s u s c i t a t e d , H i l d a d e s c r i b e d f e e l i n g more f e a r f u l a n t i c i p a t i n g emotional d i s c o m f o r t or d i s c o m f o r t  a s s o c i a t e d with  than towards the p a i n  treatment.  H i l d a t a l k e d e x t e n s i v e l y about her experience terms of l o s i n g her " d i g n i t y , " " p r i v a c y , " the  i n the CCU i n  "independence" and j u s t  " r e g u l a r " way of doing t h i n g s . As w e l l , H i l d a suggested how  d i f f i c u l t i t was t o endure setbacks i n the process well,  of g e t t i n g  "everyday i t ' s d i f f e r e n t . . . y o u f e e l good 2 or 3 days and  then suddenly something comes i n and knocks you down and you t r y to get up." When asked about the meaning of her MI experience,  Hilda  t a l k e d about r e e v a l u a t i n g what i s important t o her. She a l s o mentioned having  a g r e a t e r awareness and a p p r e c i a t i o n f o r a l l the  61 things  t h a t are e a s i l y taken f o r granted such as  mobility,  independence, or watching a granddaughter's f i r s t step. t e r r i b l e t h i n g when you  l o s e the  knows u n t i l i t happens...what we Hilda also described her husband, and  smallest  p r i v i l e g e s . . . nobody  take f o r granted."  f e e l i n g much c l o s e r to her  r e a l i z e d the  family  " s i t u a t i o n had  "awful s t r e s s and  changed" i n t h a t he had  s t r a i n " t h a t H i l d a had  been h o s p i t a l i z e d with  felt  that  undergone the same  experienced when he  had  MI.  D e s p i t e her unfavourable experience i n the CCU, described  and  importance of simply spending  q u a l i t y time with them. In terms of her husband, she their  "It i s a  Hilda  r e c e i v i n g " e x c e l l e n t " care from the nurses, "they would  have done a n y t h i n g t o make your l i f e a l i t t l e more e a s i e r . " Although she  t a l k e d mostly about n u r s i n g  i n c i d e n t where a d o c t o r had f e l t t h a t any  care,  gone out of h i s way  e x t r a e f f o r t s made by h e a l t h  made a b i g d i f f e r e n c e t o a p a t i e n t ' s In c o n t r a s t , c a r d i o l o g i s t that  she d e s c r i b e d  Hilda described  to be  care  professionals  an i n c i d e n t w i t h  should " r i d e i t out plumbing" and  therefore  f o r a w h i l e and  "iffy"  l i v e with a l i t t l e  and  she  bad  see what happens. H i l d a f e l t u n c l e a r as t o  needed more i n f o r m a t i o n  about  allergic  suggested t h a t  p o t e n t i a l r a m i f i c a t i o n s of her d o c t o r ' s advice,  and  her  felt  recommending bypass surgery because of her h i g h l y and  Hilda  well-being.  " j u s t about threw [ h e r ] . " He  r e a c t i o n to blood t h i n n e r s ,  kind.  an  the  f e l t that  i n order t o b e t t e r understand her  she  options  limitations. Hilda talked extensively  t r a n s f e r r e d from the  about her experience of b e i n g  constant care of the CCU  t o the  independence  62  of  the c a r d i a c ward once her c o n d i t i o n had s t a b i l i z e d .  d e s c r i b e d f e e l i n g somewhere between "abandoned" and  She  "neglected"  as a r e s u l t of t h i s t r a n s i t i o n . Although H i l d a a p p r e c i a t e d r e g a i n i n g the p r i v a c y she had l o s t w h i l e i n the CCU, anxious about how  independent she was  she  felt  expected t o be and  d e s c r i b e d wanting more guidance from the nurses. At  times, H i l d a found h e r s e l f f e e l i n g concerned about  t h i n g s " such as whether  "silly  her heart monitor was working a t the  n u r s i n g s t a t i o n , or whether  her nurses knew she was t h e r e a t a l l .  Once again, she a t t r i b u t e d these concerns t o the changes i n care and a t t e n t i o n from the CCU t o the ward. H i l d a d e s c r i b e d f e e l i n g anxious about r e t u r n i n g home both i n terms of r e g a i n i n g the comfort and f a m i l i a r i t y of her home, "to be a b l e t o go out my back door and smell f r e s h a i r and look a t the  garden I planted...and t o be a b l e t o j u s t look out a t the  mountains," but a l s o i n terms of q u e s t i o n i n g her a b i l i t y t o "cope" w i t h the u n c e r t a i n t y of her h e a l t h . H i l d a r e c e i v e d s u b s t a n t i a l support from her husband f a m i l y throughout her h o s p i t a l i z a t i o n . Although she f e l t  and somewhat  " g u i l t y " about the extent of her f a m i l y ' s e f f o r t s , she confessed t h a t she would have f e l t  sad had they not made the e f f o r t .  Hilda  emphasized t h a t she had always been an independent type of person and "hate[s] t o put anybody out." In  terms of p l a n n i n g f o r the f u t u r e , H i l d a r e c o g n i z e d t h a t i t  would be b e n e f i c i a l t o t r y and slow down a b i t and adopt a more "laid  back" a t t i t u d e . Moreover,  she f e l t t h a t her sense of  urgency i n terms of g e t t i n g t h i n g s accomplished w i l l no longer be important t o her.  63  Anne Anne i s a 63-year-old woman h o s p i t a l i z e d with her f o u r t h MI. She i s married with 2 a d u l t c h i l d r e n and 1 grand c h i l d . Anne i s a homemaker, and has been h e a v i l y i n v o l v e d i n t h e E a s t e r n S t a r , a Masonic a f f i l i a t i o n f o r t h e p a s t 28 y e a r s . She has an e x t e n s i v e c a r d i a c h i s t o r y t h a t began around the age of 40 w i t h her f i r s t MI, and i n c l u d e d bypass surgery a f t e r her t h i r d MI. In terms of p r e v i o u s i l l n e s s , Anne was diagnosed with high c h o l e s t e r o l s e v e r a l years ago, has had a benign b r e a s t tumour removed, and had s e v e r a l s u r g e r i e s as a teenager  r e l a t e d t o a neck c y s t . She  a l s o r e c a l l e d t h a t her mother had an e x t e n s i v e c a r d i a c h i s t o r y , and d i e d a f t e r her 13th MI. Anne agreed t o p a r t i c i p a t e i n the study d e s p i t e i n i t i a l concerns  t h a t she had l i t t l e t o c o n t r i b u t e . As she eased i n t o t h e  i n t e r v i e w , Anne became more animated and seemed t o a p p r e c i a t e t h e o p p o r t u n i t y t o share and r e f l e c t on her e x p e r i e n c e s . While she appeared of  as a g e n t l e and s e n s i t i v e woman, she a l s o exuded an aura  s t r e n g t h , d e t e r m i n a t i o n , and independence. She recounted her  experiences i n a t h o u g h t f u l and d e t a i l e d manner, and s h i f t e d e l o q u e n t l y between v i v i d l y d e s c r i b i n g experiences and e x p l o r i n g emotional  concerns.  Anne's s t o r y began with a d e t a i l e d account of the events surrounding her f i r s t MI which o c c u r r e d over 20 years ago. While camping with her f a m i l y , Anne became i n c r e a s i n g l y  symptomatic  with p a i n and nausea. A f t e r seeking help from a nearby r u r a l h o s p i t a l , she was t o l d t h a t she was f i n e and was r e l e a s e d . A couple of days l a t e r , Anne r e t u r n e d t o t h e h o s p i t a l with  severe  p a i n and was diagnosed with MI, " i t never entered my mind I was  64  having a heart a t t a c k . . . I was mad i t was on h o l i d a y s . . . I was mad t h a t I was s i c k . . . I d i d n ' t waste time worrying about me." f e l t more concerned  about her "poor"  She  husband than h e r s e l f , and  f e l t badly about i n t e r r u p t i n g the f a m i l y ' s p l a n s . Anne was h o s p i t a l i z e d f o r a week b e f o r e b e i n g sent home and readmitted t o her own l o c a l  hospital.  I t was then t h a t Anne made the connection between her own h e a l t h and her mother's e x t e n s i v e h i s t o r y of c a r d i a c i l l n e s s , "that's the way I'm going t o d i e . . . I d i d n ' t t h i n k I was going t o die  then...but  when I do d i e . . . i t w i l l be a heart a t t a c k t h a t I  die  from." She acknowledged f e e l i n g r e g r e t f u l f o r not a s k i n g her  mother more about her heart c o n d i t i o n . Four years l a t e r , Anne experienced her second MI. She r e c a l l e d f e e l i n g a g i t a t e d s e v e r a l days b e f o r e the a t t a c k . Anne's c a r d i a c symptoms began while a t home with her husband, and i n c r e a s e d i n s e v e r i t y a f t e r b e i n g admitted t o h o s p i t a l . She was t r a n s f e r r e d t o the i n t e n s i v e care u n i t of a l a r g e r h o s p i t a l where she was kept f o r o b s e r v a t i o n and was l a t e r sent t o the c i t y h o s p i t a l f o r subsequent angiography.  She r e c a l l e d b e i n g t o l d t h a t  her t e s t r e s u l t s were p o s i t i v e , and f e e l i n g shocked when her d o c t o r suggested t h a t she was " i n o p e r a b l e " as "there was  really  n o t h i n g they c o u l d do" except p r e s c r i b e m e d i c a t i o n . She was h o s p i t a l i z e d f o r about a month. Anne d e s c r i b e d f e e l i n g  "very f r u s t r a t e d " as a r e s u l t of her  memory l o s s which l a s t e d over a year a f t e r her second MI. At times, she f e l t  " r e a l l y mad" a t her f a m i l y when they would get  angry a t her f o r g e t f u l n e s s . S e v e r a l years l a t e r , Anne had her t h i r d MI w h i l e a t home. She  65 was l u c k y t o c a t c h her husband's a t t e n t i o n b e f o r e he l e f t f o r work, "he happened t o look up because I know he c o u l d n ' t have heard me t h e window,was c l o s e d . . . b u t I guess I looked white as a sheet."  S h o r t l y t h e r e a f t e r , Anne c o l l a p s e d i n t h e bathroom, "that  was t h e o n l y time t h a t I know of t h a t I came out and s a i d I don't t h i n k I was going t o make i t t h i s time."  She was q u i c k l y  t r a n s p o r t e d t o h o s p i t a l and admitted with MI. Although  Anne remembered v e r y l i t t l e of her t h i r d MI, she  d e s c r i b e d i t as b e i n g t h e most severe. During her 2 month hospitalization,  she underwent coronary bypass surgery, and was  at one p o i n t , on a v e n t i l a t o r f o r over 16 days. P r i o r t o surgery, Anne r e c a l l e d b e i n g t o weak t o get h e r s e l f o f f t h e bed o r walk even a few steps, "that was a t e r r i b l e shock...I  couldn't b e l i e v e  I c o u l d n ' t do i t . " During her recovery, Anne's s i s t e r t o l d her t h a t the f a m i l y had been c a l l e d i n because she was not expected the day, "I never thought  to live  I was going t o d i e . . . i t  through  j u s t never  entered my mind." Anne r e c a l l e d t e l l i n g someone a f t e r r e c o v e r i n g from surgery,  " . . w e l l you know i t r e a l l y i s n ' t so bad t o go and  d i e because you're unconscious anyway...so i t doesn't  and you don't know a damn t h i n g  r e a l l y bother you a t a l l . "  Anne's c u r r e n t MI o c c u r r e d 8 years a f t e r her p r e v i o u s a t t a c k . She r e c a l l e d f e e l i n g i r r i t a b l e a few days b e f o r e the event and wondered i f she was going t o have another  a t t a c k . In r e t r o s p e c t ,  she r e c a l l e d having a vague sense t h a t something was wrong, about a month and a h a l f ,  "for  I had a funny f e e l i n g t h a t I might have  a heart a t t a c k but t h e r e ' s not a t h i n g I c o u l d put my f i n g e r on...I d i d n ' t even know what I d i d n ' t f e e l r i g h t about."  66  Anne had experienced  MI  symptoms a f t e r a strenuous morning of  working i n her garden. Being alone, neighbour f o r help and was  she immediately c a l l e d  her  q u i c k l y taken t o h o s p i t a l . Once i n  emergency, Anne r e a s s u r e d the a t t e n d i n g d o c t o r t h a t her p a i n a heart a t t a c k and not i n d i g e s t i o n . She became very i l l and t r a n s f e r r e d t o the CCU. about [my  U n l i k e previous Mis,  was was  "I d i d n ' t t h i n k  husband]...I d i d n ' t t h i n k about the k i d s . . . I j u s t  wanted the p a i n to stop." As a r e s u l t , she remembered f e e l i n g "selfish." Anne was  t r a n s f e r r e d t o the c i t y h o s p i t a l ' s CCU  where  she  underwent f u r t h e r angiography. Although she dreaded undergoing the procedure, she f e l t more apprehensive about o b t a i n i n g the results. In g e n e r a l , Anne d e s c r i b e d f e e l i n g more i n t u i t i v e l y aware of her body and  i l l n e s s symptoms s i n c e her f i r s t MI.  one p o i n t , she informed  the CCU  For example, at  nurses t h a t she was  i n heart  f a i l u r e . Although she d e s c r i b e d the c u r r e n t heart a t t a c k as one  being  of the most p a i n f u l ones, she f e l t t h a t i t had been "easy"  compared t o the o t h e r s ,  "I've  j u s t s o r t of perked up and  I'm  p r e t t y good...I'm not an i n v a l i d at a l l . " On  s e v e r a l o c c a s i o n s , Anne d e s c r i b e d f e e l i n g embarrassed at  the l a c k of p r i v a c y and the experience  of f e e l i n g exposed w h i l e  h o s p i t a l i z e d , p a r t i c u l a r l y w h i l e i n the CCU mostly occupied by men.  She  which she noted i s  f e l t more f e a r f u l of b e i n g put i n an  embarrassing p o s i t i o n than of e x p e r i e n c i n g another heart  attack.  Anne a l s o t a l k e d about the d i f f i c u l t y of b e i n g t r a n s f e r r e d from the CCU  to the c a r d i a c ward, " i n a way  you  f e e l l e t down  because i n s i d e you're r e a l l y i n a cocoon...you are i n a cocoon  67  and you're p r o t e c t e d and a l l of the sudden you're out i n t o the next room...abandoned." Anne a l s o t a l k e d about the f e e l i n g s of v u l n e r a b i l i t y she experienced and about having f e l t a f t e r her Mis, "I hate myself when I do i t . . . I  "very weepy"  j u s t hate  it...I  don't want t o l o s e t h a t k i n d of c o n t r o l . . . [ I want] people t o t h i n k I'm  i n c o n t r o l whether I am or not.  With r e s p e c t t o treatment and care, Anne d e s c r i b e d b e i n g treated  " j u s t super most of the times." She d i d however, r e c a l l a  some i n c i d e n t s where she had f e l t  h u m i l i a t e d by a few nurses and  d o c t o r s . In g e n e r a l , Anne d e s c r i b e d h e r s e l f as b e i n g "a p r e t t y good p a t i e n t because  [she does not] complain v e r y much."  When asked about the s i g n i f i c a n c e of t h i s MI, Anne t a l k e d about how  " f u r i o u s " she had f e l t because of b e i n g f o r c e d t o g i v e  up c e r t a i n a c t i v i t i e s t h a t she r e a l l y enjoys. She a l s o t a l k e d about the importance of changing her l i f e s t y l e as w e l l as having "some r e g r e t s " about not p r e v e n t i n g some of her i l l n e s s , did  "...why  I smoke...I know p a r t of i t i s h e r e d i t a r y , I know t h a t f o r  sure....80% i s probably the smoke...it took me two h e a r t a t t a c k s to why  q u i t smoking." Although she knew she would never r e a l l y know she had t h i s MI,  she a t t r i b u t e d i t t o the " s t r e s s " of b e i n g  overworked. In  terms of going home, Anne e m p h a t i c a l l y expressed her  d e s i r e t o "get out of here and get s t r o n g and s t a r t d o i n g my t h i n g again." She t a l k e d about having a l o t t o do i n c l u d i n g the r e s p o n s i b i l i t i e s r e l a t e d t o her work. She acknowledged f e e l i n g w o r r i e d a t the p r o s p e c t of not g e t t i n g her work done and  felt  t h a t she d i d not have "the l i t t l e button t h a t can shut t h a t stress o f f . "  68 Anne a l s o expressed her concerns about b e i n g alone once she r e t u r n e d home, and r e c a l l e d a f r i g h t e n i n g experience a f t e r her t h i r d MI where she had f e l t  stranded i n her k i t c h e n without  anyone b e i n g a t home. D e s p i t e her concerns, she acknowledged f e e l i n g much l e s s weak a f t e r t h i s MI than i n the p a s t . Although Anne d e s c r i b e d having f a m i l i a l and s o c i a l throughout  her i l l n e s s ,  experiences of f e e l i n g  support  she a l s o t a l k e d about p r e v i o u s "smothered" by her f a m i l y a f t e r  returning  home from the h o s p i t a l . She d e s c r i b e d times where t h e r e was little  she c o u l d do without her f a m i l y b e i n g a f r a i d t h a t she  would have another a t t a c k , and f i r m l y b e l i e v e d t h a t her i l l n e s s was probably harder on f a m i l y members than on h e r s e l f . While she wanted t o "reassure" them t h a t she was going t o be a l l r i g h t , she a l s o needed t o be the one who d e c i d e d whether or not she needed t h e i r help, "I want t o be i n c o n t r o l . . . I d i d n ' t r e a l i z e . . . but t h a t d i d bother me when I got home l a s t t i m e . . . t h a t I j u s t c o u l d not be myself." In  terms of the f u t u r e , Anne acknowledged t h a t t h e r e a r e many  t h i n g s t h a t she wants t o do i n her l i f e but wonders how l o n g she will  l i v e with her heart c o n d i t i o n . She a l s o t a l k e d about t h e  importance  of spending time with her f a m i l y , as w e l l as her  desire to t r a v e l . R e f l e c t i n g back on her experience of having f o u r Mis, Anne recognized that  "every one [was] d i f f e r e n t . . . t h e y a r e not the  same and t h a t probably was one of my b i g g e s t s u r p r i s e s . " She a l s o suggested t h a t when you experience MI symptoms, p a r t of your mind says "I can't be having another one" and the other p a r t of your mind says  "sure you a r e having another one."  69  Noreen Noreen i s a 58-year-old woman t h a t underwent coronary bypass surgery w h i l e h o s p i t a l i z e d with MI.  P r i o r t o her MI,  she  was  working p a r t - t i m e as a cook and w a i t r e s s i n a l o c a l c a f e , p r o v i d i n g c h i l d care f o r one of her daughters. Noreen has 7 a d u l t c h i l d r e n , and c u r r e n t l y l i v e s with a married daughter r u r a l town. She d e s c r i b e d a vague h i s t o r y of c a r d i a c  i n a small arrhythmia  f o r which she had taken medication f o r 10 t o 15 y e a r s . Other  than  b i r t h i n g her c h i l d r e n , Noreen had o n l y been h o s p i t a l i z e d f o r a p p e n d i c i t i s as a young c h i l d . She i s c u r r e n t l y a smoker. When I f i r s t met  Noreen, she appeared  somewhat d i s o r i e n t e d as  a r e s u l t of her medication. A few days l a t e r , she was  lucid  and  agreed t o p a r t i c i p a t e i n the study. Noreen d e s c r i b e d her experiences i n a s t r a i g h t f o r w a r d manner, and was  w i l l i n g t o share  her f e e l i n g s surrounding the dramatic course of i l l n e s s Moreover, she appeared n u r t u r i n g approach  t o m a i n t a i n a common sense and  t o coping with her i l l n e s s and  events.  self  expected  recovery. Noreen began her s t o r y by r e c a l l i n g how been, "I d i d n ' t know what was was  kinda dumped i n my  happening...the  "scared" she  had  whole experience  l a p . " For 2 months p r i o r t o her MI,  she  had experienced i n c r e a s i n g l y severe a n g i n a l symptoms. Noreen admitted t h a t she d i d not want, t o acknowledge these symptoms as being serious,  "I d i d n ' t want t o t h i n k t h a t I was  heading f o r a  heart a t t a c k so I d i d n ' t bother." She r e c a l l e d b e i n g out with her daughter when she experienced chest and arm p a i n t h a t became worsen over the evening. She taken t o the l o c a l d i a g n o s t i c c e n t e r and was  was  given n i t r o g l y c e r i n  70  which subsequently breathe. Noreen was  r e l i e v e d her chest p a i n and shortness of t o l d to go home and r e t u r n the next day  have her b l o o d p r e s s u r e checked. The next n i g h t , she had  to  a  " r e a l l y bad a t t a c k " and r e t u r n e d t o the d i a g n o s t i c c e n t e r where she was was  g i v e n more n i t r o g l y c e r i n and other medication. Again,  sent home and asked to r e t u r n t o have her blood  monitored  she  pressure  the f o l l o w i n g day. Noreen r e t u r n e d t o the d i a g n o s t i c  c e n t e r f o u r or f i v e times over the next week t o have her.blood pressure  monitored.  A week l a t e r , Noreen was  t o l d by her doctor t h a t her b l o o d  p r e s s u r e had s t a b i l i z e d . She was to  g i v e n more medication  and  asked  r e t u r n f o r f u r t h e r blood t e s t s . S h o r t l y a f t e r a r r i v i n g home,  she experienced ill.  " e x c r u c i a t i n g " chest p a i n and became  Subsequently,  she was  sent by ambulance t o the c l o s e s t  h o s p i t a l . From t h e r e , Noreen was h o s p i t a l where she was  extremely  t r a n s f e r r e d to a l a r g e r  rural  rural  t o l d t h a t she had experienced a massive  coronary a t t a c k . Noreen d e s c r i b e d her i n i t i a l mostly...that f i r s t  initial  r e a c t i o n as b e i n g " j u s t  shock was  blank  j u s t k i n d of blank."  She  became "perturbed" a t her d o c t o r and f e l t t h a t she should have been h o s p i t a l i z e d e a r l i e r ,  " i t may  of given me  needed." Noreen a l s o r e c a l l e d f e e l i n g  the leap I  "scared" t h a t she would  never see her k i d s again. S h o r t l y t h e r e a f t e r , Noreen was  flown by a i r ambulance t o the  c i t y h o s p i t a l f o r f u r t h e r treatment, She was  d e s p i t e her f e a r of  flying.  accompanied by her youngest daughter which helped t o  r e l i e v e some of her a n x i e t y . C e n t r a l t o Noreen's experience of h o s p i t a l i z a t i o n was  her  71 adverse r e a c t i o n t o t h e v a r i o u s medications she was p r e s c r i b e d . She t a l k e d e x t e n s i v e l y about her stay i n the CCU and d e s c r i b e d her experience of h a l l u c i n a t i o n s as b e i n g "scary" and " h o r r i f y i n g . " Noreen p r o v i d e d d e t a i l e d and v i v i d accounts of s e v e r a l h a l l u c i n a t i o n s , i n which t h e theme of death was frequently depicted. She recounted s e v e r a l i n s t a n c e s where she f e l t overwhelmed by her experiences w h i l e i n t h e CCU. F o r example, Noreen r e c a l l e d t e l l i n g t h e nurses  "I'm a l l by myself...don't  the same time f e e l i n g  leave me," w h i l e a t  "panicked" and screaming  "get out of here."  She f e l t badly about her o f t e n " s a r c a s t i c " and "rough"  behavior  towards the nurses and wondered why they "hadn't j u s t given me a shot... something up."  t o put me under... something  t o k i n d of shut me  In r e t r o s p e c t , she knew t h a t they were t r y i n g t o do  e v e r y t h i n g they c o u l d f o r her. Noreen d e s c r i b e d h e r s e l f as b e i n g a normally p r e t t y calm and c o o l i n d i v i d u a l ,  "the heart a t t a c k I'd  go through a hundred times again b e f o r e I'd ever go through one of  those drug t h i n g s ... i t was j u s t horrendous ... h o r r i b l e . . . the  worst experience I ever had i n my l i f e . " sent f o r angiography  Subsequently,  Noreen was  and coronary bypass surgery. During t h e  i n t e r v i e w , she made v e r y l i t t l e  r e f e r e n c e t o having undergone  surgery. In  terms of treatment and care, Noreen t a l k e d about having a  d i f f e r e n t a p p r e c i a t i o n f o r the medical p r o f e s s i o n . She d e s c r i b e d the n u r s i n g care she had r e c e i v e d as b e i n g " f a n t a s t i c " and f e l t they "deserved a medal...I don't t h i n k I ' l l ever look a t a nurse or  a n y t h i n g l i k e t h a t again and take them f o r granted." She a l s o  d e s c r i b e d the d o c t o r s as b e i n g "good people" who "know what  72  they're  doing."  Noreen t a l k e d about having throughout  her i l l n e s s ,  "a l o t of people  s u p p o r t i n g her"  i n c l u d i n g her c h i l d r e n who had been "100%  g r e a t . " Her c h i l d r e n o f t e n v i s i t e d and stayed with her,  "I was  b e t t e r as long as somebody stayed r i g h t t h e r e and hung r i g h t onto me." Noreen d e s c r i b e d f e e l i n g very concerned  about her c h i l d r e n  and wondered what was going t o happen t o them once she was "gone." She f u r t h e r d e s c r i b e d them as b e i n g j u s t about e v e r y t h i n g t h a t she has and wanted t o leave each of them a s p e c i a l message f o r when she i s no longer around. When asked about the s i g n i f i c a n c e of having had a heart a t t a c k , Noreen suggested  t h a t i t has made her stop and  contemplate the d i r e c t i o n of her l i f e p a r t i c u l a r l y s i n c e she i s without  a p a r t n e r . She a l s o acknowledged the importance t a k i n g  b e t t e r care of her h e a l t h i n t h e f u t u r e . In terms of making changes, Noreen understood  t h a t she needed t o q u i t e smoking and  c a f f e i n e , and make some "common sense"  a l t e r a t i o n s t o her d i e t .  She acknowledged t h a t her b i g g e s t c h a l l e n g e would be t o s t a y away from the c i g a r e t t e s p a r t i c u l a r l y  "when I get home and on my own  and back with my f r i e n d s and p l a y i n g bingo...and t h i n g s  like  that." In terms of going home, Noreen t a l k e d about f o c u s i n g on " j u s t g e t t i n g b e t t e r " and wanted t o "mostly  j u s t go t o bed and  recuperate." She wanted t o spend time with f a m i l y members d u r i n g her recovery and had o f f e r s t o v i s i t both her daughter and s i s t e r who l i v e out of town. More immediately,  Noreen d e s c r i b e d how  d i f f e r e n t i t was going t o be f o r her t o s t a y a t her daughter's home without  doing a l l the t h i n g s t h a t she was used t o doing  73  p r i o r t o her MI and surgery. She f e l t t h a t t h i s t r a n s i t i o n was "going t o take some g e t t i n g used t o " i n terms of having t o " s i t back and not do anything." In g e n e r a l , Noreen appeared o p t i m i s t i c towards t h e f u t u r e and  suggested  t h a t " i t w i l l work out a l r i g h t I hope...I don't  know...I guess w e ' l l j u s t have t o wait and see." She a l s o demonstrated a r e a l i s t i c approach t o r e c o v e r y i n terms of t a k i n g care of h e r s e l f and understanding i n her l i f e . child  t h e need t o make some changes  For.example, she d i d not expect t o r e t u r n t o e i t h e r  care of c a f e work, and d i d not f e e l  "too concerned"  f u t u r e employment, "I don't know what I ' l l get...but  about  I ' l l get  something somewhere along the l i n e . " Noreen f e l t t h a t i f t h e r e was one p i e c e of advice t h a t she c o u l d g i v e t o other women i t would be t o have r e g u l a r medical check-ups, p a r t i c u l a r l y i f t h e r e was any s u s p i c i o n of heart trouble. Brynn Brynn i s a 51-year-old woman without  a p r e v i o u s h i s t o r y of  c a r d i a c d i s e a s e . She i s c u r r e n t l y l i v i n g with her second husband and has t h r e e a d u l t c h i l d r e n none of whom a r e l i v i n g a t home. Although  c u r r e n t l y unemployed, Brynn has a b a c h e l o r s degree i n  n u r s i n g and has worked i n n u r s i n g f o r many y e a r s . In terms of p r e v i o u s i l l n e s s , Brynn had her g a l l bladder removed and has r e c e i v e d treatment medication  f o r d y s p l a s i a . She i s c u r r e n t l y t a k i n g  f o r depression.  Brynn was e n t h u s i a s t i c about p a r t i c i p a t i n g i n the study. She was outspoken and w i l l i n g t o share her thoughts  and f e e l i n g s  r e l a t e d t o her MI experience. Throughout the i n t e r v i e w , Brynn  74  expressed an l i v e l y sense of humour, which seemed to balance i n t r o s p e c t i v e n e s s brought on by her  sudden i l l n e s s .  her  She  f r e q u e n t l y drew upon her n u r s i n g knowledge i n terms of making sense of her  experiences.  Brynn began her  s t o r y by d e s c r i b i n g the symptoms t h a t  i n i t i a l l y a t t r i b u t e d t o i n d i g e s t i o n . Despite p r e s c r i b e d medication and  antacids,  treatment w i t h  her symptoms i n t e n s i f i e d .  next morning, Brynn's p a i n suddenly became worse and "very f r i g h t e n e d . "  She  she  The  she became  f e l t t o r n between having a sense of  " d i s b e l i e f t h a t t h i s was  happening.to me,"  and  e x p e r t i s e of a nurse and  the knowledge t h a t her symptoms were  c a r d i a c r e l a t e d . A f t e r c o n t a c t i n g her doctor she was  taken by her p a r t n e r  f o r a second time,  to the c i t y h o s p i t a l l o c a t e d only a  few minutes away. S h o r t l y t h e r e a f t e r , she was and t r a n s f e r r e d to the  having the  diagnosed with  MI  CCU.  Brynn t a l k e d e x t e n s i v e l y about her experience i n the emergency department. She things  even before  she was  described  f e e l i n g worried  admitted,  mind...you j u s t go i n t o a panic  "you  about  don't l o s e your  t h i n k i n g about a l l these  t h i n g s t h a t are crowding i n t o your mind." Brynn f e l t about f i n d i n g a c c e s s i b l e p a r k i n g , f e e l i n g . She  and  f e l t as though she had  about how  to be  small  other  worried  her p a r t n e r  "strong"  f o r him  was until  they reached the emergency and where she assumed she would be i n good hands. As w e l l , she was  concerned t h a t he was  be with her i n the treatment area and was s t a f f d i d not t r e a t him Brynn was  not allowed t o  disappointed  that  the  i n a r e a s s u r i n g manner.  s t r u c k with "the d i f f e r e n t l e v e l s of p r o f e s s i o n a l s  a s k i n g q u e s t i o n s . . . a s k i n g the same questions  over and  over" w h i l e  75  i n emergency. She f e l t aggravated by t h i s p r o c e s s ,  particularly  when she was t r y i n g t o cope with her i n c r e a s i n g p a i n . A t one p o i n t , someone had asked her t o p a r t i c i p a t e i n a r e s e a r c h study, "I was f r i g h t e n e d and i t was making me angry."  She a l s o  felt  " f r i g h t e n e d " by one p a r t i c u l a r i n t e r n who she f e l t had behaved a g g r e s s i v e l y towards her and who was not working c o l l a b o r a t i v e l y w i t h the other s t a f f . Brynn emphasized the importance  of f e e l i n g  safe and secure as a p a t i e n t and f e l t t h a t t h i s i s l a r g e l y i n f l u e n c e d by the medical s t a f f one encounters  while  hospitalized. A f t e r b e i n g h o s p i t a l i z e d , Brynn was sent f o r an a n g i o p l a s t y which confirmed t h a t she had s u f f e r e d a massive a n t e r i o r MI. Although  she r e c a l l e d very l i t t l e  she d e s c r i b e d having gone through  of her f i r s t 3 days i n the CCU, "the c r a z i e s " and was t o l d by  s t a f f t h a t her a g g r e s s i v e behavior was l i k e l y caused by a l a c k of oxygen. Brynn r e c e i v e d l o t s of support from her f a m i l y as they came from across the country t o v i s i t her, all  t h a t much...it p u l l e d me through."  experience, she t a l k e d very l i t t l e  "I d i d n ' t know they cared Other than her emergency  about the q u a l i t y of care t h a t  she had r e c e i v e d from other h e a l t h care p r o v i d e r s . She d i d b r i e f l y comment on the CCU s t a f f ,  " i t ' s great...you  s c r a t c h your  back and they run i n t o see what you a r e doing." Brynn a t t r i b u t e d her MI t o the c u r r e n t s t r e s s o r s i n her l i f e i n c l u d i n g f i n a n c i a l w o r r i e s and the d i f f i c u l t i e s t h a t both her and her p a r t n e r have had t r y i n g t o f i n d employment. She a l s o d i s c u s s e d the dramatic death of one of her best f r i e n d s , and concerns  r e l a t e d t o her p a r t n e r ' s h e a l t h .  76  Brynn d e s c r i b e d f e e l i n g  "very i n t r o s p e c t i v e " d u r i n g her  i n h o s p i t a l . She t a l k e d f r e e l y about her s p i r i t u a l b e l i e f s w e l l as her thoughts t h r e a t e n i n g event.  about having s u r v i v e d a p o t e n t i a l l y  She r e f l e c t e d on her l i f e and  time as  life  her  accomplishments r e v o l v i n g around r a i s i n g her c h i l d r e n , a d i v o r c e , b u i l d i n g an e m o t i o n a l l y s u c c e s s f u l second  surviving  marriage,  and r e t u r n i n g t o s c h o o l . "I've been p r o a c t i v e about a c e r t a i n number of t h i n g s , but I haven't looked a f t e r my  own  h e a l t h very  well." Brynn f e l t t h a t having an MI p r o v i d e d her with an o p p o r t u n i t y to  r e c o g n i z e t h a t f o r a long time she has taken care of others  and now felt  must l e a r n how  to take care of h e r s e l f . Moreover,  " g r a t e f u l " t h a t God  has g i v e n her another  b e t t e r l i f e " . Brynn a l s o f e l t t h a t she was  she  chance t o " l i v e  undergoing  a  a  t r a n s f o r m a t i o n a l or o b j e c t i v e p e r i o d and needed t o analyze  and  r e e v a l u a t e her v a l u e s . She d e s c r i b e d f e e l i n g  "emotionally l a b i l e "  throughout  h o s p i t a l i z a t i o n and found t h a t she had d i f f i c u l t y At other times, Brynn f e l t  suddenly  her  concentrating.  t e a r y and remorseful about  past events. She t a l k e d openly about death,  "I'm  not a f r a i d of  dying...if  I d i e i t ' s Gods w i l l . . . a c t u a l l y t h e r e are some g r e a t  people  l o o k i n g forward t o seeing."  I'm  When asked about the s i g n i f i c a n c e of having a MI, suggested  Brynn  t h a t her experience has brought her c l o s e r t o her  c h i l d r e n and husband. She d e s c r i b e d having a g r e a t e r sense of a p p r e c i a t i o n f o r her r e l a t i o n s h i p s with her c h i l d r e n and  how  these have evolved i n t o f r i e n d s h i p s . She hoped t h a t she would serve as a "good r o l e model" f o r them, and t h a t her  children  77  would l e a r n from her e x p e r i e n c e s . In g e n e r a l , Brynn appeared  h o p e f u l about the f u t u r e .  she a n t i c i p a t e d having t o make adjustments,  Although  she was l o o k i n g  forward t o r e t u r n i n g home. She f e l t t h a t the hardest t a s k f o r her would be t o q u i t smoking, and she expressed some " f e a r "  around  t h i s t a s k . In terms of making other changes, Brynn d e s c r i b e d wanting t o stop doing the "mini mouse," a term she d e s c r i b e s f o r b e i n g a f r a i d t o stand up f o r h e r s e l f and f e e l i n g taken advantage of by o t h e r s . In r e t r o s p e c t , Brynn suggested t h a t every household prepare themselves cardiopulmonary  f o r emergency s i t u a t i o n s by  resuscitation  should  learning  (CPR), and by p o s t i n g emergency  numbers i n a c c e s s i b l e p l a c e s . As w e l l , she emphasized the importance  of g e t t i n g a y e a r l y medical check-up.  Gina Gina i s a 44-year-old  woman with an e x t e n s i v e f a m i l y h i s t o r y  of heart d i s e a s e . She i s married and has two a d u l t c h i l d r e n . i s c u r r e n t l y employed as a c l e r k i n a beer and wine o u t l e t ,  She and  i s i n v o l v e d with b u i l d i n g a f a m i l y dude ranch. In terms of p r e v i o u s i l l n e s s , Gina had a t o n s i l l e c t o m y as a c h i l d , a hysterectomy  i n her t w e n t i e s , and s c i a t i c a . Gina was  diagnosed with slow esophageal  also  r e f l e x a f t e r an episode of severe  stomach p a i n . Gina was  i n t e r v i e w e d a few days b e f o r e undergoing  bypass surgery. She was animated  coronary  p l e a s a n t and easy t o t a l k t o , and had  sense of humour. She appeared  t o be outspoken  d i s c u s s e d her experiences i n a candid manner. Gina a l s o  an  and appeared  to a p p r e c i a t e the o p p o r t u n i t y t o share her more e x i s t e n t i a l  78  q u e s t i o n s and concerns. Gina's account began with a r e c o l l e c t i o n of stomach p a i n d u r i n g heavy housework. Since t h i s p a i n was almost i d e n t i c a l t o an episode of p a i n she experienced a year ago, she assumed i t was r e l a t e d t o an a l l e g e d stomach a i l m e n t . Subsequently, Gina  stopped  working and the p a i n subsided. A f t e r resuming work, the p a i n r e t u r n e d and again she stopped working. By the time Gina had asked her husband f o r help with the house c l e a n i n g , she had o v e r e x e r t e d h e r s e l f and was having severe p a i n . When her symptoms worsened, she r e a l i z e d she was having a MI and was taken t o the l o c a l r u r a l h o s p i t a l by her husband. Once i n emergency, the n u r s i n g s t a f f i n i t i a t e d treatment f o r stomach t r o u b l e . A f t e r more thorough t e s t i n g , she was  diagnosed  with MI and t r a n s f e r r e d t o the i n t e n s i v e care u n i t . Gina r e c a l l e d f e e l i n g d i s a p p o i n t e d t h a t she had had t o wait t o see a d o c t o r i n emergency. She d e s c r i b e d f e e l i n g not " p a r t i c u l a r l y alarmed"  t h a t she had  s u f f e r e d a h e a r t a t t a c k , g i v e n her e x t e n s i v e f a m i l y h i s t o r y of heart d i s e a s e and her "ignorant l i f e s t y l e . "  "I knew i t was a  matter of time b e f o r e I had a MI of my own...I knew i t was coming...I j u s t d i d n ' t know when." At t h i s time, i t o c c u r r e d t o her t h a t her p r e v i o u s l y diagnosed stomach t r o u b l e was  angina.  Gina was h o s p i t a l i z e d f o r 5 days and then r e l e a s e d w i t h the instructions  "to take i t easy" and t o r e t u r n i n a few days f o r a  s t r e s s t e s t . In r e t r o s p e c t , Gina assumed t h a t t a k i n g i t easy meant not t o work or l i f t  anything, but admitted t h a t these  i n s t r u c t i o n s had not been  clarified.  L a t e r t h a t day, Gina ran a s e r i e s of errands and then v i s i t e d  79  with f r i e n d s and  f a m i l y . A f t e r being  a n g i n a l p a i n returned treatment. She was she had felt  "fairly  and  she was  s t a r t l e d w h i l e napping,  taken t o the  local hospital for  admitted to a d i f f e r e n t h o s p i t a l and  s i g n i f i c a n t " heart damage. Moreover, her  she had been p r e v i o u s l y r e l e a s e d too e a r l y and  t h a t she be  her  told  that  doctor  recommended  sent to the c i t y h o s p i t a l f o r angiography.  Gina f e l t t h a t n e i t h e r h e r s e l f or her husband had wanted t o admit the s e v e r i t y of her c o n d i t i o n , but and  take note" a f t e r her  f e e l i n g "reassured" c i t y h o s p i t a l and  "we  both had  second h o s p i t a l i z a t i o n . She  t o s i t up described  at the thought of being t r a n s f e r r e d t o  assumed t h a t she would r e c e i v e b e t t e r  Gina r e p o r t e d b e i n g  the  care.  " t o t a l l y impressed" w i t h the q u a l i t y of  care she r e c e i v e d i n the c i t y h o s p i t a l , p a r t i c u l a r l y w h i l e i n the CCU.  She  f e l t awed by the nurses a b i l i t y to p r o v i d e  " c o n s i s t e n t compassion." She  a l s o f e l t t h a t the care she  a f t e r being t r a n s f e r r e d to the ward was f e e l i n g "secure", c o u l d not  and  received  reported busier  and  spend the same amount of time with p a t i e n t s . not too s u r p r i s e d t h a t she had  had  a  MI,  " r e a l l y alarmed" at the r e s u l t s of her angiogram which  i n d i c a t e d t h a t she had bypass surgery. extent  "good" and  d e s p i t e the f a c t t h a t the s t a f f was  Although Gina was she f e l t  sincere  seven blockages and  More s p e c i f i c a l l y ,  she was  of her d i s e a s e because of her age,  required  coronary  astonished  at  the  even though she knew  she had been "gambling" with smoking and b e i n g  overweight.  Gina t a l k e d e x t e n s i v e l y about her concerns r e l a t e d t o bypass surgery.  Although the surgeon suggested t h a t  for  another 40 years"  and  exercised,  she  provided  still  "she would be  good  she watch her d i e t , q u i t smoking,  expressed her m i s g i v i n g s .  She r e c a l l e d  80  having a hysterectomy  a t age 23, a l o n g with a t l e a s t 10 o t h e r  women she had gone t o s c h o o l with, and f e l t t h a t t h e surgery was u n n e c e s s a r i l y r a d i c a l . Moreover, the surgery prevented her from having more than 2 c h i l d r e n . Gina's  felt  concerned  t h a t she was once again b e i n g  misguided  by the medical p r o f e s s i o n . She questioned t h e f a c t o r s t h a t were r e l e v a n t i n d e c i d i n g treatment  and wondered whether she had other  o p t i o n s such as a n g i o p l a s t y . Moreover, she f e l t u n c l e a r about t h e r e p e r c u s s i o n s of having bypass surgery and f e l t t h a t she had not r e c e i v e d s a t i s f a c t o r y i n f o r m a t i o n from her d o c t o r s . Although d e s c r i b e d h e r s e l f as b e i n g very outspoken, having d i f f i c u l t y approaching concerns,  Gina  she acknowledged  her d o c t o r s t o d i s c u s s these  and admitted f e e l i n g q u i t e " h e l p l e s s . "  Gina suggested t h a t her b i g g e s t f e a r surrounding the surgery i t s e l f was t h e " l a c k of c o n t r o l " and " f e e l i n g s of h e l p l e s s n e s s " t h a t she a s s o c i a t e d t o waking up i n t h e r e c o v e r y room. She r e c a l l e d s e v e r a l unpleasant experiences r e l a t e d t o other surgeries. At one p o i n t d u r i n g her h o s p i t a l i z a t i o n , Gina had c o n s i d e r e d c a l l i n g a cab and checking h e r s e l f out. "I r e a l l y d i d n ' t want t o do t h i s . "  She acknowledged her reasons  for staying included  "keeping i t t o g e t h e r f o r the f a m i l y , " and because she would probably otherwise d i e . When asked about the meaning of her MI experience, responded  Gina  by suggesting t h a t she needed t o " c l e a n up her  l i f e s t y l e , " and a t t r i b u t e d her i l l n e s s t o the " s t r e s s l e v e l " i n her l i f e .  She contemplated  purpose i n l i f e  e x i s t e n t i a l q u e s t i o n s such as her  and f e l t as though i t was time t h a t she she make  81 some important d e c i s i o n s about the d i r e c t i o n of her l i f e .  She  expressed her thoughts  and  around l e a v i n g an abusive marriage  f e l t t h a t p u r s u i n g a d i f f e r e n t l i f e s t y l e would do more f o r her psyche and her h e a l t h than would q u i t t i n g smoking or weight.  losing  Gina a l s o r e p o r t e d having s e v e r a l v i s i o n s and  w h i l e h o s p i t a l i z e d . She a l s o d i s c u s s e d p r e v i o u s  dejavues  spiritual  experiences t h a t encouraged her t o examine i s s u e s around death. In  r e t r o s p e c t , Gina f e l t  not "go a l i t t l e  " d i s a p p o i n t e d " t h a t her d o c t o r d i d  deeper" i n terms of i n v e s t i g a t i n g her  suspected  stomach problems e s p e c i a l l y c o n s i d e r i n g her f a m i l y h i s t o r y of heart d i s e a s e . Moreover, she f e l t t h a t her symptoms c o u l d have served as a warning had she been p r o p e r l y diagnosed. Gina d i d not express concerns  about r e t u r n i n g home, as  emphasized her "backup" i n terms of s t r o n g f a m i l i a l and  she  social  support. For example, her f a m i l y had made plans t o rearrange t h e i r work schedules i n order t o spend time with her a t home. Gina's  f i n a l words about her MI  the importance  experience were r e l a t e d t o  of " l i s t e n i n g t o your body."  D e s c r i p t i o n of Themes Nine themes were found t o be s i g n i f i c a n t and common t o most of  the c o - r e s e a r c h e r ' s experience of MI. Although  o p e r a t i o n a l i z e d and has i t s own did  each theme  was  d i s t i n g u i s h a b l e f e a t u r e s , they  not occur i n i s o l a t i o n t o other emergent themes.  Subsequently,  i d e n t i f i e d themes f r e q u e n t l y overlapped  and  i n t e r a c t e d with each other i n a manner t h a t r e f l e c t s the complex nature of the c o - r e s e a r c h e r ' s experience. For example, the themes of  care and support o v e r l a p with the experience of  needing  i n f o r m a t i o n i n the c a p a c i t y t h a t a c q u i r i n g s a t i s f a c t o r y  82 i n f o r m a t i o n from h e a l t h care p r o v i d e r s i s c l o s e l y r e l a t e d t o one's assessment or p e r c e p t i o n of t h e q u a l i t y of care they have received. I t i s important t o r e c o g n i z e t h a t each c o - r e s e a r c h e r o f f e r e d a unique p e r s p e c t i v e and d e s c r i p t i o n of MI experience, based on t h e i r own i n d i v i d u a l i t y and p a r t i c u l a r circumstances.  Although  these common themes were e v i d e n t i n c o - r e s e a r c h e r s accounts, t h e uniqueness  of each woman i s captured and r e f l e c t e d i n t h e  v a r i a t i o n s i n which t h e themes were expressed.  Specific  excerpts  from t h e i n t e r v i e w s have been chosen t o b e s t capture and r e v e a l the essence of the c o - r e s e a r c h e r s MI experience. The order i n which t h e themes a r e presented does not r e f l e c t the r e l a t i v e importance  or frequency of the c o - r e s e a r c h e r ' s experience.  The nine common themes t h a t emerged from t h e c o - r e s e a r c h e r s accounts  i n c l u d e the f o l l o w i n g :  1.  The experience of i l l n e s s awareness.  2.  The experience of f e e l i n g e m o t i o n a l l y overwhelmed.  3.  The experience of f e a r and worry.  4.  The experience of l o s s .  5.  Having d i f f i c u l t y a s k i n g f o r o r r e c e i v i n g help from o t h e r s .  6.  The experience of needing i n f o r m a t i o n .  7.  The experience of care and support.  8.  Making sense of t h e MI experience.  9.  The experience of p l a n n i n g f o r t h e f u t u r e .  In t h e f o l l o w i n g d e s c r i p t i o n s , pseudonyms have been i n c l u d e d t o a l l o w t h e reader t o b e t t e r f o l l o w the accounts  of each women's  experience. In some cases, excerpts of t e x t w i l l f o l l o w t h e r e s p e c t i v e order i n which women's names were recorded.  83 The Experience of I l l n e s s Awareness The  first  emerging theme concerns  women's experience of  i l l n e s s awareness. For a l l of the c o - r e s e a r c h e r s , the experience of  i l l n e s s awareness marked the b e g i n n i n g of t h e i r  accounts  d e s c r i b i n g t h e i r MI experience. Most of the women p r o v i d e d a v i v i d l y d e t a i l e d and o f t e n e x t e n s i v e d e s c r i p t i o n of how and where they experienced the i n i t i a l  symptoms of MI. Although  the nature  and s e v e r i t y of these r e p o r t e d symptoms v a r i e d across cor e s e a r c h e r s , a l l of the d e s c r i p t i o n s i n c l u d e d the i d e n t i f i c a t i o n of  one o r more symptoms a s s o c i a t e d with MI i n c l u d i n g chest, back,  neck or arm p a i n , nausea, shortness of b r e a t h , d i z z i n e s s , and extreme f a t i g u e , i n t o my n e c k . . . i t was almost  sweating,  "I had severe p r e s s u r e . . . r i g h t up  smothering  me l i k e somebody had put  the bed on t o p of my chest," "the p a i n was severe and i n my back and across the t o p of my s h o u l d e r s . . . I c o u l d have climbed the w a l l s I was i n so much p a i n , " "I was sweating buckets,"  "I j u s t  got r e a l l y s i c k and I c o u l d n ' t stop throwing up." Co-researchers of  their i n i t i a l  symptoms almost  d i f f e r e d i n the time they took t o make sense  symptoms. While some women made sense of t h e i r immediately,  others took up t o s e v e r a l days  b e f o r e seeking a s s i s t a n c e . For example, 7 of the 10 cor e s e a r c h e r s acknowledged t h a t a t some p o i n t d u r i n g t h e i r experience of i l l n e s s awareness, they had questioned whether t h e i r i d e n t i f i e d symptoms were r e l a t e d t o i n d i g e s t i o n . F o r some of  the women t h i s was a f l e e t i n g thought,  w h i l e f o r others t h e  assumption of having i n d i g e s t i o n postponed the a c t of seeking help. Co-researchers  responded t o t h e i r awareness of symptoms i n  84 s e v e r a l ways. Some of the women i d e n t i f i e d symptoms without having a sense of what was happening  t o them. Kiko d i s m i s s e d a  s e r i e s of symptoms t h a t emerged over t h e course of a few days, i n c l u d i n g an i m m o b i l i z i n g sense of f a t i g u e and "funny  feeling"  t h a t she a t t r i b u t e d t o heartburn. I t was o n l y s e v e r a l days a f t e r the i n i t i a l onset of symptoms when she was unable t o move and " r e a l l y got a hot sweat and a l l of t h e sudden s t a r t e d  tingling"  b e f o r e her son c a l l e d f o r an ambulance. Penny d e s c r i b e d her experience of what she thought was i n d i g e s t i o n t h a t had o c c u r r e d i n t e r m i t t e n t l y over a couple o f 'days. "I d i d n ' t r e a l l y t h i n k I was having a heart a t t a c k . . . because of my age, and the f a c t t h a t I don't  smoke, not  overweight... I d i d n ' t have a l l the r i s k f a c t o r s . " She d e s c r i b e d her symptoms as g r a d u a l l y i n t e n s i f y i n g ,  "I s t a r t e d t o g e t w o r r i e d  because t h e time between f e e l i n g good seemed l e s s and l e s s so we decided t h a t t h i s wasn't a n y t h i n g normal."  At t h i s p o i n t , she  asked her husband t o c a l l f o r the ambulance. Other c o - r e s e a r c h e r s appeared t o b l o c k out t h e i r  experience  of i l l n e s s awareness. Noreen d e s c r i b e d her symptoms as becoming p r o g r e s s i v e l y worse i n t h e 2 months p r i o r t o her MI. I'd f e e l r e a l l y r o t t e n one day o r I might get up i n t h e morning and have r o t t e n chest p a i n s . . . b u t they'd go...maybe l a s t f o r an hour o r I'd l a y around and take i t easy and they'd go away. So I would f o r g e t about them...push them out of my head k i n d of d e a l and...I j u s t d i d n ' t want t o t h i n k t h a t I guess...that I was heading f o r a heart a t t a c k so I d i d n ' t bother...oh I'm f i n e . . . i n d i g e s t i o n you know...cause i t is a l o t like indigestion. An important aspect of t h e experience of i l l n e s s awareness was  d e s c r i b e d by f i v e of t h e women as an i n t u i t i v e sense  that  they knew t h e i r symptoms were r e l a t e d t o MI. A l l of these women  85  responded  f a i r l y q u i c k l y t o t h e i r symptoms i n terms of help  seeking b e h a v i o r s . L y d i a and Brynn had been nurses and were f a m i l i a r with the i n d i c a t o r s of MI.  They q u i c k l y a p p r a i s e d t h e i r symptoms and  s y s t e m a t i c a l l y sought  h e l p . Brynn d e s c r i b e d f e e l i n g  f r i g h t e n e d " as her chest p a i n i n t e n s i f i e d ,  "very  "I thought  i t had t o  be heart because I have a number of f a m i l y members t h a t had heart a t t a c k s and  I know a f a i r b i t about the s i g n s and  symptoms...being a nurse." Roslynn and Anne, both with a h i s t o r y of p r e v i o u s i n t u i t i v e l y f e l t t h e i r symptoms were r e l a t e d t o MI.  MI,  Before  d e s c r i b i n g t h e i r c u r r e n t experience of i l l n e s s awareness, both p r o v i d e d a lengthy account of t h e i r heart h i s t o r y b e g i n n i n g w i t h t h e i r f i r s t Mis. An enormous amount of d e t a i l was  evident i n  these accounts d e s p i t e the f a c t t h a t t h e i r f i r s t c a r d i a c events had o c c u r r e d 6 and almost 23 years ago,  respectively.  Likely,  these s t o r i e s had been t o l d t o v a r i o u s h e a l t h care p r o v i d e r s over the years, and served t o p r o v i d e a s t a r t i n g p o i n t and context f o r t h e i r c u r r e n t MI. S e v e r a l days b e f o r e Anne's MI,  she r e c a l l e d n o t i c i n g a s h i f t  i n her mood, "funny...2 or 3 days b e f o r e I was and  I remember t h i n k i n g t o myself...oh  to have another heart attack...I'm  s o r t of  crabby...  god...I hope I'm  not going  g e t t i n g r e a l l y b i t c h y . " Anne  d i d have an a t t a c k , s e v e r a l days l a t e r , a f t e r a strenuous morning working i n the garden. A f t e r b e i n g t r a n s p o r t e d t o the  hospital,  she assured the emergency d o c t o r t h a t her symptoms were not indigestion. Roslynn d e s c r i b e d e x p e r i e n c i n g a few m i l d episodes of  angina  86 over the course of the n i g h t , "here comes another angina a t t a c k and i t s t a r t s hurting...and I thought  t h i s i s not angina... t h i s  i s heart a t t a c k . " Both Anne and Roslynn responded symptoms i n what appeared  t o be a s e r i e s  to their  of " c a l c u l a t e d s t e p s " i n  p r e p a r a t i o n t o b e i n g t r a n s p o r t e d t o the h o s p i t a l . Gina had an e x t e n s i v e f a m i l y h i s t o r y  of heart d i s e a s e and  r e p o r t e d not f e e l i n g s u r p r i s e d t h a t she had an a t t a c k . I knew what was going on...and I wasn't p a r t i c u l a r l y alarmed ...because I was w a i t i n g f o r i t b a s i c a l l y . . . I knew t h a t I d i d n ' t p a r t i c u l a r l y have stomach problems and g i v e n the h i s t o r y i n our f a m i l y , I knew i t was j u s t a matter of time b e f o r e I had a heart a t t a c k of my own. Although t h e experience of i l l n e s s awareness marks t h e b e g i n n i n g of women's accounts  of t h e MI experience, t h e process  of a p p r a i s i n g and making sense of t h e s e v e r i t y of b o d i l y s i g n s and symptoms continues throughout  the course of h o s p i t a l i z a t i o n .  The Experience of F e e l i n g E m o t i o n a l l y Overwhelmed The  second major theme emerging from t h e r e s e a r c h was t h e  experience of f e e l i n g e m o t i o n a l l y overwhelmed. In t h i s  context,  the sense of f e e l i n g overwhelmed denotes an i n t e n s e emotional r e a c t i o n t o some p a r t of t h e MI experience. Women used words l i k e "shock," "horrendous,"  "powerless,"  f o r " t o d e s c r i b e the i n t e n s i t y  "embarrassing,"  and "cared  of t h e i r r e a c t i o n s t o v a r i o u s  aspects of MI symptomology, d i a g n o s i s , and the h o s p i t a l i z a t i o n and treatment  p r o c e s s . F o r some of t h e women, f e e l i n g overwhelmed  at t h e i n t e n s i t y of t h e i r emotional r e a c t i o n s was more distressing  than f o r other women who were a b l e t o manage t h e  experience. All  c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g e m o t i o n a l l y overwhelmed  at some p o i n t p r i o r t o o r d u r i n g t h e i r  hospitalization  87  experience. For s e v e r a l women, f e e l i n g s of shock and  disbelief  comprised  t h e i r r e a c t i o n s t o the d i a g n o s i s of MI.  thinking,  "I j u s t can't b e l i e v e i t . . . I can't b e l i e v e i t ' s a heart  a t t a c k . . . I j u s t never thought  Penny r e c a l l e d  t h a t I would be the one t o have a  heart a t t a c k . " D e s p i t e her e x p e r t i s e as a nurse, Brynn d e s c r i b e d f e e l i n g overwhelmed at the i d e a of having a MI, b e l i e v e t h a t i t was of  "I j u s t c o u l d n ' t  happening t o me...you know...there i s a s o r t  d i s b e l i e f t h e r e . . . l i k e t h a t g r i e f thing...no not me...and t h i s  l i t t l e v o i c e says...yes  i t i s you."  Four of the c o - r e s e a r c h e r s d e s c r i b e d t h e i r experience i n the emergency department as b e i n g overwhelming. Although  Brynn  i n i t i a l l y f e l t t h a t because she had a r r i v e d i n emergency she " i n good hands" her sense of assurance  was  changed as the s t a f f began  treatment. The t h i n g t h a t I remember the most i s d i f f e r e n t l e v e l s of p r o f e s s i o n a l s a s k i n g q u e s t i o n s . . . and they a l l had t o come and do t h e i r own assessment...when d i d the p a i n s t a r t , how o l d are you, have your ever had t h i s b e f o r e . . . i t was very a g g r a v a t i n g . . . I j u s t f e l t l i k e l a s h i n g out a t them...I was f r i g h t e n e d and i t was making me angry... and I u s u a l l y don't get f r i g h t e n e d or angry f o r a n y t h i n g . Kiko r e c a l l e d having t o be p h y s i c a l l y r e s t r a i n e d by the emergency room s t a f f ,  "I guess they've been g i v i n g me  e v e r y t h i n g and  needles  and  I t h i n k t h a t something must have c l i c k e d or  something...I j u s t got so bad t h a t they had t o h o l d me down." S e v e r a l c o - r e s e a r c h e r s d e s c r i b e d the experience of exposed and v u l n e r a b l e while i n the CCU.  feeling  Anne and H i l d a d i s c u s s e d  t h e i r sense of f e e l i n g overwhelmed s p e c i f i c a l l y i n terms of the "embarrassment" they experienced while i n the  CCU.  So f i n a l l y I get u p s t a i r s and back i n t o i n t e n s i v e care w i t h a l l these men around me and I found t h a t very embarrassing ...I found t h a t r e a l l y embarrassing...because they were  88 r e a l l y c o n s t a n t l y on you t o have a bowel movement and the c u r t a i n stopped there...and i t was h o r r i b l e . . . I j u s t hated it. When you are l a y i n g i n bed and you're s i c k and you've got both arms i n these t h i n g s and you got t h i n g s stuck down i n t o your neck i n t o your chest r i g h t i n t o your heart...you can't t u r n over i n bed...you've got a c a t h e t e r in...you have a b s o l u t e l y no c o n t r o l over your bowels..you do but i t ' s so embarrassing t o have somebody e l s e do what you take f o r granted every day...to have a shower, t o be a b l e t o go t o the bathroom i n p r i v a c y . . . cause e v e r y t h i n g i s taken r i g h t away from you...and then you're sore and you h u r t . r . a c h i n g and p a i n i n g and you're j u s t l a y i n g there...you j u s t want t o jump out a window...I mean thank god i t doesn't l a s t . . . i t passes . . . i t ' s awful you know. Other c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g overwhelmed a f t e r r e c e i v i n g t e s t r e s u l t s from t h e i r d o c t o r s . Although Gina was s u r p r i s e d by her d i a g n o s i s of MI,  not  she d e s c r i b e d r e a c t i n g  a d v e r s e l y t o b e i n g t o l d the r e s u l t s of her angiogram, " t h a t ' s another whole s t o r y , then.I was because  r e a l l y alarmed t h a t i t was  so bad  I had seven blockages... and t h a t r e a l l y s u r p r i s e d me  know t h a t i t was  so bad."  you  S e v e r a l days b e f o r e Anne's angiogram,  the c a r d i o l o g i s t had roughly sketched her a p i c t u r e of her h e a r t , o u t l i n i n g what he thought c o u l d be wrong. Although Anne was r e a s s u r e d t h a t her c o n d i t i o n d i d not r e f l e c t the worst s c e n a r i o , her t e s t s r e s u l t s proved otherwise. I remember i t was Sunday when they came t o t a l k t o me about the angiogram...at t h a t p o i n t I was t o l d t h a t I was i n o p e r a b l e . . . t h e r e was r e a l l y n o t h i n g they c o u l d do...I would have t o go* on drugs and they wanted me on an experimental drug...I t h i n k the f e e l i n g was t o t a l d i s b e l i e f . . . I never s a i d a word...and n e i t h e r d i d my husband...you don't t h i n k of i n t e l l i g e n t q u e s t i o n s because you j u s t don't t h i n k . S e v e r a l women d e s c r i b e d f e e l i n g overwhelmed i n response t o other aspects of the treatment process i n c l u d i n g r e a c t i n g a d v e r s e l y t o medication, and m i s i n f o r m a t i o n r e l a t e d t o medical procedures. Noreen's experience of r e c o v e r i n g from MI and  bypass  89  surgery seemed m i l d i n comparison t o t h e severe e f f e c t s of t h e drug r e a c t i o n she endured f o r almost her e n t i r e  hospitalization.  I got so d i s o r i e n t e d . . . t h a t was the h o r r i b l e p a r t of i t . . . t h e h a l l u c i n a t i o n s and a l l t h e r e s t of i t . . . I wasn't who I thought I was and other people weren't...they would change l i k e r i g h t t h e r e i n t h a t c h a i r t a l k i n g t o you...and you'd change i n t o somebody e l s e . . . i t was s c a r y . . . h o r r i f y i n g . . . y o u t h i n k you're l o s i n g your mind o r I d i d . . . I thought I was r i g h t out of i t . . . t h e y had t o t i e me t o t h e bed one n i g h t t o keep me i n t h e r e . Penny had remained calm throughout her h o s p i t a l i z a t i o n u n t i l she was t o l d t h a t she r e q u i r e d a temporary pacemaker implant. Initially,  she r e a c t e d s t r o n g l y t o her p r e c o n c e i v e d n o t i o n s and  l a c k of i n f o r m a t i o n about t h e procedure. That was t h e f i r s t time t h a t I r e a l l y got w o r r i e d t h a t i t was r e a l l y s e r i o u s even though I knew t h a t I had a h e a r t a t t a c k . I f e l t I was ok...that I wasn't i n any danger...but when I heard about d o i n g a pacemaker and then they s a i d something about my h e a r t b l o c k i n g and I d i d n ' t know what they meant ...and then they t o l d me what they do and took me down and i t was j u s t so simple t o do...but I d i d n ' t know...I had major surgery i n my mind and then a 15 minute procedure was done and t h a t was i t . . . w h a t a r e l i e f . Although c o - r e s e a r c h e r s mostly d e s c r i b e d f e e l i n g overwhelmed to s i t u a t i o n s or experiences of a d v e r s i t y , two c o - r e s e a r c h e r s expressed f e e l i n g overwhelmed i n response t o t h e experience of r e c e i v i n g e x t e n s i v e care from o t h e r s . L y d i a who expressed having " l i t t l e apprehension or f e a r " surrounding t h e a c t u a l MI o r her experience of h o s p i t a l i z a t i o n , d e s c r i b e d her sense of f e e l i n g overwhelmed by the e x t e n s i v e care she r e c e i v e d from her f r i e n d s and  family. You don't r e a l i z e u n t i l a time l i k e t h i s how many and how dear t h e f r i e n d s you have a r e . . . I have been a b s o l u t e l y overwhelmed by the concern and t h e e v e r y t h i n g . . . t h e cards ...and the c a l l s . . . y o u don't q u i t e r e a l i z e t i l l a time l i k e t h i s how much your f r i e n d s mean t o you.  Penny d e s c r i b e d how deeply moved she was by t h e care she had  90  r e c e i v e d from, the nurses w h i l e i n the  CCU.  [while sobbing] I was j u s t t h i n k i n g about a l l the nurses . . . j u s t t a k i n g the t i m e . . . l i k e t o t a l k t o e x p l a i n what they were doing...everyone of them was j u s t so good...even when you d i d n ' t r i n g the b e l l or want a n y t h i n g they would s t i l l be i n t h e r e s a y i n g are you ok...do you need anything...always making sure t h a t you were comfortable as you c o u l d be under the circumstances ... and i t made a b i g d i f f e r e n c e . . . i t was r e a l l y nice. The Experience of Fear and Worry The emotional responses of f e a r or worry were common amongst most of the c o - r e s e a r c h e r s as they spoke about d i f f e r e n t  aspects  of t h e i r MI experience. Although a few of the women d e s c r i b e d sometimes f e e l i n g other adverse emotions i n c l u d i n g  powerlessness,  h e l p l e s s n e s s , or f r u s t r a t i o n , f e a r and worry were the p r i n c i p a l emotions r e p o r t e d . Lazarus  (1994) makes the d i s t i n c t i o n between f e a r and worry  i n the f o l l o w i n g manner. Fear suggests an acute high i n t e n s i t y but b r i e f s t a t e of alarm i n response t o sudden danger or i n j u r y , and disappears when danger has passed.  In c o n t r a s t , worry i s  synonymous w i t h a n x i e t y and r e f e r s t o a low or moderate s t a t e of d i s t r e s s i n response t o more vague or u n c e r t a i n t h r e a t s .  Co-  r e s e a r c h e r s accounts suggested the experience of worry emerged i n the form of a present and more f u t u r e f o c u s . For example, w h i l e some women f e l t anxious about r e c e i v i n g t e s t r e s u l t s , other women w o r r i e d about what t h e i r l i v e s would look l i k e when they r e t u r n e d home from the h o s p i t a l . Co-researchers experienced f e a r and worry i n response  to  v a r i o u s i n c i d e n t s or a n t i c i p a t e d circumstances r e l a t e d t o the MI experience. Moreover, i t i s evident t h a t the theme f e a r and worry overlapped with other major themes i n c l u d i n g l o s s and  the  91 experience of needing i n f o r m a t i o n .  More s p e c i f i c a l l y ,  i t was  o f t e n the a n t i c i p a t e d l o s s of p h y s i c a l or emotional i n t e g r i t y , o r the  l a c k of i n f o r m a t i o n  r e l a t e d t o one's a c t u a l o r a n t i c i p a t e d  experience of i l l n e s s , h o s p i t a l i z a t i o n , or treatment t h a t r e s u l t e d i n t h e experience of f e a r and worry. S e v e r a l women t a l k e d about t h e i r f e a r of l o s i n g consciousness or p h y s i c a l c o n t r o l as p a r t of t h e i r i l l n e s s Roslynn suggested t h a t  symptomology.  "the p a i n d i d n ' t scare me and I don't  t h i n k a t any stage i t scared me...what scared me t h e most was l o s i n g consciousness... l o s i n g c o n t r o l . . . a s conscious I knew I c o u l d do something about Penny d e s c r i b e d  long as I was it."  f e e l i n g a f r a i d of f a l l i n g a s l e e p  f o r the  f i r s t few days w h i l e i n the CCU. I don't know whether I thought I might d i e i n my s l e e p o r I might have an a t t a c k i n my s l e e p or p a i n w h i l e I was s l e e p i n g and not know i t . . . b u t I knew when I was a s l e e p I wouldn't have any c o n t r o l over what happened I guess...during t h e day I f e l t t h a t i f I had any p a i n I c o u l d l e t them know...whereas when I was s l e e p i n g I might n o t . . . i t might s o r t of creep up on me...I might not wake up u n t i l i t was r e a l l y bad o r I don't know...so I t h i n k I would t h i n k about t h a t f o r a b i t before I went t o s l e e p . . . a f t e r t h e f i r s t l i t t l e b i t nothing ever happened so I d i d n ' t worry. Anne d e s c r i b e d being more f e a r f u l of f a i n t i n g i n t h e h o s p i t a l h a l l on her way t o the x-ray department than of having another MI. I was sent downstairs f o r x-rays by myself...I hated i t . . . f o r one t h i n g I got l o s t . . . a n d f o r another t h i n g I was so weak I d i d n ' t want t o f a i n t i n t h e h a l l way and everybody look a t [me]...and you s o r t of panic a l i t t l e b i t . . . i t wasn't t h a t I was a f r a i d t h a t I was having a heart a t t a c k . . . I d i d n ' t know where I was going...and I was j u s t s o r t of hanging on t o t h e wall. Other co-researchers  t a l k e d about f e e l i n g anxious about  undergoing treatment procedures. For example, Gina d e s c r i b e d her  92  b i g g e s t f e a r about having bypass surgery was  r e l a t e d to being i n  the recovery room and r e - g a i n i n g consciousness. The b i g g e s t p a r t of the o p e r a t i o n t h a t I'm a f r a i d of i s the p a r t where you are i n the recovery room and you got the damn p i p e down your t h r o a t . . . a n d the l a c k of c o n t r o l down t h e r e and b e i n g d i z z y . . . I hate the d i z z y f e e l i n g . . . I hate the thought of having the p i p e down my t h r o a t and the f e e l i n g of h e l p l e s s n e s s i s d r i v i n g me crazy...and the f a c t t h a t I can't move...that r e a l l y t u r n s me o f f . Anne f e l t w o r r i e d about undergoing  the upcoming angiogram, as  w e l l as r e c e i v i n g the i n f o r m a t i o n from her t e s t  results.  So now I have t o wait u n t i l F r i d a y and have t h i s angiogram a g a i n . . . t h a t I'm dreading...I don't l i k e the angiogram because I don't like.when they shoot the dye i n y o u . . . i t ' s a h o r r i b l e f e e l i n g but i t ' s the r e s u l t s we're more w o r r i e d about. A few c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g more  uncomfortable  with aspects of the h o s p i t a l i z a t i o n process t h a t t h r e a t e n e d  their  sense of p e r s o n a l i n t e g r i t y and d i g n i t y . H i l d a f e l t more f e a r f u l of  b e i n g put i n a p o s i t i o n a g a i n s t her w i l l than from the p a i n  a s s o c i a t e d with  treatment.  I would j u s t be a f r a i d whenever they came i n what they were going t o do t o me or...not t h a t I was a f r a i d of the p a i n or the needle or nothing l i k e t h a t . . . t h a t wasn't bad...the t h i n g s t h a t you go through...you know...the p o s i t i o n t h a t you're put i n a g a i n s t your w i l l t h a t you've got no c o n t r o l over...I mean I'm not a c o n t r o l f r e a k or n o t h i n g l i k e t h a t . . . j u s t an average person. Other c o - r e s e a r c h e r s t a l k e d about f e e l i n g w o r r i e d about the e f f e c t t h a t t h e i r i l l n e s s had on t h e i r f u t u r e s . Although r e p o r t e d not f e e l i n g traumatized by her MI, was  going t o e f f e c t the r e s t of her l i f e ,  Penny  she wondered how i t  "then you  s t a r t to  t h i n k what's going t o happen a f t e r this...what e f f e c t i t i s going to  have on your l i f e  and those kinds of t h i n g s . . . I was  just  w o r r i e d you know." Kaye f e l t w o r r i e d about her a b i l i t y t o o r g a n i z e her b u s i n e s s  93  a f f a i r s now  t h a t she was  ill.  For the past couple of y e a r s ,  she  had been l o o k i n g f o r more a p p r o p r i a t e housing. Her words suggested  t h a t she f e l t more concerned  about s e c u r i n g a new  home  than about r e g a i n i n g her h e a l t h . I've got to get r i d of my house, but I've got to get enough out of i t so t h a t I can f i n d me a s e n i o r c i t i z e n ' s s u i t e somewhere where I ' l l have a roof over my head...this i s a l l p r e s s u r e . . . t h i s c r e a t e s p r e s s u r e , s t r e s s , and worry...and t h a t ' s what's on my shoulders r i g h t now...it's a l o t . . . t h a t ' s the f i r s t t h i n g t h a t h i t me r i g h t between the eyes...the worry of everything...what's going t o happen now. Other c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g w o r r i e d about t h e i r s i g n i f i c a n t o t h e r s , and the impact  t h a t t h e i r i l l n e s s had  them. Three of the f i v e c o - r e s e a r c h e r s who f e e l i n g more concerned response  needed  spouses,  described  about t h e i r husbands than themselves i n  t o t h e i r i l l n e s s . Penny was  husband was  had  on  w o r r i e d about how  her  coping with her i l l n e s s and r e c o g n i z e d t h a t he a l s o  support.  I t was s c a r y . . . I was w o r r i e d about him...I f e l t t h a t I was i n e x c e l l e n t hands and I wasn't w o r r i e d about me...I was j u s t w o r r i e d about him...I know he had f a m i l y and f r i e n d s and e v e r y t h i n g to t a l k t o but he j u s t wanted t o s i t i n the room and s t a r e at me f o r t h r e e days...I wish t h a t maybe t h e r e c o u l d have- been somebody t o help him...that's so unusual because u s u a l l y i t ' s the woman...I s o r t of f e l t s o r r y f o r him t h a t he d i d n ' t know how t o handle i t or what he should be doing. Penny a l s o d e s c r i b e d f e e l i n g concerned  about how  going to manage once she r e t u r n e d home from the  her husband  was  hospital.  I'm w o r r i e d t h a t he's going to be t r y i n g t o do e v e r y t h i n g and he's got t o work...so i t ' s him I t h i n k I ' l l worry about more than me...and t o t r y and get him not to t r e a t me l i k e I ' l l f a l l apart...I'm w o r r i e d t h a t he's w o r r i e d about me so much t h a t i t ' s going t o a f f e c t him and h i s work and s t u f f l i k e that. S e v e r a l women mentioned f e e l i n g a f r a i d t h a t f a m i l y members were not allowed to be present w h i l e they r e c e i v e d medical  94 treatment. to  Kiko f e l t  scared when the h o s p i t a l s t a f f asked her son  leave t h e emergency treatment  area.  ...they were a l l h o l d i n g me down and t h a t ' s when they n o t i c e d my son came i n . . . t h e y pushed him r i g h t out and t h a t r e a l l y made me more s c a r e d . . . t o see what they were d o i n g . . . f e a r on the one hand...and y e t I f e l t I had my o l d e s t son here and then two days b e f o r e I s a i d t o my youngest s o n . . . . i f I go I f e e l t h a t a t l e a s t I see him. Brynn r e c a l l e d f e e l i n g more concerned  f o r her spouse a f t e r  a r r i v i n g a t the emergency department. I remember them keeping my husband out of t h e s e c t i o n and he was a v e r y b i g concern of mine because he was a t t e n d i n g t o h i s own f a t h e r ' s bedside when h i s f a t h e r d i e d of a coronary ...so t h i s the second time t h a t someone c l o s e l y dear t o him...you know when you're t h a t c l o s e t o someone. One  c o - r e s e a r c h e r r e p o r t e d f e e l i n g scared f o r her c h i l d r e n  a f t e r b e i n g t o l d t h a t she had s u f f e r e d a massive heart a t t a c k . ...I f e l t scared f o r my k i d s . . . t h a t I'd never see my k i d s a g a i n . . . t h e y ' r e about a l l I have anyways...my k i d s a r e my whole b e i n g l i k e you know...well I don't have a n y t h i n g e l s e to r e a l l y worry t o o much about...but sure I thought a l o t about them the l a s t few days w h i l e a l l t h i s was happening. The Experience of Loss A l l of the c o - r e s e a r c h e r s v i v i d l y d e s c r i b e d experiences of l o s s r e l a t i n g t o some aspect of t h e i r MI experience. Loss i n t h i s context suggests a diminishment  of o r e x i s t e n c e without  something  t h a t has p e r s o n a l meaning a t t a c h e d t o i t . Loss d i r e c t l y  relates  to  which  t h e u n p r e d i c t a b l e nature of the MI experience i t s e l f  i n h e r e n t l y suggests the t r a n s i t i o n from a p l a c e of w e l l n e s s t o a p l a c e of i l l n e s s , o r p o t e n t i a l l y Co-researcher accounts  death.  suggested t h a t women experienced  d i f f e r e n t kinds of l o s s a t v a r i o u s times d u r i n g t h e MI experience. F o r some of the women l o s s was experienced as b e i n g more dramatic and d i s t r e s s f u l than f o r o t h e r s .  95 Many c o - r e s e a r c h e r s d e s c r i b e d t h e i r experience of l o s s i n terms of an impairment t o t h e i r p h y s i c a l i n t e g r i t y . They d e s c r i b e d f e e l i n g s of extreme f a t i g u e , l o s s of s t r e n g t h , and l o s s of  m o b i l i t y as a r e s u l t of MI symptomology o r treatment. Anne  r e c a l l e d t h e day when her d o c t o r d i s c u s s e d her d i a g n o s i s of MI. ...by then I was so i n c r e d i b l y t i r e d . . . I mean I cannot d e s c r i b e how i n c r e d i b l y t i r e d you a r e . . . t h a t I t h i n k I was past r e a c t i n g t o anything...I wasn't a s l e e p but I was t o o t i r e d t o t a l k . . . d o e s t h a t make sense...even my hands were tired. Kaye had asked her son t o c o n t a c t her p h y s i c i a n because she was p h y s i c a l l y unable t o make t h e phone c a l l . ...I'd s i t i n the c h a i r f o r a few minutes a t t h e phone and then I'd have t o stand up and then I c o u l d n ' t stand any longer so I'd s i t down...it was a most embarrassing moment and i t made me very angry...I'm used t o f i n i s h i n g what I s t a r t t o do and I c o u l d n ' t f i n i s h my c o n v e r s a t i o n . Although Penny understood  t h a t her husband f e l t much s a f e r when  she was b e i n g c l o s e l y monitored, at  she d e s c r i b e d f e e l i n g  frustrated  having l o s t her m o b i l i t y . ...he f e l t a l o t s a f e r when I was hooked up t o e v e r y t h i n g but of course he had no i d e a how awkward and f r u s t r a t i n g . . . t r y i n g to s l e e p a t n i g h t and t h i n g s a l l over your arms and w i r e s . . . l i k e they d i d n ' t l e t me walk...they d i d n ' t have me w a l k i n g around. A number of c o - r e s e a r c h e r s r e p o r t e d some memory l o s s d u r i n g  t h e i r MI experience. Memory l o s s was o f t e n a s s o c i a t e d w i t h c a r d i a c a r r e s t or l o s s of consciousness, a r e a c t i o n t o medication, or t o f e e l i n g overwhelmed with the events l e a d i n g t o h o s p i t a l i z a t i o n . Penny t r i e d t o r e c a l l t h e sequence of t e s t s and procedures  t h a t o c c u r r e d p r i o r t o b e i n g admitted t o t h e CCU.  I t h i n k i t seemed t h a t i t was an hour a t t h e most t h a t I was t h e r e and then they took me up t o CCU...I t h i n k they took me f o r an x-ray t o o . . . I c o u l d n ' t remember... should have w r i t t e n ...I keep s a y i n g t h a t . . . e v e r s i n c e i t ' s happened I should of wrote e v e r y t h i n g down l i k e what happened because I s o r t of  96  forgotten...so  I don't r e a l l y know what happened.  Anne and Roslynn d e s c r i b e d  the prolonged memory l o s s t h a t  they had i n c u r r e d as a r e s u l t of previous  Mis.  Both women's  accounts suggested t h a t they a n t i c i p a t e d t h i s t o be an i n e v i t a b l e p a r t of t h e MI experience. As a u n i v e r s i t y p r o f e s s o r a t t h e time of her f i r s t a t t a c k , Roslynn f e l t  enormously d i s t r e s s e d by her  experience of memory l o s s . ...I knew the depression was coming and t h e i n t e n s i t y of which depends on t h e i n t e n s i t y of the heart a t t a c k and t h e p a r t of the mind t h a t i s a f f e c t e d . . . a n d t h e p a r t of t h e mind t h a t i s a f f e c t e d i s u s u a l l y the memory l o s t and t h a t i s t h e most f r u s t r a t i n g t h i n g t h a t c o u l d ever happen... e s p e c i a l l y t o a teacher and t h a t f o r me was the most scary p a r t of i t a l l because you know your m a t e r i a l . . . you know how t o teach..you know the k i d s but t h e r e ' s always t h a t q u e s t i o n t h a t you f e a r t h a t you have f o r g o t t e n the answer and I'd r a t h e r f e a r a heart a t t a c k than f e a r i n g the questions t h a t I can't answer because I f o r g o t t h e answer...and i t ' s not r e a l l y f e a r . . . r e a l l y i t ' s f r u s t r a t i o n . . . a n d t h a t happens and i t i s i n e v i t a b l e i t w i l l happen a g a i n . . . i t i s very embarrassing . . . f o r me i t was about 6 months before I recovered some of the memory. In a d d i t i o n t o t h e p h y s i c a l l o s s t h a t women r e p o r t e d , co-researcher  accounts r e v e a l e d  to the l o s s of p e r s o n a l women d e s c r i b e d  other  experiences more c l o s e l y r e l a t e d  and emotional i n t e g r i t y . F o r example,  experiences of l o s s of p r i v a c y , d i g n i t y , and  independence i n response.to t h e process of h o s p i t a l i z a t i o n and the i n t r u s i o n s made by teams of h e a l t h care p r o f e s s i o n a l s . L y d i a described  the l a c k of p r i v a c y t h a t she experienced as a r e s u l t of  the constant CCU.  a t t e n t i o n and m o n i t o r i n g t h a t o c c u r r e d  while i n the  Once on the c a r d i a c ward, L y d i a requested t h a t she be  t r a n s f e r r e d i n t o a p r i v a t e room. I n i t i a l l y when you come f o r t h e f i r s t 2 o r 3 days t h e r e ' s such constant m o n i t o r i n g t h a t you don't have much time t o accept things...you're being c o n s t a n t l y monitored...you keep w i s h i n g maybe they'd go away so you c o u l d sleep...you know a l l n i g h t and a l l day...over and over...which I can c e r t a i n l y  97  understand and I'm time t o y o u r s e l f .  g r a t e f u l f o r . . . b u t doesn't g i v e you much  H i l d a ' s b r i e f memory of her experience of c a r d i a c  arrest  r e v o l v e d around the f e e l i n g s a s s o c i a t e d w i t h a l o s s of d i g n i t y . I j u s t turned grey and l i g h t headed and completely m i s s i n g r i g h t out of my l i f e . . . t h a t ' s the l a s t t h i n g I remember ...they were c a l l i n g my name and shaking me...and then...the worst p a r t came...it's not j u s t the p a i n . . . i t ' s l o s i n g the d i g n i t y , l o s i n g your independence, l o s i n g y o u r . . . l i k e I've been the type of woman t h a t . . . I have 9 c h i l d r e n . . . a n d I've always had c o n t r o l of e v e r y t h i n g . S e v e r a l women r e p o r t e d having a g r e a t e r sense of p r i v a c y and independence once they were t r a n s f e r r e d from the CCU t o the c a r d i a c ward. Although H i l d a t a l k e d about the adjustment of having t o be more independent on the c a r d i a c ward, she a p p r e c i a t e d r e g a i n i n g her sense of p r i v a c y . ... I can have my p r i v a c y here which I l o s t when I was i n the other ward...that bothered me so much...you know embarrassing when t h i n g s t h a t had t o be done f o r you...you never had t o have done b e f o r e . . . here I don't have t o do t h a t . . . a n d a t the same time i f I need something I l e t them know...but not a l l the time c a l l i n g . . . b u t i t ' s l i k e i f I want t o get out and brush my t e e t h i n the middle of the a f t e r n o o n I can do i t . . . i t ' s p r e p a r i n g myself I guess f o r when I go home so I can do what I do normally a t home. Other c o - r e s e a r c h e r s t a l k e d about l o s s i n terms of no l o n g e r b e i n g a b l e t o take t h i n g s f o r granted. Anne t a l k e d about  feeling  angry t h a t she w i l l have t o g i v e up important t h i n g s i n her  life  as a r e s u l t of. having another MI. ...and t h e r e were other times when I was r e a l l y f u r i o u s ...things l i k e what I used t o take f o r granted and I cannot take f o r granted any more...to know t h a t I have t o g i v e up some t h i n g s t h a t I don't want t o g i v e up l i k e dancing because i t bothers me when I do i t . . . H i l d a t a l k e d about the l o s s of b e i n g a b l e t o take t h i n g s f o r granted i n more s i m p l i s t i c terms such as j u s t c a r r y i n g out o r d i n a r y p e r s o n a l hygiene w h i l e i n the h o s p i t a l .  98 ...but i t ' s the wee l i t t l e t h i n g s u n t i l they a r e taken away t h a t you don't r e a l i z e t h a t you miss... l i k e t r y i n g t o brush your t e e t h . . . s t a n d i n g i n a shower...or j u s t going t o t h e bathroom t h a t you take f o r granted everyday...you're t r y i n g to cooperate with t h e nurses and do e v e r y t h i n g you a r e supposed t o do...I mean most people do...but t h e r e a r e s t i l l the l i t t l e wee t h i n g s t h a t a l l o f the sudden become so important... t h a t i t upsets you f o r some reason o r another ...you go t h r e e weeks and your h a i r i s not washed...and they're t r y i n g t o save your l i f e and a l l you're t h i n k i n g about i s g e t t i n g your h a i r washed and g e t t i n g your body powdered but i f you a r e used t o having e v e r y t h i n g washed and cleaned and when i t doesn't happen...it's a change from your regular...with.me i t ' s t h e simple t h i n g s t h a t you took f o r granted t h a t have become extremely important t o me. Having D i f f i c u l t y A s k i n g f o r o r R e c e i v i n g Help From Others Most o f t h e c o - r e s e a r c h e r accounts d e s c r i b e d experiences o f e i t h e r having d i f f i c u l t y with a s k i n g f o r h e l p o r r e c e i v i n g h e l p from o t h e r s . A l l t h e c o - r e s e a r c h e r s p o r t r a y e d themselves s t r o n g l y independent  as b e i n g  and s e l f s u f f i c i e n t women and t o be i n a  p o s i t i o n o f dependence o r the focus of a t t e n t i o n was l a r g e l y u n f a m i l i a r and uncomfortable. Women's accounts suggested t h a t they had v a r y i n g l e v e l s o f uncomfortableness  i n response t o  e i t h e r a s k i n g f o r o r r e c e i v i n g h e l p from o t h e r s . D i f f i c u l t y a s k i n g f o r h e l p i s d e f i n e d as f e e l i n g uncomfortable with approaching e i t h e r care o r support p r o v i d e r s f o r a s s i s t a n c e o r i n f o r m a t i o n w h i l e h o s p i t a l i z e d . In c o n t r a s t , d i f f i c u l t y  receiving  help r e l a t e s t o f e e l i n g uncomfortable with r e c e i v i n g a t t e n t i o n o r a s s i s t a n c e from e i t h e r care o r support p r o v i d e r s w h i l e hospitalized. A few c o - r e s e a r c h e r s ' accounts suggested t h a t they had d i f f i c u l t y outwardly a s k i n g f o r h e l p from f a m i l y members. Although Kiko f e l t p h y s i c a l l y unable t o telephone f o r h e l p when she became symptomatic, she d i d not appear t o understand her f a m i l y ' s concern t h a t she had not t r i e d t o c o n t a c t them.  99  They a l l t o l d me why d i d n ' t you call...why d i d n ' t you c a l l me...but I mean even i f I d i d get t o the phone and c a l l my s i s t e r - i n - l a w . . . w h a t can they do cause they can't get i n the house...they can't do i t . . . I know with my s i s t e r I got her key cause i f a n y t h i n g happens I've got t o get i n the house. S e v e r a l of the women r e p o r t e d having d i f f i c u l t y i n terms of a s k i n g h e a l t h care p r o v i d e r s f o r e i t h e r i n f o r m a t i o n or a s s i s t a n c e at some p o i n t d u r i n g t h e i r MI  experience.  For example, a few c o - r e s e a r c h e r s mentioned having  difficulty  viewing t h e i r symptoms as b e i n g s e r i o u s enough t o r e q u i r e a s s i s t a n c e . Although H i l d a f e l t her i l l n e s s symptoms were not s e r i o u s enough t o seek medical a t t e n t i o n , her husband concerned  and drove her t o the  was  hospital.  I thought i t ' s probably i n d i g e s t i o n or something...it w i l l pass...and always f e l t embarrassed or f o o l i s h t o go t o the h o s p i t a l cause I thought w e l l maybe I'm going i n t h e r e and i t ' s n o t h i n g s e r i o u s . . . I'm j u s t going i n t h e r e and they have enough people t h a t are s i c k enough t h a t they don't need me i n t h e r e . . . I d i d n ' t t h i n k my c o n d i t i o n was s e r i o u s enough. Other c o - r e s e a r c h e r s t a l k e d about haying d i f f i c u l t y a s k i n g t h e i r d o c t o r s f o r i n f o r m a t i o n r e l a t e d t o t h e i r i l l n e s s . Gina uneasy about d i s c u s s i n g her apprehensions her surgeon.  Her account  felt  of bypass surgery w i t h  a l l u d e s t o the power imbalance  that  f r e q u e n t l y e x i s t s between d o c t o r s and t h e i r p a t i e n t s . Well you know how i t i s when you get those d o c t o r s coming i n your room...you got t h r e e other p a t i e n t s and guests and o t h e r people and c l e a n e r s . . . y o u want t o t a l k p e r s o n a l l i k e t h a t and i t ' s a l i t t l e d i f f i c u l t . . . I shouldn't say they seem t o be i n a rush a l l the time...but' t h e y ' r e p r e o c c u p i e d and they want t o keep moving...I don't know...and then t o a c t u a l l y say t h a t t o them t o t h e i r face...would be somewhat c r i t i c a l . . . Oh God ...do I want t o c r i t i c i z e a guy who i s going t o be h o l d i n g my heart i n h i s hand?...I don't know...normally I'm not l i k e t h a t . . . normally I'm very outspoken most of the time and q u i t e o f t e n I r e g r e t having been so outspoken...I'm f e e l i n g a t t h i s time t h a t I b e t t e r keep my mouth shut and do what I'm t o l d . Co-researchers a l s o d e s c r i b e d f e e l i n g uncomfortable knowing when i t was  with  a p p r o p r i a t e t o ask f o r help from the n u r s i n g  100 s t a f f . S e v e r a l women t a l k e d about f e e l i n g u n c l e a r as t o what they were expected t o do on t h e i r own a f t e r b e i n g t r a n s f e r r e d from t h e CCU t o t h e c a r d i a c ward. H i l d a r e c a l l e d g e t t i n g upset about a p a r t i c u l a r i n c i d e n t b e f o r e she was informed by the nurses t h a t they j u s t assumed she would r i n g i f she needed h e l p . I'm t h e type of person t h a t I don't l i k e t o bother p e o p l e . . . I don't l i k e t o be a burden on anybody and l i k e I s a i d I'm a f a i r l y independent person and I don't want t o be on those t h i n g s r i n g i n g every f i v e minutes... I need t h i s and I need that...you know be a p e s t . . . I don't l i k e t o be t h a t type of person...so t h e r e ' s t h i n g s t h a t I t h i n k . . . w e l l I c o u l d do t h a t myself without b o t h e r i n g them...but l i k e they say i f you need us a l l you have t o do i s c a l l . Women t h a t had d i f f i c u l t y r e c e i v i n g h e l p from others f r e q u e n t l y d e s c r i b e d s i t u a t i o n s where f a m i l y members had made arrangements based on t h e i r i n t e r p r e t a t i o n of the p a t i e n t ' s needs. L y d i a t a l k e d about the arrangements t h a t her s i s t e r s and f r i e n d had made t o come s t a y with her a f t e r she was d i s c h a r g e d from h o s p i t a l . Although she i n i t i a l l y t r i e d t o convince them t h a t she d i d not need t h e i r help, she e v e n t u a l l y acquiesced. I don't t h i n k I need anybody much but they say I shouldn't l i f t or c a r r y g r o c e r i e s o r anything...so I suppose i n my mind i t ' s j u s t as w e l l t h a t someone i s around...to vacuum and a l l that...and I keep s a y i n g t o my f r i e n d s you know you don't need t o come s t a y with me f o r these two days...I'11 be f i n e ...now everyone won't l i s t e n t o me so somebody w i l l be w i t h me. Anne's husband suggested t h a t he get somebody i n t o do t h e i r o n i n g a f t e r she r e t u r n e d home from the h o s p i t a l . Although she was agreeable t o h i s o f f e r , Anne was not prepared t o r e l i n q u i s h a l l of her household r e s p o n s i b i l i t i e s d u r i n g her r e c o v e r y , "I s a i d ya...do t h a t because  I can't s i t down and i r o n f o r whatever  reason...that w i l l be n i c e f o r a while...but not t h e washing and t h a t because with automatic machines I can do a l l t h a t . "  101  Kaye d e s c r i b e d f e e l i n g very uncomfortable with r e c e i v i n g help from others who saw her having d i f f i c u l t y  walking.  Gee I can't walk a b l o c k . . . i f t h e r e ' s l o t s of c a r s out t h e r e parked on the s t r e e t . . . I l e a n up a g a i n s t every t h i r d c a r . . . s o I won't go f o r a walk cause I don't want people s e e i n g me l e a n i n g on a car...because I'm funny t h a t way...I don't want them s t o p p i n g and 'can I h e l p ' when otherwise I'm not i n d i f f i c u l t y except t h a t I can't w a l k . . . i t ' s embarrassing t o have people stop...can I help you...very embarrassing. Hilda discussed f e e l i n g  " g u i l t y " about a t t h e c o l l e c t i v e  e f f o r t s t h a t her c h i l d r e n had made i n terms v i s i t i n g her w h i l e hospitalized. I f e e l g u i l t y about them coming but i f they don't come...I wouldn't t e l l them...but i n my mind I'd f e e l a l i t t l e sad ...I'm t h a t type of person...I hate t o put anybody o u t . . . l i k e the nurses or anybody...I hate t o put anybody out i f i t ' s not r e a l l y necessary.... I'd hate t o be a burden t o anybody... I've always been so independent and I don't know why I would f e e l g u i l t y but you do...you t h i n k i t ' s making i t harder on them. Another  c o - r e s e a r c h e r a n t i c i p a t e d having d i f f i c u l t y with  g i v i n g up her former r o l e of performing c h i l d care and house chores w h i l e l i v i n g with her daughter. Noreen expressed her concern about b e i n g i n a p o s i t i o n of not b e i n g a b l e t o contribute. It w i l l be a l i t t l e d i f f e r e n t because I know [my daughter] i s not going t o want me t o do a n y t h i n g . . . t h a t ' s going t o be t h e b i g g e s t t h i n g r i g h t t h e r e . . . she's going t o q u i t her j o b f o r a w h i l e . . . I t h i n k i t ' s going t o be a r e a l r o l e r e v e r s a l f o r a w h i l e . . . i t ' s going t o take some g e t t i n g used t o . . . t o have t o s i t back and not do anything. The Experience of Needing Information All  of the c o - r e s e a r c h e r s i n t h i s study i d e n t i f i e d  needing  i n f o r m a t i o n as b e i n g c r u c i a l t o t h e i r experience of MI. A c q u i r i n g concrete i n f o r m a t i o n has important i m p l i c a t i o n s i n terms of understanding the nature of MI, and a l l aspects of e t i o l o g y , symptomology, d i a g n o s i s , treatment, and p r o g n o s i s . Morse and  102 Johnston (1991) suggest t h a t a l a c k of understanding  about what  i s o c c u r r i n g t o one's body undermines an i n d i v i d u a l ' s sense of power and c o n t r o l . They suggest t h a t i n order t o r e g a i n a sense of c o n t r o l a f t e r having had a heart a t t a c k , t h e person must be able t o make sense of t h e i r MI. Moreover, a c t i v e l y  seeking  i n f o r m a t i o n from h e a l t h care p r o v i d e r s appears t o r e p r e s e n t a means of e x e r t i n g b e h a v i o r a l c o n t r o l over an otherwise and o f t e n f r i g h t e n i n g experience, sense of t h e i r MI  unfamiliar  as w e l l as e n a b l i n g one t o make  experience.  In t h i s context,  t h e experience  of needing i n f o r m a t i o n  suggests the need t o , o b t a i n concrete and r e l e v a n t knowledge i n order t o f u r t h e r understand the p e r s o n a l r e l e v a n c e experience.  Co-researcher  of t h e MI  accounts suggested t h a t t h e need f o r  i n f o r m a t i o n was t r a n s l a t e d i n t o d i f f e r e n t experiences  f o r the  women. The  experience  of needing i n f o r m a t i o n c l e a r l y o v e r l a p s  with  other emerging themes such as the theme of care and support, and making sense of t h e MI. The q u a l i t y of c o - r e s e a r c h e r s '  perceived  care w i l l , i n p a r t , be r e l a t e d t o how s a t i s f i e d they a r e with t h e c a l i b r e of i n f o r m a t i o n they r e c e i v e d from t h e i r d o c t o r s .  This  i n e v i t a b l y a l l u d e s t o the i s s u e of p h y s i c i a n s a c t i n g as gatekeepers t o c o n t r o l the amount of medical women have access t o . Co-researcher's  information that  experience  of not r e c e i v i n g  s a t i s f a c t o r y i n f o r m a t i o n appeared t o be r e l a t e d t o having  poor  rapport with one's d o c t o r . As w e l l , needing i n f o r m a t i o n o v e r l a p s with the theme making sense, i n t h a t the c l a r i t y and depth t o which one understands t h e i r MI experience  w i l l i n f l u e n c e how one makes sense o f t h e i r  103 MI  experience  f u t u r e . The experience  i n terms of i m p l i c a t i o n s f o r the present  a b i l i t y of the c o - r e s e a r c h e r will  and  the  to make sense of  her  l i k e l y i n f l u e n c e her a b i l i t y t o a d j u s t t o  MI.  A l l of the women i n the study mentioned the importance of seeking concrete  i n f o r m a t i o n from medical  p r o f e s s i o n a l s , namely  t h e i r d o c t o r s . I t appeared t h a t p a r t of the process i n f o r m a t i o n from medical  of a s k i n g f o r  p r o f e s s i o n a l not o n l y decreased  the  d i s t a n c e i n the d o c t o r - p a t i e n t r e l a t i o n s h i p , but i t allowed women to  experience  process.  a sense of i n c l u s i o n i n t h e i r own  Co-researcher  treatment  accounts suggested t h a t some of the women  were more a s s e r t i v e than others i n terms of i n f o r m a t i o n  seeking.  Penny asked her d o c t o r d i r e c t l y f o r p i c t u r e s of her angiogram results. I asked i f I c o u l d have p i c t u r e s . . . I wanted proof t h a t a l l those a r t e r i e s were c l e a r . . . I wanted t o be able t o see what had happened and what the damage was and where i t was... I f e l t b e t t e r when I had that...when he s a i d ya no problem w e ' l l g i v e you a p i c t u r e . . . I f e l t b e t t e r when I c o u l d a c t u a l l y see f o r myself... t h a t was probably the best f e e l i n g to do t h a t . A f t e r her f i r s t MI,  Roslynn made the commitment to r e g a i n c o n t r o l  of her h e a l t h and to l e a r n as much as p o s s i b l e about heart disease. Because I was so i g n o r a n t and r e a l i z e d t h a t I was i g n o r a n t and t h i s ignorance brought on t h i s heart a t t a c k I decided t h a t was i t . . . I was going to l e a r n e v e r y t h i n g there was t o l e a r n about heart c o n d i t i o n s and heart d i s e a s e s . . . i n order f o r me t o never l o s e c o n t r o l of the symptoms and i f i t d i d happen again I knew e x a c t l y what happened and e x a c t l y what t o do. For some c o - r e s e a r c h e r s ,  a c q u i r i n g i n f o r m a t i o n about the  s t a t u s of t h e i r c o n d i t i o n s allowed  them to more c l e a r l y  formulate  the s i g n i f i c a n c e of the i l l n e s s event. L y d i a d i d not have a c l e a r understanding  of the s i g n i f i c a n c e of her MI  u n t i l she  received  104 the r e s u l t s from her upcoming angiogram. I'm not sure what i t means [to have had a heart a t t a c k ] . . . u n t i l I have an angiogram which w i l l be sometime next week...I don't know e x a c t l y what's going t o be i n v o l v e d . . . i t may i n v o l v e a n g i o p l a s t y . . . p r o b a b l y not i f I pass." Hilda f e l t  so s u r p r i s e d a t h e a r i n g her d i a g n o s i s and d o c t o r ' s  recommendations t h a t she was  unable t o ask the q u e s t i o n s she  needed t o i n order t o f u l l y c l a r i f y what he had s a i d t o her. I thought I was a l l c l e a r e d up and he t o l d me t h a t t h i s morning...he j u s t about threw me...it k i n d of changes your l i f e t o o . . . I t h i n k w e l l do you l i v e w i t h . . . o r are you going t o . . . i t k i n d of threw me f o r a minute so I d i d n ' t r e a l l y get a chance t o t a l k t o him but tomorrow I w i l l ask him more about i t . . . b u t I mean what does t h i s mean...does t h i s mean t h a t I go on the r e s t of my l i f e and I'm going t o have p a i n a l l the time or am I going t o be l i m i t e d t o doing such and such a t h i n g or do I have t o s t a y on s p e c i a l d i e t or t h i s s o r t of t h i n g . Other women t a l k e d about t h e i r d o c t o r s having t o l d them i n f o r m a t i o n or medical terminology t h a t they d i d not understand. For example, Penny suggested know...everybody s a i d i t was  a massive  "I was  clearly  j u s t w o r r i e d you  heart a t t a c k . . . I don't  even r e a l l y know what t h a t means." Both L y d i a and Brynn f e l t t h a t they b e n e f i t t e d from  their  n u r s i n g experience i n terms of having a g r e a t e r awareness of both c a r d i a c i l l n e s s and the h o s p i t a l r o u t i n e . For L y d i a , her p r e v i o u s work as an emergency room nurse allowed her t o have a g r e a t e r sense of f a m i l i a r i t y w i t h h o s p i t a l procedures and  treatment.  I t h i n k having worked i n an emergency probably has helped a t a time l i k e t h i s because you know what's going t o happen and what's going on and you're c e r t a i n l y more aware than you would be i f you hadn't...even b e i n g a nurse I t h i n k makes a b i g d i f f e r e n c e I t h i n k probably because people don't get alarmed and u p t i g h t . H a l f of the c o - r e s e a r c h e r s i n the study had been t r a n s f e r r e d from s m a l l r u r a l h o s p i t a l s t o the l a r g e r c i t y h o s p i t a l where they  105 r e c e i v e d more e l a b o r a t e c a r d i a c c a r e . S e v e r a l of these women, i n c l u d i n g Penny and Gina welcomed the o p p o r t u n i t y t o be t r a n s f e r r e d t o the c i t y and f e l t t h a t they would r e c e i v e more i n f o r m a t i o n about t h e i r h e a r t . "I  f e l t t h a t I would get more  i n f o r m a t i o n . . . t h a t I would know more a f t e r coming here and have a b e t t e r i d e a of where I was know e x a c t l y what was t h a t I was  a t . . . t h a t was  going on,"  important I wanted t o  " i n a sense I f e l t r e a s s u r e d  probably going t o get b e t t e r medical c a r e . "  Co-researcher accounts suggested t h a t when women had difficulty  a c q u i r i n g i n f o r m a t i o n from t h e i r d o c t o r s they  sometimes experienced c o n s i d e r a b l e d i s t r e s s . Kaye f e l t  angry  about the l a c k of i n f o r m a t i o n from her d o c t o r s and was u n c e r t a i n t h a t she a c t u a l l y had s u f f e r e d a MI.  Because Kaye's d a u g h t e r - i n -  law worked i n the same h o s p i t a l t h a t she was  admitted t o , she  used her n u r s i n g e x p e r t i s e and f a m i l i a r i t y with the d o c t o r s t o l e a r n more about Kaye's c o n d i t i o n ,  "I've  got a c u r i o u s daughter-  in-law...she got a h o l d of [my d o c t o r ] and s a t down with him looked a t my x-rays of me."  and  Gina's f e l t concerned t h a t she d i d  not have enough i n f o r m a t i o n t o make an informed c h o i c e about having bypass  surgery, "am  I being r a i l r o a d e d into  medicine... l e t ' s do i t t h i s way to  mainstream I  and get i t over with...do  go through t h i s . . . ! wish I knew...I wish you c o u l d t e l l  Moreover, she d i d not f u l l y bypass  understand why  she was  have me."  scheduled f o r  surgery when other h e a r t p a t i e n t s were undergoing  less  i n v a s i v e treatment. ...there was a lady t h a t was brought i n l a s t n i g h t . . . s h e had another d o c t o r who recommended p u t t i n g t h i s t h i n g i n her a r t e r i e s by her heart...metal d e v i c e . . . i t holds i t open...she wanted the bypass but I thought Jesus C h r i s t , you can have my b y p a s s . . . I ' 1 1 take your s t e n t any day...I mean she's not a l l  106  cut up...so what t h e h e l l ' s going on h e r e . . . l i k e t h e r e ' s some women g e t t i n g one treatment and a n o t h e r . . . i s i t t h e l u c k o f the draw...what t h e h e l l i s going on here t h a t ' s what I'd l i k e t o know...they haven't e x p l a i n e d t h a t t o me...not t o my satisfaction. Common amongst c o - r e s e a r c h e r accounts was t h e experience of r e c e i v i n g m i s i n f o r m a t i o n from t h e i r d o c t o r s . A t l e a s t h a l f of t h e women recounted b e i n g t o l d by d o c t o r s t h a t t h e i r p r e s e n t i n g symptoms were not c a r d i a c r e l a t e d o r i n d i c a t i v e of t h e p r e l i m i n a r y s i g n s of MI. Anne s u f f e r e d her f i r s t  MI w h i l e on  v a c a t i o n w i t h her f a m i l y . The emergency d o c t o r a t t h e s m a l l r u r a l h o s p i t a l suggested t h a t "you're  on h o l i d a y s [Anne]...you've  overeaten...well t h a t ' s what i t is...you've over eaten...yes  I'm  sure i t ' s j u s t the r i c h food b e i n g on h o l i d a y s . " Roslynn r e c a l l e d e x p e r i e n c i n g angina s e v e r a l days b e f o r e her MI. Assuming i t was her medication,  she was seen by her d o c t o r  who subsequently gave her a c l e a n b i l l  of health.  He looked a t me...had blood p r e s s u r e taken and he s a i d you sound j u s t f i n e . . . h e s a i d your c h o l e s t e r o l i s down...you're j u s t f i n e . . . i s e v e r y t h i n g ok a t work...I s a i d y a . . . I ' l l t e l l you i n 3 years you can r e v e r s e the p r o c e s s . . . I am almost sure t h a t we can c l e a r out t h a t a r t e r y f o r you no problem...so I was a l l e l a t e d about that...no I was cured t h a t was i t . . . 1 j u s t don't l i k e t h e i d e a . . . f r u s t r a t i n g . . . b e c a u s e on Tuesday I was doing so w e l l . . . o n F r i d a y I've got a heart attack...hey what's happening here and why? Gina r e p o r t e d b e i n g diagnosed  1 year e a r l i e r with stomach  problems and put on medication. A f t e r e x p e r i e n c i n g the i d e n t i c a l p a i n with her MI, she was convinced t h a t her stomach p a i n was misdiagnosed  angina.  When I stop and t h i n k about i t a l l my stomach problems t h a t began l a s t year...which we have s i n c e d i s c o v e r e d a r e h e a r t r e l a t e d . . .-I'm d i s a p p o i n t e d t h a t my d o c t o r d i d n ' t p i c k t h a t up because we have a good r a p p o r t . . . he's a young f e l l o w and we r e l a t e v e r y w e l l . . . I shouldn't have had a heart a t t a c k . . . b u t I d i d n ' t know i t was a warning...they were t e l l i n g me i t was  107  stomach...it c o u l d have been a warning had I known...I would of q u i t e smoking then and t h e r e . . . I knew I was t a k i n g a r i s k doing what I was doing and t h a t I am a high r i s k f a c t o r . . . I would have q u i t . . . I know I would have because I had done i t b e f o r e . . . I enjoy smokes, but I'm not s t u p i d . The Experience of Care and The  Support  seventh major theme concerns the experience of care and  support t h a t a l l of the c o - r e s e a r c h e r s d e s c r i b e d i n t h e i r accounts.  In t h i s context, care r e f e r s t o the p e r c e i v e d q u a l i t y  of medical treatment,  a t t e n t i v e n e s s , and concern t h a t co-  r e s e a r c h e r s r e c e i v e d from h e a l t h care p r o v i d e r s w h i l e h o s p i t a l i z e d with MI.. Support  r e f e r s more t o the s o c i a l  t h a t the women r e c e i v e d from f a m i l y members and  support  friends.  Care When d e s c r i b i n g the experience of care they r e c e i v e d from h e a l t h care p r o v i d e r s , most of the c o - r e s e a r c h e r s made a p o i n t of d i s t i n g u i s h i n g between the care they had r e c e i v e d from the  nurses  and t h a t which they r e c e i v e d from t h e i r d o c t o r s . Women used words such as " e x c e l l e n t , " "wonderful"  "awesome," and  t o d e s c r i b e the care t h a t they r e c e i v e d from  nurses.  Aspects of care t h a t c o - r e s e a r c h e r s i d e n t i f i e d as b e i n g meaningful  i n c l u d e d : p e r s o n a l and d e l i b e r a t e  attention,  immediacy, s i n c e r i t y and compassion, t h o u g h t f u l n e s s and r e s p e c t , t a k i n g the time t o p r o v i d e i n f o r m a t i o n , and  nurturance.  Gina t a l k e d about her experience i n the c i t y  hospital's  CCU. I was t o t a l l y impressed with CCU...big time...they're r e a l l y good people...those doors, they swished wide open and they pushed us i n and t h e r e was immediately two nurses coming towards us g r e e t i n g us...by name and t e l l i n g us t h e y ' r e g l a d to see you, g l a d you made i t here and e v e r y t h i n g i s ok and whatnot... j u s t awesome.  108 Gina d e s c r i b e d more s p e c i f i c a l l y her p e r c e p t i o n s of the d i f f e r e n c e s between the care she r e c e i v e d i n the c i t y versus rural  the  hospital.  Here you have a c o n s i s t e n t compassion so t o speak...they are c o n s i s t e n t with t h e i r concern...whereas i n [the r u r a l h o s p i t a l ] . . . i f t h e y ' r e l o o k i n g a t you...ok...they're paying a t t e n t i o n t o you r i g h t now...but the minute t h e i r back i s turned t h e y ' r e gone...they appear more s i n c e r e here...I'm sure they must be t r a i n e d t o do t h a t because they can't a l l be t h a t nice...you know r e a l l y . . . t h e y must go through some s p e c i a l t r a i n i n g . . . u n l e s s they're hand p i c k e d by somebody . . . t h a t ' s what I f e e l anyway...they are awesome. H i l d a a l s o t a l k e d e x t e n s i v e l y about the o u t s t a n d i n g n u r s i n g care she r e c e i v e d . A l l those nurses...they were e x c e l l e n t . . . t h e y went over and beyond t h e i r c a l l of what they needed t o do...they would j u s t do a n y t h i n g t o make you comfortable and they seemed t o f e e l so s o r r y f o r you or something.... t h a t you were g e t t i n g a l l those needles and going f o r t h i s t e s t . . . t h e y would have done a n y t h i n g t o make your l i f e a l i t t l e more e a s i e r . . . sometimes I t h i n k they know more than the d o c t o r s . S e v e r a l c o - r e s e a r c h e r s d e s c r i b e d the t r a n s i t i o n i n care as they were t r a n s f e r r e d from the CCU used words l i k e  "abandoned" and  t o the c a r d i a c ward. Women  "upset" t o d e s c r i b e the  experience of t r a n s i t i o n from r e c e i v i n g almost  constant care t o  the e x p e c t a t i o n of f u n c t i o n i n g much more independently. A few of the women's accounts  suggested t h a t some of the r e p o r t e d a n x i e t y  around t h i s t r a n s i t i o n stemmed from b e i n g u n c l e a r as t o what they were expected t o be a b l e t o do. H i l d a d e s c r i b e d at l e n g t h her experience of t r a n s i t i o n from the CCU  t o the c a r d i a c ward.  ...everybody says oh y o u ' l l r e a l l y l i k e i t u p s t a i r s . . . and you do and you don't...you're so used t o b e i n g cared f o r . . . r e a l l y r e a l l y tended t o l i k e a l l the time...and then a l l of the sudden t h e r e ' s k i n d of nobody... t h a t makes you t h i n k w e l l they are way down the h a l l . . . y o u s i t and you t h i n k of s i l l y t h i n g s l i k e . . . I hope the monitor i s working down t h e r e . . . o r do they know you're here because you never see everybody a l l day...you're so used t o having the nurses t h e r e a l l the time i n and out you k i n d of you f e e l not abandoned...not n e g l e c t e d  109 . . . i t ' s kinda somewhere i n between...I t h i n k t h e f i r s t day I was t o the p o i n t t h a t I was a l i t t l e upset. In a l a r g e r sense, H i l d a compared the experience  of t r a n s i t i o n  from t h e care of the CCU t o the c a r d i a c ward t o the experience of t r a n s i t i o n from h e a l t h t o i l l n e s s . I t ' s a change... i t ' s a b i g change... i t ' s r e l y i n g on something and then a l l of the sudden i t ' s g o n e . . . i t ' s l i k e almost r e v e r s i n g i t s e l f . . . l i k e when you f i r s t get your heart a t t a c k and then you s t a r t t o depend...you're so independent a t f i r s t ...then you depend...you have t o depend on someone f o r e v e r y t h i n g and then a l l of t h e sudden... s t a r t i n g back t h e other way and i t ' s change...you're changing a l l t h e time and your t r y i n g t o a d j u s t t o your s i t u a t i o n . . . you have t o l e a r n to have a l o t of p a t i e n c e with y o u r s e l f , with t h e nurses, with everybody... and they have t o do t h e same t h i n g . When c o - r e s e a r c h e r s  d i s c u s s e d t h e q u a l i t y of care t h a t they  had r e c e i v e d from d o c t o r s , they o f t e n spoke i n terms of having a sense of "rapport." T h i s sense of rapport was c l o s e l y l i n k e d with the degree t o which the d o c t o r p r o v i d e d s a t i s f a c t o r y  treatment  and i n f o r m a t i o n and the manner i n which t h i s i n f o r m a t i o n was provided.  I t was c l e a r from the women's accounts  that  medical  care r e c e i v e d from doctors h e l d t h e p o t e n t i a l f o r having i m p l i c a t i o n s upon the women's experience  notable  of MI. F o r example,  a c q u i r i n g s a t i s f a c t o r y i n f o r m a t i o n from one's d o c t o r p l a y s a fundamental r o l e i n p e r c e p t i o n s of t h e o v e r a l l q u a l i t y of care r e c e i v e d from h e a l t h care p r o v i d e r s . C l e a r l y , t h e theme of care i s c l o s e l y interwoven Co-researchers  with t h e experience  of needing  i n the study d e s c r i b e d having mixed r a p p o r t  with t h e i r d o c t o r s . A few of t h e women r e p o r t e d extremely  information.  experiencing  s a t i s f a c t o r y care from t h e i r d o c t o r s .  L y d i a d e s c r i b e d the i d e a l rapport t h a t she maintains both her c a r d i o l o g i s t and her g e n e r a l I have great admiration  with  practitioner.  and confidence i n [my c a r d i o l o g i s t ]  110 ...she r e a l l y i s a l o v e l y person and I have always been f u l l of admiration f o r her...she i n s t i l l s a l l s o r t s of f a i t h and confidence i n me...my GP i s a very c a r i n g man t o o . . . h i g h l y i n t e l l i g e n t . . . I've always had confidence i n him. Penny's c a r d i o l o g i s t had been h i g h l y recommended from s e v e r a l respected  sources.  ...he's the best...and a l l my f a m i l y as soon as they heard t h a t I had him...there was j u s t a b i g s i g h of r e l i e f . . . t h a t as f a r as they were concerned I had the b e s t and I f e e l t h a t way and I t h i n k i t ' s important... so I'm happy about t h a t and I'm prepared t o do whatever he says. Noreen a l s o p r a i s e d her c a r d i o l o g i s t and surgeon. ...they're good people those d o c t o r s what t h e y ' r e doing too...but t h e y ' r e a l l so human...they never get r e a l l y l i k e o r you know...they're always so they do.  and surgeons...they know a l l so good...they're inhumane o r business n i c e about e v e r y t h i n g  A few c o - r e s e a r c h e r s d e s c r i b e d f e e l i n g "angry"  " f r u s t r a t e d " and  towards t h e i r d o c t o r s . These f e e l i n g s o c c u r r e d i n  response t o t h e p e r c e i v e d i n a t t e n t i v e n e s s , l a c k of concern, o r l a c k of i n f o r m a t i o n on the p a r t of t h e d o c t o r . Kaye expressed her anger and f r u s t r a t i o n i n not knowing what had happened t o her b e g i n n i n g with her a r r i v a l i n t h e emergency department, and towards her c a r d i o l o g i s t f o r "not s i t t i n g down with  [ h e r ] " and p r o v i d i n g her with concrete i n f o r m a t i o n . ...as f a r as I'm concerned...I f e e l t h a t we should be a b l e t o s i t down w i t h our d o c t o r when we can get an appointment w i t h him and go over e v e r y t h i n g thoroughly... so we know...and t e l l us t h e t r u t h whether we a r e going t o be a b l e t o do a n y t h i n g about g e t t i n g i t where...to t h e point...where you can a t l e a s t walk around the b l o c k .  Kaye f u r t h e r d e s c r i b e d a p a r t i c u l a r l y d i s t r e s s i n g i n c i d e n t t h a t o c c u r r e d with her c a r d i o l o g i s t . ...he s a y s . . . i f t h i s happens again what do you want me t o do...I looked a t him and s a i d what a r e you t a l k i n g about ...you mean t o t e l l me t h a t you a r e j u s t going t o l e t me d i e . . . s e e what I mean...so i f you want a n y t h i n g from t h e d o c t o r o r you've had anything...you've got t o f i g h t l i k e a  Ill d e v i l t o f o l l o w i t up and shouldn't have t o . . . t h a t should come a b s o l u t e l y a u t o m a t i c a l l y . Kaye's anger and d i s s a t i s f a c t i o n w i t h her doctor motivated  her t o  look i n t o f i n d i n g another p h y s i c i a n with whom she f e l t t h a t her needs would be more r e a d i l y met. Anne d i s c u s s e d how angry she had been with her own d o c t o r a t h i s l a c k of a t t e n t i v e n e s s a f t e r sending her t o t h e i n t e n s i v e care from h i s o f f i c e . ...and the doctor d i d n ' t show up f o r e v e r and ever and ever ... I d i d have a heart s p e c i a l i s t and he was super I t h i n k ...but my own doctor d i d n ' t show up and t h r e e days l a t e r when he d i d show up he came p a n t i n g i n and goes t h e r e you a r e . . . I thought you went home...and I was mad...I was j u s t f u r i o u s ...you t w i t . . . I thought how can a d o c t o r put you i n t h e h o s p i t a l from h i s office...dump you i n t o i n t e n s i v e c a r e . . . I never wanted t o go i n t h e f i r s t place...and then l o s e me... t h a t ' s what made me f u r i o u s . . . i t has n o t h i n g t o do w i t h my heart...nothing. Anne d e s c r i b e d f e e l i n g angry with another on her j u s t p r i o r t o undergoing  d o c t o r who "dumped"  bypass surgery. She t a l k e d about  s e e i n g him when she woke i n t h e r e c o v e r y room. ...of course when t h a t doctor s a i d I was middle aged and t h a t my prognosis was r e a l l y lousy and on and on and look what brought you here I mean you were on death's door f o r a month ...and when he looked o v e r . . . i f I'd the s t r e n g t h I t h i n k I would have stuck out my tongue a t him ( l a u g h s ) . . . I was so mad...well I ' l l show you. Noreen d e s c r i b e d f e e l i n g had gone t o seen everyday  "perturbed" with t h e d o c t o r t h a t she  f o r almost  a week i n t h e small  d i a g n o s t i c center i n her r u r a l town. She wondered why he had not taken more immediate a c t i o n i n terms of t r e a t i n g her symptoms as MI. ...I thought what the heck i s going on here...I got k i n d of a l i t t l e perturbed a t the doctor t h e r e because I f i g u r e d they should of had me over here a week anyway...may of g i v e n me the leap I needed you know and then I thought... i t ' s nobody's f a u l t but your own...you d i d i t you know.  112  Brynn d e s c r i b e d f e e l i n g very angry towards an i n t e r n t h a t worked on her a f t e r she a r r i v e d i n the emergency department. ...I c o u l d t e l l he was i n a b i t of a p a n i c . . . d i d n ' t want t o appear as though he d i d n ' t know how t o handle h i m s e l f . . . people were w a i t i n g and s t a n d i n g back out of r e s p e c t t o him ...I was j u s t h o r r i f i e d . . . j u s t wanted him away from me... f e l t he was a g g r e s s i v e and he took away from the r i g h t s of others...mine were some of those r i g h t s . . . b u t some of the r i g h t s of other people t h a t had t h e i r duty t o do...and he d i d n ' t r e a l i z e how these t h i n g s a l l have t o go c o l l a b o r a t i v e l y . . . h e wasn't a good p l a y e r . . . a n d I knew i t was from i n e x p e r i e n c e . . . I t h i n k h i s behavior had an impact of my f e a r and sense t h a t I-was safe...my needs of f e e l i n g s a f e and secure having come t o the h o s p i t a l . . . so I t h i n k t h a t ' s r e a l l y a key thing...who you encounter has a b i g impact..because I know t h a t s t r e s s and p a i n w i l l add more and more t o c h r o n i c tissue. Support S o c i a l support was  e v i d e n t i n a l l of the c o - r e s e a r c h e r s  accounts. D e s p i t e the f a c t t h a t most of the women used words l i k e "wonderful"  and  "very good" t o d e s c r i b e t h e i r experience of  support, s o c i a l support was  more p r o f o u n d l y experienced f o r some  than f o r o t h e r s . A l l of the women conveyed a genuine sense of a p p r e c i a t i o n f o r the support they had r e c e i v e d from f r i e n d s  and  f a m i l y as a p o s i t i v e experience. Moreover, r e c e i v i n g support others was  almost always d e p i c t e d as b e i n g a p o s i t i v e  Undoubtedly f o r many of the women, the presence  experience.  of f a m i l y and  f r i e n d s r e p r e s e n t e d the o n l y element of f a m i l i a r i t y experienced while  they  hospitalized.  Women r e c e i v e d support a t d i f f e r e n t times throughout MI  from  their  experience. For most of the women, f a m i l y had accompanied them  t o the h o s p i t a l d u r i n g the onset of i l l n e s s awareness. Kiko recounted how  her son had come home much e a r l i e r than  She wondered how was  expected.  she would have gotten a s s i s t a n c e otherwise,  j u s t f o r t u n a t e t h a t my  son came back...he kept s a y i n g  why  "I  113 d i d n ' t you c a l l me  e a r l i e r . . . n o way  phone... i t ' s not as easy as you  [I] c o u l d get t o a  say."  A f t e r H i l d a woke up i n the middle of the n i g h t with severe chest and neck p r e s s u r e , i t was the s i t u a t i o n ,  "he took me  her husband t h a t took charge of  i n because he was  I was... although I knew something A f t e r b e i n g diagnosed with MI Noreen was  was  going  more concerned on."  i n her s m a l l r u r a l  hospital,  t o be taken on an emergency f l i g h t t o the c i t y c e n t e r  f o r f u r t h e r treatment. Knowing t h a t her mother had a " r e a l of f l y i n g " Noreen's daughter  accompanied her d u r i n g the  "I d i d n ' t have t o come alone...she h e l d my For one woman, whose spouse was responded  a t work, a neighbour  when she c a l l e d f o r h e l p . Anne had telephoned  "she was  flight,  quickly her  having her  down almost b e f o r e I hung up...I was  r e a l l y lucky...my neighbour got me  fright  hand."  neighbour t o come over when -she r e a l i z e d she was f o u r t h MI,  than  really  t o the h o s p i t a l even f a s t e r  than an ambulance c o u l d . " Almost  a l l of the c o - r e s e a r c h e r s d e s c r i b e d the importance  of  t h e i r s o c i a l support i n terms of " j u s t b e i n g t h e r e " w h i l e i n the hospital. Noreen t a l k e d s p e c i f i c a l l y about having her o l d e s t son s t a y with her w h i l e she was  i n the  ...that week he spent a he j u s t s a t a t the edge okay as l o n g as I c o u l d and I l o s t c o n t a c t with  CCU.  b i g p a r t of h i s time t h e r e w i t h me... of my bed and h e l d my hand and I was f e e l him...the minute he l e t go of me him...I went r i g h t i n t o a p a n i c .  Brynn r e c a l l e d waking up a t one p o i n t t o having almost her  entire  f a m i l y , which i s s c a t t e r e d a c r o s s the country, i n her h o s p i t a l room.  114 I wake up and my c h i l d r e n a r e there...my s i s t e r i s there...my n i e c e i s t h e r e . . . I had a l o t of s u p p o r t . . . i t was k i n d of l i k e a r e a l g i f t because...I d i d n ' t know they a l l cared t h a t much . . . i t p u l l e d me through because I'm adopted o r i g i n a l l y and i f t h e r e ' s a n y t h i n g t h a t w i l l motivate me i s a n y t h i n g t o do w i t h my k i d s . . Penny d e s c r i b e d what her days looked l i k e w h i l e she was i n t h e CCU. ...during the day I had tapes t o l i s t e n t o and t h e r e was always t h i n g s going on...I had tons of v i s i t o r s and they were s u r p r i s e d they l e t me have so many v i s i t o r s but they d i d . . . I had l o t s of v i s i t o r s and I f e l t good. One c o - r e s e a r c h e r f e l t t h a t her MI experience had brought her much c l o s e r t o her spouse who a l s o had a h i s t o r y of MI. H i l d a suggested t h a t because men t y p i c a l l y have h e a r t a t t a c k s and a r e taken care of by t h e i r wives, they r a r e l y know what i t f e e l s  like  t o experience the emotional s t r a i n of b e i n g a c a r e g i v e r . With us the s i t u a t i o n i s reversed...he had t o take on the r o l e t h a t ' I took...I'm the one t h a t ' s l a y i n g i n t h e r e with a l l the tubes and needles and the hurt...and when they c a l l e d him i n the middle of the n i g h t and t o l d him t h a t I had had a c a r d i a c a r r e s t and they had saved my l i f e . . . h e ' s the one t h a t got a l l shook up, c o u l d n ' t eat, and went through e v e r y t h i n g t h a t I went through... t u r n i n g white and scared a l l the time ...you get t o the p o i n t t h a t you j u s t want t o cry...which sometimes you almost need t o r e l i e v e it...now we've been on both s i d e s of the c o i n and because we have i t ' s brought us a l o t c l o s e r t o g e t h e r . . . I understand both s i d e s of what he went through, and he understands t o o . Three of the f i v e c o - r e s e a r c h e r s who had spouses, d e s c r i b e d f e e l i n g more concerned about t h e i r husbands than themselves a t d i f f e r e n t times d u r i n g t h e i r MI experience. Penny d e s c r i b e d her husband as wanting t o spend as much time as he c o u l d w i t h her w h i l e she was h o s p i t a l i z e d . I t was s c a r y . . . cause I was w o r r i e d about him...I f e l t t h a t I was i n e x c e l l e n t hands and I wasn't w o r r i e d about me...I was j u s t w o r r i e d about him...I know he had f a m i l y and f r i e n d s and e v e r y t h i n g t o t a l k t o but he j u s t wanted t o s i t i n the room and s t a r e a t me f o r t h r e e days... I wish t h a t maybe t h e r e c o u l d have been somebody t o help him...that's so unusual  115 because u s u a l l y i t ' s the woman...I s o r t of f e l t s o r r y f o r him t h a t he d i d n ' t know how t o handle it...what he should be doing. S i m i l a r l y , other c o - r e s e a r c h e r s f e l t t h a t the experience of MI was  o f t e n much harder on the f a m i l y than on o n e s e l f , "I do  r e a l i z e now  t h a t although you get the p a i n maybe i t ' s harder  the f a m i l y than i t i s on you,"  "I r e a l l y thought  on  about...what the  k i d s would go through more than you...you t h i n k more of your f a m i l y of what you're  l e a v i n g behind...what they have t o go  through a f t e r y o u . . . i f anything happens t o  you."  Most of the c o - r e s e a r c h e r s d e s c r i b e d the on-going  support  t h a t they were going t o r e c e i v e from f a m i l y and f r i e n d s once they were d i s c h a r g e d from h o s p i t a l . Arrangements were f r e q u e n t l y made independent  of what the women had requested. Gina t a l k e d about  her f a m i l y making themselves  more a c c e s s i b l e i n order t o take  care of her d u r i n g her recovery from bypass surgery. I got a l o t of f r i e n d s and my k i d s are top notch...my husband too...the o l d e r one i s going t o change her working hours around t o accommodate me so she can be w i t h me i n the day time...my husband's s e l f employed so he can g i v e me a l l of the time I want t h e r e . One  of Roslynn's  b i g g e s t concerns  b e i n g h o s p i t a l i z e d was daughter these  about r e t u r n i n g home a f t e r  t a k i n g care of her aging mother. Her  made arrangements t o v i s i t , which helped t o a l l e v i a t e  concerns.  ...my daughter i s coming over and she's going t o be h e l p f u l i n the p r a c t i c a l sense of making sure the house i n order and spending time w i t h her and she would spend time with my mother l e a v i n g me f r e e t o do whatever I need t o do. For a few of the c o - r e s e a r c h e r s , the e x p e c t a t i o n s or arrangements t h a t f a m i l y or f r i e n d s had made f o r them a f t e r l e a v i n g the h o s p i t a l d i d not r e a l l y c o i n c i d e w i t h what they  116 wanted f o r themselves.  Kiko d e s c r i b e d how  she agreed t o s t a y with  her step-daughter a f t e r l e a v i n g the h o s p i t a l her  i n order t o p l e a s e  sons. I want t o go d i r e c t l y home but then my son says no...that means t h a t my other son from [overseas] would come home... j u s t t o s a t i s f y him we have t o say we are going over t o h i s s i s t e r s f o r a few days and she's got teenagers running around the house and t h e r e i s always somebody t h e r e . . . s o t h a t way [I] r e a s s u r e my youngest son cause he does a l o t of t r a v e l l i n g . . . w i t h [him] worrying about [me] I don't t h i n k h e ' l l get h i s work done...so I t e l l him I ' l l go t o h i s s i s t e r s . . . b u t I t h i n k I'd r a t h e r be home. Although L y d i a f e l t t h a t she d i d not need anyone t o s t a y with  her a f t e r b e i n g d i s c h a r g e d from the h o s p i t a l ,  her f a m i l y and  f r i e n d s were i n s i s t e n t . ...my s i s t e r s thought I should have somebody take care of me f o r a w h i l e , so my s i s t e r i s coming up from Colorado and s h e ' l l be with me f o r two or t h r e e weeks...she won't be here u n t i l Sunday...so a very good f r i e n d i s coming home w i t h me today and t h e r e w i l l be someone with me u n t i l she gets here on Sunday...I don't t h i n k I need anybody much but they say I shouldn't l i f t g r o c e r i e s or anything...so I suppose i n my mind i t ' s j u s t as w e l l t h a t someone i s around t o vacuum and a l l t h a t ( l a u g h s ) . . . I keep s a y i n g t o my f r i e n d s you know you don't need t o come stay with me f o r these two days...I'11 be fine...now everyone won't l i s t e n t o me...so somebody w i l l be with me. Anne a p p r e c i a t e d the support t h a t she had r e c e i v e d from her f a m i l y d u r i n g her experience of having f o u r Mis, y e t she a l s o d i s c u s s e d the importance  of not l e t t i n g "the f a m i l y smother you"  once you r e t u r n home from the  hospital.  ...smother you so t h a t you are a f r a i d t o move because t h e y ' r e w a t c h i n g . . . i f you c o u l d somehow r e a s s u r e your f a m i l y t h a t j u s t because you t u r n f a s t or you burped or you bumped your elbow and went "ow" or something t h a t they don't t h i n k t h a t you are going t o have another heart a t t a c k or something...you almost f e e l smothered and i f you c o u l d j u s t r e a s s u r e the f a m i l y . . . j u s t l e t me be a human...I'll be ok and i f I'm not I ' l l t e l l you...because you do f e e l t o t a l l y smothered a t one point. Another v a l u e d means of support f o r f o u r of the co-  117 r e s e a r c h e r s was  t h e i r s t r o n g r e l i g i o u s or s p i r i t u a l  belief  systems. T h i s " f a i t h " p r o v i d e d these women with a framework f o r making sense of t h e i r experience, i n c l u d i n g a p e r s p e c t i v e on ideas around death. L y d i a made s e v e r a l r e f e r e n c e s t o her  faith.  I'm a C a t h o l i c with a s t r o n g f a i t h and the thought I might not s u r v i v e t h i s episode d i d n ' t r e a l l y bother me...I have a very s t r o n g f a i t h as I was s a y i n g and so I t h i n k maybe heaven's j u s t a p l a c e . . . a l o t b e t t e r p l a c e than t h i s world ...so I have very l i t t l e apprehension or f e a r of death or whatever. Brynn a l s o t a l k e d about her s p i r i t u a l  beliefs.  ... I t h i n k i n the l a s t week has been t h a t sense of a p p r e c i a t i o n and I don't mind a d m i t t i n g t h a t I've been s a y i n g my prayers ... i t ' s almost thanks ... I've always had a v e r y c l o s e r e l a t i o n s h i p w i t h God...I have no f e a r of d y i n g . . . i f I die i t ' s Gods w i l l . . . I looked a f t e r enough emergencies myself to know t h a t you can have a l l the h i g h l y t e c h n i c a l s k i l l s and personnel but i f i t ' s t h e i r time i t ' s t h e i r time. Although  care and support were d e s c r i b e d as  separate  e n t i t i e s , the c o - r e s e a r c h e r ' s experience of r e c e i v i n g care and support was  d e s c r i b e d more as a whole experience. In other words,  women d i d not n e c e s s a r i l y compartmentalize  the experience of care  and support although they were a b l e t o i d e n t i f y elements of Nonetheless,  r e c e i v i n g q u a l i t y medical treatment by  medical p r o f e s s i o n a l s , as w e l l as having a s t r o n g s o c i a l appeared  each.  concerned support  t o be c r u c i a l i n terms of f a c i l i t a t i n g the co-  r e s e a r c h e r ' s sense of s e c u r i t y and comfort w h i l e h o s p i t a l i z e d with a l i f e  t h r e a t e n i n g i l l n e s s such as MI.  Subsequently,  some of  the women experienced care and support more p r o f o u n d l y than o t h e r s . Moreover, c o - r e s e a r c h e r s t h a t d i d r e c e i v e both a s t r o n g sense of care and support appeared  t o be l e s s d i s t r e s s e d  others by the e n t i r e t y of t h e i r MI  experience.  than  118 Making Sense of the MI Experience The e i g h t h emerging theme i s making sense of t h e MI experience. Co-researchers attempted  t o understand t h e i r MI  experience a f t e r they had undergone t h e i r i n i t i a l r e a c t i o n s t o the event. In t h i s context, making sense of t h e MI experience suggests an i n d i v i d u a l ' s e f f o r t s a t understanding t h e p e r s o n a l s i g n i f i c a n c e o r p e r c e i v e d meaningfulness  of t h e i l l n e s s  Co-researcher accounts i n d i c a t e d t h a t t h e r e were  event.  commonalities  i n h e r e n t t o t h e making sense p r o c e s s . Not o n l y d i d women attempt to  i d e n t i f y t h e reasons f o r having the MI, but many r e p o r t e d  undergoing a more e x i s t e n t i a l experience of a p e r s o n a l review o r p e r s o n a l awakening. The women drew upon i n f o r m a t i o n o b t a i n e d from v a r i o u s sources i n order t o help them make sense of t h e i r MI experience i n c l u d i n g medical p r o f e s s i o n a l s , p r e v i o u s h i s t o r y of i l l n e s s ,  life  history  and experience, as w e l l as p e r s o n a l v a l u e s and b e l i e f s . Most of the women attempted  t o i d e n t i f y reasons  that  e x p l a i n e d why they had a MI. I d e n t i f y i n g p o s s i b l e causes of t h e i r MI allowed women t o p e r c e i v e t h e i r c o n d i t i o n as b e i n g t r e a t a b l e and p r o v i d e d them with more of a sense of i n c l u s i o n i n t h e i r own i l l n e s s process. Roslynn d i s c u s s e d t h e importance  f o r a heart p a t i e n t t o f i n d  the reason f o r having t h e a t t a c k i n order "to keep c o n t r o l t h a t reason." She a t t r i b u t e d her c u r r e n t MI t o improper  over  d i e t and  the s t r e s s of l i v i n g with a "demanding" e l d e r l y parent. So where d i d I go w r o n g . . . f i r s t t h i n g I d i d wrong i t was i n d u l g e i n some food t h a t I shouldn't have indulged...no a l c o h o l . . . n o smoking...nothing of t h e s o r t . . . b u t food was one of t h e c o n t r i b u t i n g f a c t o r s . . . the second c o n t r i b u t i n g f a c t o r i s t h e s t r e s s t h a t I s u s t a i n e d from the l a c k of freedom  119 knowing t h a t I c o u l d not go home without e i t h e r f a c i n g a b a t t l e of w i t s w i t h somebody t h a t I d e a r l y l o v e but I j u s t can't stand c o n t r o l l i n g me t h a t way...and knowing t h a t t h e r e was no p l a c e f o r me t o go...there was no home any more. For  some of the women, t h e r e appeared t o be an u n d e r l y i n g  sense of p e r s o n a l r e s p o n s i b i l i t y f o r having s u f f e r e d a MI. T h i s s e l f blame posture suggests t h a t MI c o u l d p o t e n t i a l l y have been avoided i f c e r t a i n measures had been taken. Some of the women appeared t o be r e g r e t f u l f o r not having made e a r l i e r changes. Despite her e x t e n s i v e f a m i l y h i s t o r y of heart d i s e a s e , Gina i d e n t i f i e d l i f e s t y l e and s t r e s s as b e i n g the main reasons why  she  s u f f e r e d a MI a t a younger age than her other b r o t h e r s and sisters. I was gambling was what I was doing...the smoke and the weight...and I l o s t . . . i n a n u t s h e l l . . . I need t o c l e a n up my ignorant l i f e s t y l e . . . w a y too much stress...way more heart ache than one person should have t o go through i n the f i r s t twenty years of marriage I guess...and then c l e a n up my l i f e s t y l e a l i t t l e b i t . . . g e t the weight o f f and q u i t smoking. Anne d i s c u s s e d f e e l i n g somewhat r e g r e t f u l about not having made changes e a r l i e r i n her  life.  ...change i n my l i f e s t y l e . . . and some r e g r e t s because some of i t I c o u l d have prevented...not smoking...it took me two heart a t t a c k s t o q u i t smoking...but some I don't r e a l l y have r e g r e t s because of the h e r e d i t a r y p a r t of i t I have no c o n t r o l over t h a t a t all...why I have high c h o l e s t e r o l w e l l even the d o c t o r ' s don't know...but I do have i t . A few women were unable t o i d e n t i f y reasons why  they had  had  a MI. D e s p i t e her e f f o r t s , Kaye c o u l d not f i g u r e out "what she did"  t h a t would e x p l a i n why  she had a MI.  My n i e c e t h a t ' s a nurse...she phoned me...and her mother s a i d f o r God's sake what d i d you do...I d i d n ' t do a n y t h i n g t h a t ' s the trouble...[my n i e c e ] says a u n t i e what d i d you do...I s a i d I don't know...it hasn't h i t me y e t what I did...because I s a i d I wasn't s c r u b b i n g w a l l s or I'd have blamed i t on t h a t ...and I wasn't c u t t i n g the lawn...I wasn't washing the f l o o r . . . 1 wasn't bending over doing the bath tub o u t . . . I s a i d I've j u s t had t h i s p a i n f o r a l o n g time and i t j u s t kept  120 b u i l d i n g up...got worse and Penny was  worse.  unable to i d e n t i f y any behavior t h a t c o u l d p o s s i b l y  l i n k e d t o the occurrence of her MI. was  Subsequently, she  be  f e l t her  MI  a f r e a k i n c i d e n t t h a t happened f o r no p a r t i c u l a r reason. ...I don't know what i t means to have had a heart a t t a c k . . . I know I've had one...I know t h a t i t ' s unusual f o r someone l i k e me to have had one...I j u s t t h i n k i t ' s some k i n d of f r e a k t h i n g t h a t happened...I wasn't doing anything t h a t I shouldn't of been d o i n g . . . i t was j u s t something t h a t happened...I don't f e e l t h a t I've done anything wrong and I don't t h i n k I would have done anything d i f f e r e n t l y i f I had known t h i s was going to be the outcome...no t h a t ' s not t r u e ...I guess I would have i f there was something I c o u l d have done d i f f e r e n t l y but I don't t h i n k t h a t t h e r e ' s anything t h a t I c o u l d have done to prevent i t .  L y d i a was  more i n t r i g u e d by her  having a MI  than by s e a r c h i n g  l a c k of emotional response t o  f o r reasons to e x p l a i n her  illness.  I don't know why I am r e a l l y not very perturbed about t h i s . . . i t r e a l l y doesn't concern me t h a t much I don't know why ...even I am s u r p r i s e d t h a t I d i d n ' t f e e l a l i t t l e more something t h a t I d i d . . . I r e a l l y d i d n ' t . . . I was very calm and c o l l e c t e d . . . I t h i n k people vary a l o t i n t h e i r emotions... i t was j u s t another day i n my l i f e . Other co-researchers  f e l t t h a t they had been granted a second  chance at l i v i n g a f t e r s u r v i v i n g t h e i r MI. MI  to a "bunch of s t r e s s o r s " i n her  life.  Brynn a t t r i b u t e d her She  f e l t as though  had been given a warning about her h e a l t h as w e l l as opportunity  t o l e a r n how  she  an  to b e t t e r take care of h e r s e l f .  ...there are t h i n g s i n my l i f e t h a t . . i f I c o u l d go back...I c o u l d have done b e t t e r . . . o r j u s t not done them...I'm a t t h a t stage i n my l i f e now where I'm going to have to l e a r n whole new coping s k i l l s . . . I t h i n k t h i s was k i n d of a dramatic f l a g waving i f you w i l l from on high...I'm t e l l i n g you you've got t o do a b e t t e r job...a l o t of i t i s g r a t e f u l t h a t I've been given another chance t o l i v e a b e t t e r l i f e you know what I mean...I guess I wasn't doing i t r i g h t so...I do b e l i e v e i n God and I t h i n k he gave me another chance to tune up. Kiko f e l t t h a t having been given a second chance, she needed t o help others  r e a l i z e the value of  life.  121 ...once you have i t [MI] you r e a l i z e how much l i f e means to you...be good t o everybody...you had a chance you've got back i n you l i f e again so i t ' s now i t would be my t u r n t o help somebody else...make the younger ones r e a l i z e what t h e y ' r e l i f e i s l i k e . . . w o r t h i t . . . I ' v e got t h r e e g r a n d c h i l d r e n I t h i n k they r e a l l y take t h e i r l i f e too e a s y . . . l i f e i s r e a l l y to c h e r i s h . In a s i m i l a r v e i n , other c o - r e s e a r c h e r s d e s c r i b e d what appeared to be a p e r s o n a l awakening and  found themselves t o be i n  a p o s i t i o n of making p i v o t a l l i f e d e c i s i o n s . For some of women, a sense of p e r s o n a l awakening and appeared to be as important suggested  t h a t she was  impending change  as coping with t h e i r i l l n e s s .  Gina  at a crossroads i n her l i f e i n terms of  making a d e c i s i o n to leave her marriage. e i t h e r d e c i s i o n was  these  She  recognized that  going t o have an impact on her h e a l t h .  ...why am I here and what i s my purpose i n l i f e and what i s my j o b . . . I wish I knew...I'm coming to a great b i g branch i n my l i f e . . . n o w am I going t o the r i g h t or am I going t o go t o the l e f t . . . a n d I don't know what I am going t o do...am I going t o stay i n my l i f e s t y l e but l e a r n how t o d e a l with my i n n e r c o n f l i c t or w i l l I j u s t dump i t a l l and go o f f on my own...I have ah i d e a of what I'd l i k e to do f o r myself and whether I ' l l a c t u a l l y do i t or not i s another t h i n g . . . I would l i k e to have a whole t o t a l l y d i f f e r e n t l i f e . . . I t h i n k t h a t would do more f o r me and my psyche and my h e a l t h than anything...more so than smoking or e a t i n g or the g e n e t i c s t h a t supposedly cause t h i s . Roslynn p o i n t e d out the s y n c h r o n i c i t y of becoming i n v o l v e d i n t h i s r e s e a r c h p r o j e c t and her own a c e n t r e f o r heart p a t i e n t s l i k e  p e r s o n a l v i s i o n of e s t a b l i s h i n g herself.  . . . l i k e t h i s heart a t t a c k b u s i n e s s . . . I don't b e l i e v e i t j u s t happens... i t ' s got medical cause but my p h i l o s o p h y i s t h a t i t may happen because I need to do t h i s c e n t r e . . . I need t o have met you f o r some -reason...maybe t h i s sounds a b s o l u t e l y c r a z y and o f f the e a r t h . . . I don't know and I don't care what you t h i n k but when you came and t a l k e d me...my mind snapped back to what I had s a i d to my d o c t o r and I thought hey...maybe t h i s i s what I'm here for...maybe t h i s i s the time I have to d e c i d e . . . i t ' s l i k e p i e c e s of p u z z l e t h a t come and f a l l i n t o place. H i l d a f e l t t h a t she had changed her whole a t t i t u d e as a r e s u l t of  122 having s u r v i v e d a c a r d i a c a r r e s t . ... I t h i n k i t makes me aware of more t h i n g s i n a way d i f f e r e n t than b e f o r e . . . simple...very very simple way t h a t most people take f o r g r a n t e d . . . i t ' s e v e r y t h i n g you do i n l i f e . . . i t ' s brought me a l o t c l o s e r t o my f a m i l y and my husband...you seem t o change your whole a t t i t u d e . . . w e l l I a c t u a l l y died...they had t o b r i n g me back with the paddles and everything...yaa I a c t u a l l y d i e d . . . t h a t was i t . . . i t was a l l over...but the f a c t t h a t I came back I j u s t f i g u r e d I'm back here f o r a reason you know...maybe t o teach somebody else t h i s . Brynn d e s c r i b e d transforming  her MI  as a time f o r r e e v a l u a t i o n ,  "a whole  or having a look at myself... almost l i k e  an  o b j e c t i v e p e r i o d where i t ' s high time t h a t I analyse my As w e l l , she her f a m i l y ,  suggested t h a t her MI " i t ' s brought me  values."  had brought her much c l o s e r t o  c l o s e r and  I t h i n k an  appreciation  ...now our r e l a t i o n s h i p i s e v o l v i n g more i n t o a f r i e n d s h i p . " Noreen a l s o t a l k e d about her MI  as b e i n g a time f o r  personal  reflection. ...makes you stop and t h i n k more than anything I think...you have a l o t of time i n here to t h i n k about your l i f e and where i t ' s going e s p e c i a l l y i f you're b a s i c a l l y by y o u r s e l f . . . l i k e I know I've got my f a m i l y and I know I have my k i d s and t h a t but i f you're a couple... t h e r e ' s t h a t couple there too...when you're one person i t k i n d of makes you stop and wonder and contemplate t h i n g s a b i t . . . b u t I don't have any m i s g i v i n g s or anything much. For most of the c o - r e s e a r c h e r s , p o t e n t i a l l y l i f e threatening represent  the experience of a  event such as MI  appeared t o  an ongoing process of sense making and  researchers  adjustment.  f r e q u e n t l y appeared to be making sense of  aspects of t h e i r MI  Co-  other  experience i n c l u d i n g h o s p i t a l r o u t i n e s  and  treatment procedures, r e l a t i o n s h i p s with medical p r o f e s s i o n a l s and  f a m i l y members, l i f e events, i s s u e s of m o r t a l i t y , and  own  emotional responses.  their  For example, p a r t of the process of sense making f o r s e v e r a l  123 c o - r e s e a r c h e r s i n v o l v e d comparing MI t o other i l l n e s s e s .  I t was  as though these women had c o n s t r u c t e d a continuum of i l l n e s s s e v e r i t y and ranked MI as b e i n g l e s s severe than other L y d i a suggested  illnesses.  t h a t having Alzheimers was more s e r i o u s than  s u f f e r i n g an MI. She wondered i f t h i s b e l i e f was a c o n t r i b u t i n g f a c t o r t o t h e f a c t t h a t she was not upset by her MI. I have two s i s t e r s with Alzheimers and maybe t h i s has a f f e c t e d the way I f e e l . . . b e c a u s e I can't t h i n k of a n y t h i n g worse and I would very much r a t h e r end i t a l l now than have to go through something l i k e t h a t . . . I t h i n k t h a t makes a d i f f e r e n c e f o r me. Kaye t a l k e d about the high c o s t s of medicare and t h e expense of having a c h r o n i c i l l n e s s such as cancer, been n u r s i n g women with cancer...and  "my g i r l f r i e n d s have  of course t h a t drags out and  out and out...I j u s t pray t o God I don't get a n y t h i n g  like  t h a t . . . i t ' s a long h a u l . " Although  a couple of c o - r e s e a r c h e r s a p p r a i s e d t h e i r  overall  experience with MI as b e i n g t h r e a t e n i n g , other women d i d not. The p e r c e p t i o n of f e e l i n g threatened i s r e l a t e d t o s e v e r a l f a c t o r s i n c l u d i n g the degree t o which a woman's i d e n t i t y has been compromised as a r e s u l t of her i l l n e s s . Kiko d e s c r i b e d f e e l i n g f o r t u n a t e compared t o other p a t i e n t s and was determined  t h a t she  was going t o r e c o v e r . . . . I ' l l get b e t t e r . . . y o u can't be b e a t i n g i t too long...you can't be b e a t i n g i n and s a y i n g you can't do t h i s and you can't do t h a t so I s t i l l determined...I don't know...when I look a t t h e other people I t h i n k t h a t I'm f o r t u n a t e . Although  Penny d i d not f e e l traumatized by her MI and maintained  a p o s i t i v e outlook, she d i d express  c u r i o s i t y about her f u t u r e .  It sounds l i k e a t e r r i b l e t h i n g t o have a don't f e e l t h a t traumatized y e t . . . I don't down the road i t ' s going t o h i t me...I do me...but I don't d w e l l on i t . . . a n d I mean  heart a t t a c k but I know i f somewhere ask...I do say why i t ' s happened and  124 t h e r e ' s not much you can do about i t j u s t s o r t of go on...and t r y t o see t h a t i t doesn't happen again. On t h e other hand, Kaye's account  suggested  she a p p r a i s e d her  o v e r a l l experience with MI as b e i n g t h r e a t e n i n g , "I don't t h i n k i t ' s a n y t h i n g wonderful...I  don't t h i n k i t ' s a wonderful  experience a t a l l . . . I t h i n k i t ' s a t e r r i b l e t h i n g t o be t o l d t h a t you've had a heart a t t a c k . " The Experience of P l a n n i n g f o r t h e Future The  n i n t h major theme emerging from the r e s e a r c h was t h e  experience of p l a n n i n g f o r the f u t u r e . In t h i s context, p l a n n i n g f o r t h e f u t u r e suggests  the process whereby c o - r e s e a r c h e r s  contemplate t h e d i r e c t i o n they would l i k e t h e i r l i v e s t o f o l l o w i n terms of doing s p e c i f i c t h i n g s , adopting s p e c i f i c or making l i f e changes o r adjustments.  attitudes,  Inherent t o t h i s  d e s c r i p t i o n i s the i d e a of c h o i c e and i n t e n t i o n a l i t y . The way i n which c o - r e s e a r c h e r s made sense of t h e i r MI experience i n f l u e n c e d t h e i r a t t i t u d e s about t h e f u t u r e . In g e n e r a l , most of the women i n t h e study demonstrated a p o s i t i v e a t t i t u d e towards both t h e f u t u r e and a r e a l i s t i c a t t i t u d e towards r e c o v e r i n g from MI. These women contemplated  both short-term and long-term  p l a n s , however,  some women were more a c t i v e than others i n terms of p l a n n i n g f o r the f u t u r e . Co-researchers  t h a t p r o v i d e d c a u s a l e x p l a n a t i o n s about t h e i r  i l l n e s s , a l s o tended Roslynn  t o p l a n s t r a t e g i e s t o improve t h e i r h e a l t h .  t a l k e d about the measures t h a t she needed t o take i n  terms of r e c t i f y i n g her h e a l t h . These i n c l u d e d r e d u c i n g her s t r e s s a t home and f i n d i n g an a l t e r n a t e arrangement of care w i t h her mother, as w e l l as undergoing  her own h e a l i n g regime t o  125 c h a l l e n g e t h e need t o have bypass surgery. I w i l l have a v o l u n t e e r coming now twice a week t o take care of her cause I've got t o r e g a i n my l i b e r t y i n order t o cure m y s e l f . . . t h a t ' s t h e o n l y way I ' l l r e g a i n my freedom i s when my mother t r a n s f e r s her r e l i a n c e onto somebody e l s e . . . o n l y a t t h a t time can I move i n t o my c o n t r o l . . . I know I can t r e a t m y s e l f . . . I know I can go f o r walks...I can go onto m e d i c a t i o n ...nobody has g i v e n me the chance t o t r e a t m y s e l f . . . I want the chance t o t r e a t myself n a t u r a l l y b e f o r e the k n i f e i s going t o c u t me open. Noreen a n t i c i p a t e d making some s p e c i f i c changes i n terms of q u i t t i n g smoking and a l t e r i n g her d i e t . I know I ' l l be a l o t more c a r e f u l with my body i n t h e future...whether i t w i l l do me any good o r not I have no i d e a but i t ' s f o r sure worth a t r y . . . l i k e smoking who needs i t . . . the day I had my heart a t t a c k was the l a s t day I had a c i g a r e t t e . . . and I've always been p r e t t y a c t i v e . . . I've never had much of a weight problem...and I've always a t e f a i r l y h e a l t h y too...so I don't know what's going t o happen but I know I'm going t o have t o use common sense and c u t down on s a l t , sugar, and f a t byproducts... I've a l r e a d y c u t a l o t of bad h a b i t s out of my d i e t . Other c o - r e s e a r c h e r s t a l k e d about t a k i n g steps r e l a t e d t o improving t h e i r sense of p e r s o n a l w e l l b e i n g . Kaye needed t o have a sense of p r e p a r a t i o n f o r t h e f u t u r e and emphasized how important i t was f o r her t o r e t u r n t o t h e process of s e l l i n g her house and f i n d i n g more s u i t a b l e accommodation.  Perhaps t a k i n g  care of her house a f f a i r s was what she needed t o do t o reduce her s t r e s s l e v e l and i n d i r e c t l y b e n e f i t her h e a l t h . ...so I w i l l do as much as I p o s s i b l y can...have two or t h r e e y a r d s a l e s . . . I have t o f e e l prepared...I've got t o get r i d o f the p l a c e I've got and the worry of a l l t h e work..and I want t o go i n t o a brand new p l a c e . . . I ' v e got t o have enough c l e a r when I s e l l t h e house I'm in...money wise so I've got a p l a c e t o l i v e w h i l e I'm s t i l l a l i v e . . . a r o o f over my head i n o t h e r words...I've got t o get out t h e r e and s e t t l e d . . . a n d then i f I die... I die. Brynn t a l k e d about making changes i n terms of p e r s o n a l growth. ...I won't do t h e m i n i mouse...mini mouse... she's a f r a i d of s t a n d i n g up f o r herself...maybe I was not as r e p r e s s e d but I know more about myself now...one way t h a t I would change  126 would be t h a t I've l e t people f r i g h t e n me whereas they don't now...it t h a t s t r i c t u p b r i n g i n g you know. Kiko f e l t t h a t she needed t o d r a f t a w i l l a f t e r having been faced with the u n p r e d i c t a b i l i t y of MI. As w e l l , she d e s c r i b e d her plans to continue  t r a v e l l i n g d e s p i t e her h e a l t h ,  "I s t i l l would l i k e t o  go and t r a v e l . . . I've been going every year...so I would  still  l i k e t o go i n s t e a d of s t a y i n g a t home." Other co-researchers  d i s c u s s e d t h e i r u n c e r t a i n t y towards t h e  f u t u r e . Although Anne was eager t o resume l i v i n g her l i f e  fully,  she a l s o expressed some u n c e r t a i n t y about becoming i l l while travelling. I hope t o j u s t go home and get c r a c k i n g and do what I have t o do and d r i v e t h e c a r and "I wonder how long can I go f o r . . . t h e r e ' s so many t h i n g s I want t o do and t h a t ' s one t h i n g I t h i n k about...I want t o go down t o t h e S t a t e s . . . there's a l l s o r t s of t h i n g s happening down t h e r e t h a t we've been i n v i t e d t o and I'm a f r a i d t o do because I don't want anything t o happen t o me while I'm down t h e r e . H i l d a expressed concerns about how she was going t o "cope" with the u n c e r t a i n t y of her h e a l t h . I'd r a t h e r go home with a c l e a n b i l l of h e a l t h i n s t e a d o f having t o take p a r t of my problem home with me now...if I don't have [the bypass] then I'm going t o be t a k i n g t h e problem home with me and how I'm supposed t o cope with t h a t o r whatever I have no i d e a . Noreen f e l t worried  as t o what would happen t o her c h i l d r e n i f  she d i d not s u r v i v e her i l l n e s s . ...what's going t o happen t o them...maybe leave a message f o r them a f t e r they're gone which i s one t h i n g t h a t I want t o do when I get out of here... compose a l e t t e r t o each one of them...just some l i t t l e t h i n g t h a t ' s there when I'm not t h e r e any more...that they might be able t o get something from. Penny f e l t some u n c e r t a i n t y around what she was going t o be able t o do once she r e t u r n e d  home.  ...not knowing how much I'm going t o be able t o do...[my  127 husband] i s w o r r i e d about having t o go back t o work and I'm going how I'm going t o cope with t h i n g s when he's not t h e r e . . . t h o s e t h i n g s don't r e a l l y worry me...I'11 do whatever I can and whatever can't get done and t h a t k i n d of thing...I'm not going t r y . . . f e e l I have t o vacuum once a week o r do any of those t h i n g s . . . I t o l d [my husband] t h a t I'm going t o do whatever t h e d o c t o r t h i n k s t h a t I'm up t o doing and wait and see. Some of the women with f a m i l i e s f e l t  t h a t they wanted t o s e t  examples f o r t h e i r c h i l d r e n . Brynn wanted t o be a model t o her c h i l d r e n i n terms of how t o b e t t e r take care of themselves. ...the c o n t r i b u t i o n . . . y o u know t h a t I t h i n k I've s e t f o r my c h i l d r e n . . . I mean p e r s o n a l l y I f e e l t h a t I can t a l k t o them o r teach them...I've t a l k e d t o them about look a t t h e f a c t t h a t I smoke and I'm overweight... use i t as an example... maybe of what not t o do...don't l e t t h i n g s get too f a r along b e f o r e you take a c t i o n . S e v e r a l c o - r e s e a r c h e r s t a l k e d about the importance  of b e i n g  a b l e t o see progress i n terms of t h e i r r e c o v e r y from MI. Penny felt  t h a t she c o u l d be p a t i e n t with the process of r e c o v e r y i f  she c o u l d reach s m a l l m i l e s t o n e s a l o n g t h e way. ...I can l i v e w i t h not knowing e x a c t l y what day I'm going to be a b l e t o do t h i s . . . a s l o n g as I know t h a t t h e r e ' s going t o be gradual steps a l o n g the way...sort of l i k e m i l e s t o n e s t h a t you know...at some p o i n t you can do t h i s and a t some p o i n t you can do t h i s . . . s o m e t h i n g t o aim f o r and t o know when you get t o each one...I don't want i t t o take a l o n g time but I guess t h e r e ' s not much you can do . . . f o l l o w the d o c t o r ' s orders I g u e s s . . . t r y t o do t h e best. Summary Co-researchers  d e s c r i b e d t h e i r experience of MI as b e i n g  more than an i l l n e s s event c h a r a c t e r i z e d by h o s p i t a l i z a t i o n . Nine common themes emerged from women's accounts e x p e r i e n c e s . The presence  of t h e i r MI  of these themes suggests  that i t i s  the i n t e r a c t i o n and e x p r e s s i o n of these themes t h a t c o n s t i t u t e the c o - r e s e a r c h e r ' s MI experience.  Important here i s t h e  n o t i o n of examining the e n t i r e t y of a women's experience of MI  128 as opposed t o a d e s c r i p t i o n of the d i s e a s e . Although  i t i s c l e a r t h a t t h e r e are commonalities  c o - r e s e a r c h e r accounts,  across  t h e r e was much v a r i a b i l i t y i n terms of  how these themes were expressed.  Moreover, the s i g n i f i c a n c e  t h a t c o - r e s e a r c h e r ' s a t t a c h e d t o the themes or aspects of the themes a l s o  varied.  129 CHAPTER FIVE D i s c u s s i o n of t h e F i n d i n g s Introduction The purpose of t h i s study was t o e x p l o r e t h e nature of women's experience of MI. In-depth were conducted  semi-structured interviews  with 10 female c o - r e s e a r c h e r s , between the ages  of 40 and 75, t h a t were h o s p i t a l i z e d and diagnosed with MI. More s p e c i f i c a l l y , t h i s study explored women's experience of MI d u r i n g the acute phase of h o s p i t a l i z a t i o n and r e c o v e r y . Although the study was p i o n e e r i n g i n some a s p e c t s , some of t h e f i n d i n g s were nonetheless c o n s i s t e n t w i t h p r e v i o u s r e s e a r c h . Phenomenological  data a n a l y s i s of the t r a n s c r i b e d  i n t e r v i e w s l e d t o t h e i d e n t i f i c a t i o n of nine common themes. These nine common themes i n c l u d e d the f o l l o w i n g e x p e r i e n c e s : i l l n e s s awareness, f e e l i n g e m o t i o n a l l y overwhelmed, f e a r and worry, l o s s , d i f f i c u l t y a s k i n g f o r or r e c e i v i n g help from o t h e r s , needing i n f o r m a t i o n , care and support, making sense of the MI experience, and p l a n n i n g f o r t h e f u t u r e . Despite the uniqueness  and v a r i a b i l i t y t h a t c h a r a c t e r i z e d  women's experience of MI, a l l nine themes were e v i d e n t i n almost a l l of t h e c o - r e s e a r c h e r ' s accounts. Although  each  theme had i t s own d i s c e r n a b l e f e a t u r e s , s e v e r a l of t h e themes i n t e r a c t e d w i t h each other, thereby r e f l e c t i n g the complex nature of the MI experience. I n t e g r a t i n g Current and Previous Previous Q u a l i t a t i v e  Research  Research  The present r e s e a r c h i d e n t i f i e d s e v e r a l themes t h a t were c o n s i s t e n t with p r e v i o u s r e s e a r c h . F o r example, a number o f  130 themes were s i m i l a r t o f i n d i n g s i n Dunn's (1985) study t h a t examined women's p e r c e p t i o n s of t h e i r i l l n e s s experience w i t h MI p o s t - h o s p i t a l d i s c h a r g e . Dunn found t h a t l o s s p r o v i d e d an o v e r r i d i n g framework t h a t c h a r a c t e r i z e d women's e x p e r i e n c e s . The c u r r e n t study a l s o i d e n t i f i e d l o s s as a common theme, although l o s s d i d not r e f l e c t the c o - r e s e a r c h e r s dominant experience. During the acute phase of recovery, the time frame examined i n t h i s study, themes such as i l l n e s s  awareness,  f e e l i n g e m o t i o n a l l y overwhelmed, f e a r and worry, the need f o r i n f o r m a t i o n , and making sense of the MI  experience, were found  t o be of equal s i g n i f i c a n c e . In Dunn's study, these themes were subsumed under d i f f e r e n t aspects of the l o s s framework. T h i s would make sense i n terms of the time which e l a p s e d between the MI  event and r e s e a r c h i n t e r v i e w s i n Dunn's study  as c o - r e s e a r c h e r s had more of an o p p o r t u n i t y t o  fully  experience recovery and a s s i m i l a t e t o the e f f e c t s of MI as the sense of l o s s appeared  t o evolve with  time.  S i m i l a r l y , although both a n x i e t y and d e p r e s s i o n occur w i t h s i g n i f i c a n t frequency a f t e r MI  (Mayou et a l . , 1978), i t i s  o n l y when an i n d i v i d u a l has had s u f f i c i e n t time t o comprehend the r e a l i t y of the p o t e n t i a l t h r e a t t o l i f e and the p o t e n t i a l f o r f u t u r e i n c a p a c i t y t h a t the d e p r e s s i o n i s l i k e l y t o p r e s e n t with c l i n i c a l prominence (Degre-Coustry  & G r e v i s s e , 1982).  Although Dunn made r e f e r e n c e t o the theme of support,  and  r e c e i v i n g help, these themes were construed i n a much d i f f e r e n t manner than the c u r r e n t study. In Dunn's study, women r e p o r t e d e x p e r i e n c i n g a l a c k of a n t i c i p a t e d support t h e i r f a m i l i e s , p a r t i c u l a r l y from t h e i r husbands, a f t e r  from  131 r e t u r n i n g home from t h e h o s p i t a l . Previous r e s e a r c h i n t h i s area supports t h i s f i n d i n g  (Boogard, 1984, 1985).  In c o n t r a s t , most women i n t h e c u r r e n t study r e p o r t e d r e c e i v i n g a great d e a l of support from f a m i l y and f r i e n d s . The acute and l i f e t h r e a t e n i n g nature of t h e MI experience i s more prominent d u r i n g e a r l y h o s p i t a l i z a t i o n Subsequently, illness  (Byrne,  1990).  t h e r e i s a great need f o r support d u r i n g t h i s  phase as t h e heart p a t i e n t i s o f t e n  extremely  p h y s i c a l l y and e m o t i o n a l l y v u l n e r a b l e . The f i v e  co-researchers  with spouses d e s c r i b e d them as b e i n g very s u p p o r t i v e p r i o r t o and d u r i n g h o s p i t a l i z a t i o n . E i t h e r these women experienced a d i f f e r e n t q u a l i t y of support than r e p o r t e d i n p r e v i o u s r e s e a r c h o r perhaps, more r e a l i s t i c a l l y , the nature of support women r e q u i r e and r e c e i v e changes once they r e t u r n home a f t e r h o s p i t a l d i s c h a r g e and move through Eaker (1989) suggests  the process of r e c o v e r y .  t h a t women l a c k i n g s o c i a l  support  were found t o have higher m o r t a l i t y r a t e s post MI compared t o women who r e p o r t e d having l a r g e s o c i a l networks. T h i s i s p a r t i c u l a r l y r e l e v a n t f o r o l d e r women, where l i v i n g  alone  because of spousal death i s normative. Current study f i n d i n g s a l s o r e v e a l e d t h a t many of t h e cor e s e a r c h e r s had d i f f i c u l t y a s k i n g f o r o r r e c e i v i n g help from medical p r o f e s s i o n a l s , f a m i l y , and/or f r i e n d s . Moreover, d u r i n g the h o s p i t a l i z a t i o n process, s e v e r a l women's r e p o r t s suggested  they f e l t  s t r i p p e d of t h e i r r o l e s as n u r t u r e r s and  c a r e t a k e r s , and o f t e n f e l t uncomfortable  with b e i n g i n t h e  p o s i t i o n o f r e c e i v i n g care and a t t e n t i o n from o t h e r s . Dunn a l s o i d e n t i f i e d women's d i f f i c u l t y a s k i n g f o r o r r e c e i v i n g  132 help i n the context of r e t u r n i n g home t o t h e i r f a m i l i e s and t o household  r e s p o n s i b i l i t i e s . Boogard (1984, 1985)  r e s u l t s i n her study examining r e h a b i l i t a t i o n post Jensen and A l l e n  found  similar  women's and men's experience of  MI. (19.94) conducted  a meta-analysis of t h r e e  methods of q u a l i t a t i v e r e s e a r c h examining w e l l n e s s , and i l l n e s s ,  health, disease,  i n c l u d i n g s t u d i e s from grounded theory,  phenomenology, and ethnography. The  s y n t h e s i s of grounded  theory r e s e a r c h , which i n c l u d e d one  study examining  (Johnson  MI  & Morse, 1990), i d e n t i f i e d a s e r i e s of phases  r e l a t i n g t o the process of l i v i n g with h e a l t h - d i s e a s e . These phases suggest t h a t people's  experience of i l l n e s s moves a l o n g  a t r a j e c t o r y b e g i n n i n g with a l a c k of understanding of the i l l n e s s , and ending as the i n d i v i d u a l comes t o terms w i t h t h e i r new  l i f e . More s p e c i f i c a l l y , Jensen and A l l e n  identified  the phases of t h i s process t o i n c l u d e comprehending, managing, b e l o n g i n g , n o r m a l i z i n g , and v a l u i n g . T h i s s y n t h e s i s or developed  theory p r o v i d e s a means t o make sense of the p r e s e n t  r e s e a r c h i n terms of a r r a n g i n g v a r i o u s experiences and themes i n t o some form of sequence based on the c o - r e s e a r c h e r ' s experience. The u n f o l d i n g process of the MI  experience and emergent  themes, as d e s c r i b e d by most of the women i n the c u r r e n t study, a l s o appeared  t o resemble a s i m i l a r t r a j e c t o r y .  The  process of l i v i n g with d i s e a s e began with women e x p e r i e n c i n g an i l l n e s s awareness i n a s i m i l a r f a s h i o n t o Jensen A l l e n ' s n o t i o n of "comprehending." Co-researchers appeared  and  then  t o begin "managing" or coping with the events of  133 i l l n e s s and h o s p i t a l i z a t i o n . Emotional r e a c t i v i t y i n c l u d i n g a sense of l o s s appeared  t o be p a r t of t h i s p r o c e s s . F o r these  women, "belonging" r e f e r r e d more t o t h e experience of care and support than t o the process of r e n e g o t i a t i n g i n t e r - p e r s o n a l r e l a t i o n s h i p s i n the c a p a c i t y of a person  l i v i n g with c h r o n i c  i l l n e s s as i d e n t i f i e d by Jensen and A l l e n .  "Normalizing" and  " v a l u i n g " p a r a l l e l s t h e way women i n t h e c u r r e n t study made sense of t h e i r MI experience, and contemplated  the future  d i r e c t i o n of t h e i r l i v e s . T h i s l a t t e r phase marks t h e end of the t r a j e c t o r y as w e l l as t h e end of the acute i l l n e s s phase and the h o s p i t a l i z a t i o n p r o c e s s . U n l i k e most of t h e s t u d i e s i n Jensen and A l l e n ' s (1994) s y n t h e s i s of grounded r e s e a r c h , most of the c o - r e s e a r c h e r s i n t h i s study had not y e t had t h e o p p o r t u n i t y t o f u l l y i n t e g r a t e t h e i r experience of MI i n t o the l a r g e r context of t h e i r as i n t e r v i e w s took p l a c e d u r i n g h o s p i t a l i z a t i o n .  lives  Nonetheless,  the t r a j e c t o r y d e s c r i b e d by Jensen and A l l e n i n many ways i s an a p p r o p r i a t e meta-structure d e s c r i b i n g the experience of t h e women i n t h i s study. Perhaps t h i s suggests t h a t t h e process of l i v i n g with i l l n e s s i s comprised  of not one, but a s e r i e s of  t r a j e c t o r i e s t h a t begin with a l a c k of understanding of t h e i l l n e s s and end with a sense of having coming t o terms w i t h the experience. Jensen and A l l e n ' s (1994) s y n t h e s i s of studies  phenomenological  (none of which examined t h e experience of MI)  i d e n t i f i e d common themes t h a t d e s c r i b e d t h e l i v e d  experience  of h e a l t h and d i s e a s e . F o r the purpose of t h i s d i s c u s s i o n , I focus on the phenomenological  themes t h a t r e l a t e t o t h e l i v e d  134 experience of d i s e a s e only, which i n c l u d e l o s s of v i t a l i t y , sense of imbalance  o r u n c e r t a i n t y , sense of a l i e n a t i o n ,  hopelessness, pessimism, and transcendence.  S i m i l a r i t i e s were  e v i d e n t between these themes and aspects of themes t h a t emerged from the c u r r e n t r e s e a r c h . F o r example, l o s s of v i t a l i t y d e s c r i b e d many women's experience of l o s s of p h y s i c a l and emotional  i n t e g r i t y . The sense of imbalance  p a r a l l e l e d the  experience of f e e l i n g e m o t i o n a l l y overwhelmed, f e a r , and a n x i e t y . Although  several co-researchers described f e e l i n g a  sense of u n c e r t a i n t y towards t h e i r f u t u r e and towards t h e i r recovery process, most of t h e women maintained a somewhat p o s i t i v e , h o p e f u l , and r e a l i s t i c a t t i t u d e about t h e i r MI experience and towards t h e f u t u r e . T h i s resonated with and A l l e n ' s theme of transcendence  Jensen  as opposed t o t h e theme of  pessimism. S e v e r a l themes emerged from the c u r r e n t r e s e a r c h t h a t were not addressed  i n Jensen and A l l e n ' s phenomenological  synthesis  i n c l u d e d having d i f f i c u l t y a s k i n g f o r and r e c e i v i n g help  from  o t h e r s , the experience of needing i n f o r m a t i o n , and the experience of care and support. C u r a t i v e versus C a r i n g Another area of p r e v i o u s r e s e a r c h examines i s s u e s r e l a t e d to women, medicine,  and h e a l t h (Oakley,  d i f f e r e n t i a t e s between medicine's  1993).  Oakley  c u r a t i v e model of h e a l t h and  i l l n e s s , w i t h the c a r i n g and environmental  model found i n  n u r s i n g . C u r a t i v e denotes a focus upon p h y s i c a l r e p a i r and i s informed by the b e l i e f t h a t good medical p r a c t i c e i s based upon a r a t i o n a l , detached  a t t i t u d e . Inherent t o t h i s approach  135 i s t h e p a t r i a r c h a l d o c t o r / p a t i e n t r e l a t i o n s h i p where t h e p r o f e s s i o n a l i s s o l e l y r e s p o n s i b l e f o r making judgments and treatment d e c i s i o n s about t h e w e l f a r e of p a t i e n t s . In c o n t r a s t , c a r i n g has become synonymous with the n u r s i n g p r o f e s s i o n , which supports i n d i v i d u a l i s a necessary  the b e l i e f that caring f o r the c o n d i t i o n f o r r e s t o r i n g one's  h e a l t h . Oakley (1993) f u r t h e r suggests t h a t r a t e s of p a t i e n t s a t i s f a c t i o n with n u r s i n g care a r e g e n e r a l l y higher  than  p a t i e n t s a t i s f a c t i o n with the care d e r i v e d from p h y s i c i a n s f o r two  reasons.  First,  nurses tend t o o f f e r emotional  support,  and  second, nurses o f t e n p r o v i d e i n f o r m a t i o n t o p a t i e n t s who  have d i f f i c u l t y o b t a i n i n g s u f f i c i e n t i n f o r m a t i o n from t h e i r d o c t o r s . T h i s i s c o n s i s t e n t with the f i n d i n g s of t h e c u r r e n t study where co-researchers  d e s c r i b e d the r e l a t i o n s h i p t o  h e a l t h care p r o f e s s i o n a l s as b e i n g an i n f l u e n t i a l f a c t o r i n t h e i r experience  of MI.  More s p e c i f i c a l l y , women i n t h e c u r r e n t study  typically  d i s t i n g u i s h e d between the care they r e c e i v e d from nurses and the care r e c e i v e d from doctors while h o s p i t a l i z e d . A l l of t h e women expressed  t h e i r a p p r e c i a t i o n f o r t h e compassionate and  r e s p e c t f u l q u a l i t y of care and a t t e n t i o n they r e c e i v e d from the n u r s i n g s t a f f . In c o n t r a s t , women d e s c r i b e d having mixed r a p p o r t with t h e i r d o c t o r s , although  a few d e s c r i b e d  feeling  very s a t i s f i e d . These women f e l t t h a t r a p p o r t was based on t h e degree t o which t h e i r doctors p r o v i d e d and  s a t i s f a c t o r y treatment  i n f o r m a t i o n , as w e l l as the manner i n which  doctors  r e l a t e d t o them as i n d i v i d u a l s . These f a c t o r s a r e important i n as much as the p e r c e i v e d sense of care and t h e amount of  136 information  women were given  sense of t h e i r MI  c o n t r i b u t e d to how  they made  experience.  Importance of Communication Other r e s e a r c h  i n the area of communication and  patient  s a t i s f a c t i o n appears t o support these l a t t e r f i n d i n g s . In general,  e f f e c t i v e communication between p a t i e n t s and  health  care p r o f e s s i o n a l s has been w i d e l y c i t e d i n the l i t e r a t u r e a p r e r e q u i s i t e t o p a t i e n t s a t i s f a c t i o n with h e a l t h care  as  (Spiro  & H e i d r i c h c i t e d i n Burgoon, et a l . , 1987). Weisman and  Teitelbaum (1985) argue t h a t f a c t o r s  s i g n i f i c a n t f o r p a t i e n t s a t i s f a c t i o n i n c l u d e the of i n f o r m a t i o n ,  and  the n e g o t i a t i v e q u a l i t y and  of the d o c t o r - p a t i e n t Buller  communication a f f e c t i v e tone  relationship. Similarly, Buller  (1987) found t h a t p a t i e n t ' s e v a l u a t i o n s  were based on p h y s i c i a n ' s  communication and  and  of medical  care  technical  competence. In other words, p a t i e n t ' s e v a l u a t i o n s  of  communication s t y l e s were s t r o n g l y a s s o c i a t e d with r e c e i v i n g s a t i s f a c t o r y medical care. B u l l e r and B u l l e r a l s o found t h a t p h y s i c i a n s who  adopted a more a f f i l i a t i v e  s t y l e of  communication with t h e i r p a t i e n t s , which comprised of personcentered  q u a l i t i e s such as empathy, genuineness, a u t h e n t i c i t y ,  warmth, and  a non-judgemental a t t i t u d e , g e n e r a l l y produced  more f a v o u r a b l e  evaluations  based on dominance and  than d i d communication s t y l e s  c o n t r o l . T h i s f i n d i n g has  been  documented by s e v e r a l other  researchers  Burgoon et a l . , 1987;  I r i s h , Roter, E h r l i c h , & M i l l e r ,  1994;  Hall,  (Ben-Sira,  1980;  S t r e e t & Weimann, 1987). Moreover, the q u a l i t i e s  p a t i e n t s i d e n t i f i e d as being  favourable  i n physician  that  137 evaluations  ( B u l l e r & B u l l e r , 1987), c l o s e l y resembled  person-centered q u a l i t i e s t h a t many c o - r e s e a r c h e r s i n the n u r s i n g s t a f f while  the  identified  hospitalized.  C o n s i d e r i n g the extent t o which communication i s an i n h e r e n t f a c t o r i n so many tasks w i t h i n h e a l t h care s e t t i n g s , it  should not be s u r p r i s i n g t h a t the communication s t y l e of  medical p r o f e s s i o n a l s p l a y s an important r o l e i n p e r c e i v e d medical competence. In g e n e r a l , the manner i n which medical p r o f e s s i o n a l s communicate with t h e i r p a t i e n t s may  be more  important than the content of the communication ( B u l l e r & Buller,  1987). Consequently,  communication s t y l e should be a  major concern f o r p h y s i c i a n s i n order t o help f a c i l i t a t e  the  q u a l i t y of p e r c e i v e d medical care and the s a t i s f a c t i o n of t h e i r p a t i e n t s . Moreover, i t would l i k e l y be b e n e f i c i a l f o r p h y s i c i a n s t o t a i l o r t h e i r communication s t y l e s t o meet the needs of the i n d i v i d u a l p a t i e n t . Importance of  Information  Study f i n d i n g s suggested was  c r u c i a l t o t h e i r MI  understanding  t h a t women's need f o r i n f o r m a t i o n  experience, not o n l y i n terms of  symptoms and treatment,  and a p p r a i s i n g the  q u a l i t y of care r e c e i v e d from h e a l t h care p r o f e s s i o n a l s ,  but  a l s o i n terms of seeking h e a l t h i n f o r m a t i o n . Information allowed s e v e r a l c o - r e s e a r c h e r s t o have a g r e a t e r sense of involvement  i n t h e i r i l l n e s s p r o c e s s . Moreover i t enabled them  to make informed d e c i s i o n s about treatment,  lessened the  u n c e r t a i n t y of what t o expect i n the f u t u r e , and i n g e n e r a l , served as a means t o f a c i l i t a t e a g r e a t e r understanding t h e i r MI  experience. Although the importance  of  of o b t a i n i n g  138 i n f o r m a t i o n emerged i n previous  research  not r e p o r t e d as b e i n g as urgent  as i n t h e c u r r e n t  Perhaps t h e need f o r concrete critical  (Dunn, 1985), i t was study.  i n f o r m a t i o n may appear more  f o r women i n the h o s p i t a l i z a t i o n phase of i l l n e s s  than d u r i n g p o s t - h o s p i t a l d i s c h a r g e where t h e acuteness of t h e emergency and t h e l i k l i h o o d of death i s not as imminent. Co-researcher  accounts suggested t h a t some women were more  a c t i v e and s u c c e s s f u l a t seeking i n f o r m a t i o n than o t h e r s . M i l l e r ' s research  ( c i t e d i n M i l l e r , Brody, & Summerton, 1988)  on i n f o r m a t i o n p r o c e s s i n g s t y l e s may a l s o be u s e f u l i n terms of making sense of these  f i n d i n g s . M i l l e r suggested t h a t when  i n d i v i d u a l s a r e threatened  by unfavourable  i n f o r m a t i o n - p r o c e s s i n g behavior  will  events,  their  l i k e l y f o l l o w one of two  main dimensions. Subsequently, i n d i v i d u a l s w i l l tend t o e i t h e r seek out and monitor f o r i n f o r m a t i o n r e l e v a n t t o t h e t h r e a t , or d i s t r a c t from and b l u n t t h r e a t r e l e v a n t i n f o r m a t i o n . In t h e case of MI, r e l e v a n t i n f o r m a t i o n may i n c l u d e t h e p e r c e p t i o n of b o d i l y symptoms, as w e l l as i n f o r m a t i o n a c q u i r e d from h e a l t h care p r o f e s s i o n a l s . Most of the women i n t h e study, monitors, MI,  like  appeared t o seek out i n f o r m a t i o n r e l a t e d t o t h e i r  w h i l e other women, l i k e b l u n t e r s , tended t o d i s t r a c t  from  acquiring d i r e c t information r e l a t e d to t h e i r condition. M i l l e r , e t a l . , (1988) suggested t h a t a medical p r o f e s s i o n a l ' s management of acute medical  problems might  i n c l u d e a s p e c i f i c and r o u t i n e assessment i n order t o i d e n t i f y and respond t o a p a t i e n t ' s p r e f e r r e d i n f o r m a t i o n  processing  s t y l e and subsequent need f o r i n f o r m a t i o n . F o l l o w i n g  this  assessment, the p h y s i c i a n c o u l d then t a i l o r t h e degree of  139 i n f o r m a t i o n disseminated  t o t h e i n d i v i d u a l based on t h a t  person's i d e n t i f i e d needs. T h i s h i g h l i g h t s t h e importance of maintaining  a c o l l a b o r a t i v e r e l a t i o n s h i p between p h y s i c i a n s  and t h e i r p a t i e n t s . I t i s l i k e l y t h a t other f a c t o r s may i n f l u e n c e women's p r o p e n s i t y f o r i n f o r m a t i o n seeking i n c l u d i n g previous experiences,  s o c i o - c u l t u r a l f a c t o r s , t h e knowledge t o ask f o r  and d i s c u s s s p e c i f i c i n f o r m a t i o n and concerns,  and t h e a b i l i t y  t o c h a l l e n g e treatment d e c i s i o n s . S e v e r a l of these f a c t o r s a l l u d e t o t h e power d i f f e r e n t i a l i n h e r e n t i n t h e s o c i a l l y c o n s t r u c t e d d o c t o r - p a t i e n t r e l a t i o n s h i p whereby male d o c t o r s f r e q u e n t l y assume they know what i s best f o r female p a t i e n t s . Whereas co-researcher  accounts suggested t h a t  doctors  i n t e r p r e t e d women's l a c k of i n f o r m a t i o n seeking as e i t h e r understanding, was  i n d i f f e r e n c e , or p e r m i s s i o n ,  women's s i l e n c e  o f t e n r e l a t e d t o f e a r f u l n e s s and d i s e n t i t l e m e n t around  speaking being  out. F o r example, Gina, who d e s c r i b e d h e r s e l f as  "normally  outspoken," was c e r t a i n t h a t she d i d not want  to " c r i t i c i z e " t h e surgeon "who [was] going t o be h o l d i n g [her] heart i n h i s hand" d e s p i t e f e e l i n g s c e p t i c a l about t h e recommendation f o r bypass surgery.  S i m i l a r l y , Anne d e s c r i b e d  h e r s e l f as b e i n g a " p r e t t y good p a t i e n t " because she d i d not "complain very much" d e s p i t e f e e l i n g a few o c c a s i o n s . More s p e c i f i c a l l y ,  " f u r i o u s " with d o c t o r s on she d e s c r i b e d one i n c i d e n t  where "[she] d i d n ' t say a word and kept very q u i e t " a f t e r a s p e c i a l i s t had been e x c e s s i v e l y i n s e n s i t i v e i n h i s d e l i v e r y of a discouraging surgical  prognosis.  Future r e s e a r c h examining the k i n d of i n f o r m a t i o n most  140 wanted by female  c a r d i a c p a t i e n t s , as w e l l as the most  e f f e c t i v e means t o communicate t h i s i n f o r m a t i o n would have important  i m p l i c a t i o n s f o r f u t u r e h e a l t h care f o r women.  S t r e s s o r s A s s o c i a t e d with MI Other r e s e a r c h i n t h e area of heart d i s e a s e suggests t h a t the s t r e s s o r s a s s o c i a t e d with MI a r e d i v e r s e and may v a r y depending of t h e i r meaningfulness Lazarus,  to the i n d i v i d u a l  1979; Compas & Orosan 1993; King, 1985). Co-  r e s e a r c h e r s d e s c r i b e d v a r y i n g degrees impacted  (Cohen &  t o which they were  by p h y s i c a l and emotional s t r e s s o r s . The cause of  d i s t r e s s v a r i e d g r e a t l y amongst the women and ranged i n s e v e r i t y from f e e l i n g anxious t o e m o t i o n a l l y overwhelmed i n response  t o p h y s i c a l symptomology, treatment procedures, t h e  process of r e c e i v i n g care, and the worry surrounding t h e need to  manage p e r s o n a l a f f a i r s . M u l t i p l e f a c t o r s t h a t i n f l u e n c e d  how women made meaning of t h e i r MI experience i n c l u d e d the s e v e r i t y of MI and t h e r e s u l t i n g degree of f u n c t i o n a l impairment, p r e v i o u s experience of MI, o r o t h e r c a r d i a c h i s t o r y , d i r e c t o r i n d i r e c t experience of p r e v i o u s h o s p i t a l i z a t i o n o r other i l l n e s s , h i s t o r y of r a p p o r t with d o c t o r s , p e r c e i v e d q u a l i t y of medical care and s o c i a l current l i f e  support,  s t r e s s , s o c i o c u l t u r a l f a c t o r s , and p e r s o n a l i t y  t r a i t s such as coping s t y l e and s e l f esteem. A p p r a i s a l s and Coping An i n d i r e c t f i n d i n g of t h e c u r r e n t study demonstrated t h a t c o - r e s e a r c h e r s u t i l i z e d v a r i o u s s t r a t e g i e s i n order t o cope with t h e p o t e n t i a l l y l i f e t h r e a t e n i n g experience of MI. F o r example, although H i l d a maintained a p o s i t i v e focus and  141 d e s c r i b e d f e e l i n g changed as a r e s u l t of her MI and experience of c a r d i a c a r r e s t , L y d i a appeared  t o d i s t a n c e h e r s e l f from t h e  s e v e r i t y of having s u f f e r e d a MI. In c o n t r a s t , one of Penny's s t r a t e g i e s i n v o l v e d d i r e c t l y a s k i n g her d o c t o r s f o r i n f o r m a t i o n and r e s u l t e d i n a l l e v i a t i n g f e e l i n g s of a n x i e t y . Co-researcher accounts demonstrated  that  individual  d i f f e r e n c e s were e v i d e n t i n t h e way t h a t women assessed t h e s e v e r i t y of t h e i r c a r d i a c T h i s process appears  event. t o p r o v i d e support f o r Lazarus and  Folkman's (1984) model of s t r e s s and coping, which  suggests  t h a t a p p r a i s a l s a r e an e v a l u a t i v e c o g n i t i v e process  through  which an i n d i v i d u a l judges t h e p e r s o n a l s i g n i f i c a n c e of a t r a n s a c t i o n with the environment.  Subsequently,  individuals  a p p r a i s e both the s i t u a t i o n with r e s p e c t t o i t s importance f o r t h e i r w e l l - b e i n g , as w e l l as i n terms of t h e i r  available  coping r e s o u r c e s . Lazarus and Folkman f u r t h e r suggest t h a t understanding a person's a p p r a i s a l of meaning, o r what i s p e r s o n a l l y a t stake i n a s t r e s s f u l encounter, p r o v i d e s r e l e v a n t i n f o r m a t i o n f o r understanding why the s i t u a t i o n has been a p p r a i s e d as s t r e s s f u l . Moreover, the degree of s t r e s s t h a t an i n d i v i d u a l experiences w i l l depend on how much of a stake t h a t person has i n t h e outcome of the s t r e s s f u l encounter o r event.  Typically,  s t r e s s f u l encounters a r e a p p r a i s e d as b e i n g e i t h e r r e l a t e d t o l o s s , t h r e a t e n i n g , harmful, o r c h a l l e n g i n g . For women i n the c u r r e n t study, a p p r a i s a l s  significantly  e f f e c t e d t h e impact of t h e MI event, as w e l l as t h e r e s u l t i n g s u b j e c t i v e r e a c t i o n s and c h o i c e s of coping. Although  some co-  142 r e s e a r c h e r s appeared to a p p r a i s e t h e i r MI more as a t h r e a t and expressed illness,  a n x i e t y about the a n t i c i p a t e d negative impact  of the  other women seemed to a p p r a i s e MI more i n terms of  immediate harm and l o s s . For example, although Penny d e s c r i b e d not f e e l i n g immediately t o be concerned  "traumatized" by her MI,  she appeared  about f u t u r e r a m i f i c a t i o n s of the event  wondered what she c o u l d do to prevent another  and  a t t a c k . In  c o n t r a s t , Kaye a p p r a i s e d her MI as b e i n g a " t e r r i b l e t h i n g " and appeared more a d v e r s e l y e f f e c t e d , both p h y s i c a l l y e m o t i o n a l l y , by the  and  experience.  Sykes (1994) suggested  t h a t i n d i v i d u a l s who  made n e g a t i v e  c o g n i t i v e a p p r a i s a l s of MI and of t h e i r a b i l i t y t o cope were l i k e l y t o experience g r e a t e r l e v e l s of r e s u l t i n g a n x i e t y , whereas i n d i v i d u a l s t h a t maintained appraisals  (saw  subsequently  more p o s i t i v e c o g n i t i v e  some b e n e f i t stemming from t h e i r  demonstrated lower  MI),  l e v e l s of m o r b i d i t y  (Affleck,  Tennen, Croog, & Levine c i t e d i n Sykes, 1994). T h i s p r o v i d e s support f o r Lazarus and Folkman's (1984) b e l i e f t h a t a p p r a i s a l s and coping processes  e f f e c t a d a p t a t i o n a l and h e a l t h  outcomes. T h i s has important  i m p l i c a t i o n s f o r medical p r a c t i c e as  an  i n d i v i d u a l ' s a p p r a i s a l of t h e i r i l l n e s s c o n d i t i o n i s i n f l u e n c e d by many f a c t o r s i n c l u d i n g t h e i r p e r c e i v e d sense of care from h e a l t h care p r o f e s s i o n a l s . As t h i s study  has  demonstrated, o b t a i n i n g concrete i n f o r m a t i o n from d o c t o r s nurses  i s an important  aspect of t h i s c a r e .  and  Subsequently,  p r o v i d i n g p a t i e n t s with c l e a r and comprehensive i n f o r m a t i o n i s l i k e l y one  f a c t o r t h a t w i l l i n f l u e n c e how  they a p p r a i s e t h e i r  143 i l l n e s s as w e l l as v a r i o u s aspects of the h o s p i t a l  experience.  Keckeisen and Nyamathi (1990) suggest t h a t i n c r e a s e d knowledge and i n f o r m a t i o n f o r the MI p a t i e n t may  promote f e e l i n g s of  having a g r e a t e r sense of c o n t r o l over one's h e a l t h , and  may  p o s i t i v e l y influence t h e i r psychological well-being. It i s important t o emphasize t h a t a p a t i e n t ' s i n f o r m a t i o n needs are s p e c i f i c t o t h a t person and w i l l be i n f l u e n c e d by  their  a p p r a i s a l s or what i s a t stake f o r the person. For example, Roslynn a p p r a i s e d the e f f e c t s of memory l o s s as b e i n g a t h r e a t t o her i d e n t i t y as a p r o f e s s o r , and a c t i v e l y  sought  i n f o r m a t i o n t h a t would enable her t o o f f s e t aspects of the memory l o s s and help t o a l l e v i a t e f e e l i n g s of powerless this  around  experience. Current study f i n d i n g s a l s o appear t o support  the  l i t e r a t u r e ' s c o n t e n t i o n t h a t the t h r e a t t o p e r s o n a l h e a l t h i s not always the most s t r e s s f u l aspect of one's i l l n e s s  (Compas  & Orosan, 1993). Co-researchers most f r e q u e n t l y i d e n t i f i e d f e e l i n g concerned  about r e l a t i o n s h i p s and the w e l l b e i n g of  s i g n i f i c a n t others as b e i n g what was  most a t stake w i t h the  onset of MI. A few other women i d e n t i f i e d t h e i r a b i l i t y t o manage p e r s o n a l a f f a i r s as b e i n g most t h r e a t e n e d by i l l n e s s . These concerns  their  appear t o p a r a l l e l the c a t e g o r i e s of  a f f i l i a t i o n and achievement-power t h a t were i d e n t i f i e d i n Compas's ( c i t e d i n Compas & Orosan, 1993)  work w i t h  cancer  p a t i e n t s as b e i n g aspects of t h e i r i l l n e s s or treatment t h a t they c o n s i d e r e d t o be most s t r e s s f u l . In g e n e r a l , other concerns  i d e n t i f i e d by c o - r e s e a r c h e r s appeared  under Compas' comprehensive framework and  t o be subsumed  paralleled  144 categories i n c l u d i n g altruism-humanitarianism,  l i f e and  m o r t a l i t y , and autonomy. Gilligan's may  (1982) work i n the area of women's development  be u s e f u l i n terms of making sense of c o - r e s e a r c h e r s  concern f o r others d e s p i t e t h e i r i l l n e s s event. A c c o r d i n g t o Gilligan,  female i d e n t i t y i s r o o t e d i n connections t o others  and r e l a t i o n s h i p s as a r e s u l t of the s o c i a l i z a t i o n  process  b e g i n n i n g i n i n f a n c y . More s p e c i f i c a l l y , a d u l t women d e f i n e themselves  i n terms of t h e i r r e l a t i o n s h i p s , and i n terms of  j u d g i n g t h e i r a b i l i t y t o care f o r o t h e r s .  Subsequently,  women's t r a d i t i o n a l r o l e s have t y p i c a l l y been t h a t of c a r e t a k e r , n u r t u r e r , and h e l p e r , i n t h e i r networks of r e l a t i o n s h i p s with men and the f a m i l y . As the c u r r e n t study and p r e v i o u s r e s e a r c h demonstrates (Boogard,  1984, 1985; Dunn,  1985), women o f t e n have d i f f i c u l t y n e g o t i a t i n g t h e i r  roles  a f t e r r e c e n t l y e x p e r i e n c i n g a l i f e t h r e a t e n i n g event such as MI. These f i n d i n g s have c l e a r i m p l i c a t i o n s f o r h e a l t h care p r o f e s s i o n a l s i n terms of p r o v i d i n g c a r d i a c care and r e h a b i l i t a t i o n s e r v i c e s t h a t are more germane t o women. An important of  f a c t o r i n t h i s care i n v o l v e s adopting a p e r s p e c t i v e  h e a l t h care t h a t acknowledges women's r e l a t i o n a l and  familial  concerns.  Future r e s e a r c h i n the area of a p p r a i s a l s and coping s t r a t e g i e s w i l l p r o v i d e h e a l t h care p r o f e s s i o n a l s with more i n f o r m a t i o n about what aspects of MI a r e f e l t t o be s t r e s s f u l to  women, and t o more f u l l y understand  between coping and adjustment  the r e l a t i o n s h i p  i n women with MI. Moreover,  145 l o n g i t u d i n a l r e s e a r c h may be b e t t e r s u i t e d t o examine the a d a p t a t i o n a l outcome of MI p a t i e n t s . Developmental C o n s i d e r a t i o n s Other f i n d i n g s from t h e c u r r e n t study suggest t h a t although the emergent common themes were observed a c r o s s cor e s e a r c h e r s , women's experience of these themes o f t e n v a r i e d in  t h e manner i n which they were expressed. I n d i v i d u a l  d i f f e r e n c e s c o n t r i b u t e d t o how these themes were expressed. For  example, because c o - r e s e a r c h e r s ranged i n age between 40  and 75 y e a r s , t h e i r developmental maturation and c o r r e s p o n d i n g developmental i s s u e s a l s o v a r i e d a c c o r d i n g t o age. A c c o r d i n g to  stage t h e o r i s t s such as E r i k s o n or Levinson ( c i t e d i n  Kimmel, 1990), the primary developmental t a s k s f o r a 40-yearold  woman d i f f e r s i g n i f i c a n t l y than f o r a 75-year-old woman.  Whereas m i d l i f e t r a n s i t i o n i s o f t e n c h a r a c t e r i z e d by c r i s i s and r e - e v a l u a t i o n of e a r l i e r l i f e ,  l a t e adulthood may be  c h a r a c t e r i z e d by i s s u e s surrounding r e t i r e m e n t , a growing awareness of the f i n a l i t y of l i f e , life  and accomplishments.  and an e v a l u a t i o n of one's  The v a r i a b i l i t y i n developmental  i s s u e s was e v i d e n t i n concerns expressed by s e v e r a l cor e s e a r c h e r s i n c l u d i n g Gina and Kaye. Whereas, Gina was a t a crossroads i n terms of making c r i t i c a l d e c i s i o n s about t h e f u t u r e d i r e c t i o n of her l i f e ,  Kaye d e s c r i b e d t h e importance o f  f e e l i n g prepared f o r t h e f i n a l stages of her l i f e . Undoubtedly,  d i f f e r e n c e s i n developmental maturation and  c o r r e s p o n d i n g i s s u e s , as w e l l as one's experience of h i s t o r i c a l events impacted the meaning t h a t c o - r e s e a r c h e r s a t t r i b u t e d t o t h e i r MI experience.  146 S i m i l a r l y , other r e s e a r c h e r s  (Parchert & Creason, 1989;  Rankin, 1995) emphasize the importance of c o n s i d e r i n g developmental  context as i t r e l a t e s t o women's r e c o v e r y from  MI. More s p e c i f i c a l l y , Rankin (1995) argues t h a t normative age and h i s t o r y f a c t o r s a r e i n f l u e n t i a l components i n the process of r e c o v e r y from MI. Subsequently,  younger and o l d e r cohorts  of women a r e l i k e l y t o experience MI d i f f e r e n t l y due t o developmental  and cohort d i f f e r e n c e s . To r e i t e r a t e , t h i s was  demonstrated i n the c u r r e n t study as developmental  context  appeared t o i n f l u e n c e how women made meaning of t h e i r MI experience. Understanding developmental  t h e p o t e n t i a l e f f e c t s of  f a c t o r s a r e important  i n g i v i n g h e a l t h care  p r o f e s s i o n a l s more i n f o r m a t i o n about t h e types of i s s u e s and concerns  t h a t may be r e l e v a n t t o women e x p e r i e n c i n g MI. Future  r e s e a r c h i n t h i s area might focus on examining cohorts of women where f a c t o r s r e l a t e d t o age, s o c i a l i z a t i o n , and s o c i a l context are more homogeneous. D e b r i e f i n g t h e MI Experience Study f i n d i n g s a l s o suggested  t h a t almost  a l l of the c o -  r e s e a r c h e r s responded p o s i t i v e l y t o having the o p p o r t u n i t y t o t a l k about t h e i r MI experience as w e l l as t o t h e o p p o r t u n i t y of p o t e n t i a l l y h e l p i n g other female heart p a t i e n t s by d i s c u s s i n g t h e i r experience. Although  many of these women had  r e p e a t e d l y d e s c r i b e d the events and symptoms l e a d i n g t o t h e i r MI t o v a r i o u s medical p r o f e s s i o n a l s , t h e h o s p i t a l i z a t i o n process does not t y p i c a l l y have the resources t h a t would a l l o w women (or men) t o t h e r a p e u t i c a l l y d e b r i e f t h e i r experience of a p o t e n t i a l l y l i f e t h r e a t e n i n g event.  147 In recent  research,  Pennebaker (1988, 1993)  demonstrated  the p o t e n t i a l h e a l t h b e n e f i t s of d i s c l o s i n g t r a u m a t i c e x p e r i e n c e s . More s p e c i f i c a l l y , Pennebaker proposed t h a t e i t h e r t a l k i n g or w r i t i n g about an u p s e t t i n g be p s y c h o l o g i c a l l y and  experience  could  p h y s i c a l l y b e n e f i c i a l . Pennebaker's  f i n d i n g s suggested t h a t h e a l t h improvements i n terms of immunological f u n c t i o n were observed i n i n d i v i d u a l s constructed  a coherent s t o r y of d i s c l o s u r e c o n s i s t i n g of a  high p r o p o r t i o n  of words t h a t expressed negative emotions  (such as a n x i e t y  or  sadness).  In other research,  Gruen ( c i t e d i n Byrne, 1990)  the e f f e c t s of b r i e f h o s p i t a l - b a s e d  psychological  throughout the acute r e c o v e r y phase of a f i r s t MI predominantly male sample. The  examined intervention on  the f a c i l i t a t i o n  a d a p t i v e behavior d u r i n g the r e h a b i l i t a t i o n phase. from Gruen's study suggested t h a t i n t e r v e n t i o n experienced a range of p h y s i c a l and  s i g n i f i c a n t l y less anxiety  of  Findings  patients  fewer days i n the and  depression  than  patients.  Both Pennebaker (1988, 1993) 1990)  the  emotional b e n e f i t s  i n c l u d i n g fewer days i n i n t e n s i v e care, h o s p i t a l , and  a  i n t e r v e n t i o n focused on  r e s o l u t i o n of emotional d i s t r e s s , and  control  who  research  psychological  and  Gruen's ( c i t e d i n Byrne,  supports the implementation of e a r l y i n t e r v e n t i o n f o l l o w i n g MI.  Future r e s e a r c h  might  examine the h e a l t h b e n e f i t s of i n c l u d i n g c o u n s e l l i n g or o t h e r therapeutic  work i n the treatment plans f o r female  MI  patients. U n l i k e most of the p r e v i o u s r e s e a r c h  t h a t has  examined  148 women's experience study  of MI post h o s p i t a l d i s c h a r g e ,  focused on t h e i n i t i a l phase of women's MI  while s t i l l  the current experience  h o s p i t a l i z e d . As adjustment t o MI i s an ongoing  and dynamic process,  f u t u r e r e s e a r c h , f o c u s i n g on both the  acute and recovery phases of MI would be i d e a l i n terms of more thoroughly experience. experience  c a p t u r i n g t h e e n t i r e t y of women's MI  L o n g i t u d i n a l s t u d i e s t h a t f o l l o w women's of MI throughout the phases of i l l n e s s , i n c l u d i n g  h o s p i t a l i z a t i o n , post h o s p i t a l d i s c h a r g e ,  and recovery a t home  c o u l d be u s e f u l i n a c h i e v i n g a g r e a t e r understanding  of t h i s  process. Misdiagnosis  or D i s m i s s a l of Symptoms  Another i n d i r e c t study the c o - r e s e a r c h e r s experience  f i n d i n g r e v e a l e d t h a t over h a l f of  i n t h e c u r r e n t study r e p o r t e d  of having  some  c a r d i a c symptoms e i t h e r d i s m i s s e d or  misdiagnosed by d o c t o r s . S e v e r a l of these women r e p o r t e d seeking medical intuitively  help p r i o r t o b e i n g diagnosed with MI, as they  sensed t h a t something was wrong with t h e i r h e a l t h ,  but were t o l d by p h y s i c i a n s t h a t t h e i r p r e s e n t i n g symptoms were e i t h e r not c a r d i a c i n o r i g i n or nothing t o be concerned about. S e v e r a l 'researchers have suggested t h a t p h y s i c i a n s have pursued a l e s s a c t i v e o r a g g r e s s i v e approach t o the d i a g n o s i s and management of heart d i s e a s e i n women than i n men  (Ayanian  & E p s t e i n , 1991; S t e i n g a r t , e t a l . , 1991; Wenger, 1990, 1992). For example, Wenger (1992) suggests t h a t because chest p a i n i s u s u a l l y a s s o c i a t e d with normal coronary  a r t e r i e s i n women, as  compared t o men, p h y s i c i a n s o f t e n s t i l l  believe that  these  149 symptoms i n women w i l l not l i k e l y be f o l l o w e d by s e r i o u s c a r d i a c events, o r a r e a t t r i b u t e d t o non-cardiac  causes  ( S t e i n g a r t e t a l . , 1991). Rankin  (1995) suggests t h a t because t h e medical community  has maintained t h e b e l i e f t h a t heart d i s e a s e i s a s e r i o u s h e a l t h concern o n l y f o r men, i t i s not s u r p r i s i n g t h a t women, p a r t i c u l a r l y o l d e r women, have a l s o adopted t h e b e l i e f  that  they a r e not a t r i s k f o r CHD and MI (Rankin, 1995). Women need to become more educated r e g a r d i n g the i n c i d e n c e of heart d i s e a s e i n females, and t o t h e importance  of e a r l y  cardiac  symptom i d e n t i f i c a t i o n . H o p e f u l l y , t h i s w i l l r e s u l t  i n women  becoming more p r o a c t i v e h e a l t h care consumers and i n s i s t e n t t h a t t h e i r d o c t o r s take a more s e r i o u s stance towards t h e assessment of c a r d i a c  symptomology.  F i n a l l y , although t h i s study focused on examining women's experience of MI, t h e r e i s c u r r e n t l y a l a c k of r e s e a r c h documenting men's experience of MI. Future r e s e a r c h  examining  the p e r s o n a l meanings and p e r c e p t i o n s of men's experience of MI has s i g n i f i c a n t rehabilitation,  i m p l i c a t i o n s f o r treatment and  and c o u l d l e a d t o the i d e n t i f i c a t i o n of gender  s i m i l a r i t i e s and d i f f e r e n c e s w i t h i n t h i s . a r e a . B a r r i e r s t o Conducting the Study The process of conducting t h i s study has been time consuming and d o t t e d with unforeseen c h a l l e n g e s . At times, I f e l t t h a t t h i s process was almost as i n f o r m a t i v e and e d u c a t i o n a l as the s t o r i e s themselves.  of MI gleaned from t h e women  In a odd s o r t of way, I f e e l f o r t u n a t e t o have  experienced, f i r s t hand, some of t h e a t t i t u d e s t h a t have been  150 and continue t o be counter p r o d u c t i v e t o f a c i l i t a t i n g c a r d i a c r e s e a r c h on women. At the same time,  I have gained a b e t t e r  sense of the depth t o which t r a d i t i o n a l and a t t i t u d e s are s t i l l  patriarchal  embedded a t a systems l e v e l i n the medical  p r o f e s s i o n , and the extent t o which these a t t i t u d e s  continue  t o serve as b a r r i e r s t o women's h e a l t h c a r e . Some of the c h a l l e n g e s I experienced conducting t h i s r e s e a r c h appeared  t o be r e l a t e d t o f r i c t i o n stemming from  the  maintenance of d u a l r o l e s , working i n the h o s p i t a l i n the p o s i t i o n of c a r d i o l o g y t e c h n o l o g i s t , and as graduate  student  r e s e a r c h e r . Not o n l y i s the p o s i t i o n of c a r d i o l o g y t e c h n o l o g i s t mostly c o n f i n e d t o women, i t i s a f a i r l y  low  r a n k i n g p o s i t i o n i n the h i e r a r c h y of h o s p i t a l s t a t u s . In c o n t r a s t , the p o s i t i o n of graduate  student r e s e a r c h e r o f f e r s  the l u x u r y of more independence, r e s p o n s i b i l i t y , and  decision  making. The t r a n s i t i o n from the p o s i t i o n of c a r d i o l o g y t e c h n o l o g i s t , who  i s subordinate t o most other medical  t o t h a t of r e s e a r c h e r , who  requested help from  staff,  specific  h o s p i t a l s t a f f i n order t o f a c i l i t a t e my p r o j e c t , r e s u l t e d i n a power c o n f l i c t . Although most of the h e a l t h care p r o f e s s i o n a l s responded  t o the p r o j e c t i n a s u p p o r t i v e manner,  t h e r e were a few i n c i d e n t s which I b r i e f l y d e s c r i b e . The f i r s t c h a l l e n g e arose when approval f o r the study  had  t o be o b t a i n e d from the h o s p i t a l e t h i c s committee, a process s i m i l a r t o the requirements committee. Once approval was I was  of the u n i v e r s i t y  ethics  obtained from h o s p i t a l  officials,  r e q u i r e d t o o b t a i n f u r t h e r approval from the head of the  c a r d i o l o g y department. The department head greeted the  151 research  proposal  with o v e r t and b l a t a n t s c e p t i c i s m towards  the worthwhileness of t h e p r o j e c t , t h e c r e d i b i l i t y of q u a l i t a t i v e research,  and towards t h e a b i l i t y t o o b t a i n a  graduate degree u s i n g t h i s methodology. U n t i l I had a c t u a l l y r e c e i v e d approval  t o proceed with the study, I f e l t t h a t t h e  p r o j e c t was i n jeopardy s o l e l y based on the department head's initial  response. H i s posture p a r a l l e l e d t h e a t t i t u d e s t h a t  have c o n t r i b u t e d t o the minimal degree of v i s i b i l i t y women have been a l l o t t e d i n c a r d i a c Another c h a l l e n g e  that  research.  arose w h i l e I was t r y i n g t o organize a  system whereby c a r d i a c care nurses acted as an i n i t i a l between p o t e n t i a l co-researchers  liaison  and myself f o r purposes of  c o n f i d e n t i a l i t y . Although most of the nurses were w i l l i n g t o o f f e r t h e i r a s s i s t a n c e , one of t h r e e head nurses adversely  t o my request  for assistance.  reacted  In an i n d i r e c t manner,  she made i t c l e a r t h a t she would not f a c i l i t a t e the p r o j e c t . Again, I sensed t h a t power dynamics were o p e r a t i n g .  Moreover,  I f e l t t h e r e was i r o n y i n having d i f f i c u l t y encouraging a female nurse t o help f a c i l i t a t e a h e a l t h r e l a t e d p r o j e c t examining t h e experiences of women with heart d i s e a s e  (often  thought of as a l i f e s t y l e d i s e a s e ) , p a r t i c u l a r l y when t h e majority  of h e a l t h care workers o r n u r s i n g  t y p i c a l l y work under h i g h l y s t r e s s f u l Finally,  s t a f f are women who  conditions.  I was a c u t e l y aware of my own r e l u c t a n c e  to the research  as being  to refer  f e m i n i s t i n nature i n order t o  circumvent p o t e n t i a l d i s c r i m i n a t i o n from h o s p i t a l o f f i c i a l s and/or medical p r o f e s s i o n a l s . I n t u i t i v e l y ,  I f e l t that a  f e m i n i s t l a b e l might p o t e n t i a l l y d i s c r e d i t the r e s e a r c h  152 project  i t s e l f and myself  as a r e s e a r c h e r .  Study L i m i t a t i o n s The q u a l i t a t i v e  and phenomenological  nature of t h e study  required that co-researchers p a r t i c i p a t e  i n terms of  a r t i c u l a t i n g t h e i r thoughts  related  and f e e l i n g s  to their  experience of MI. D e s p i t e f e e l i n g c o n f i d e n t t h a t cor e s e a r c h e r ' s were a b l e t o a r t i c u l a t e t h e i r experience of MI, and t h a t these s t o r i e s  closely reflected their  understanding  of t h e i r experience, t h e study i s l i m i t e d by the extent t o which women were w i l l i n g and able t o d i s c l o s e  their  experience. F o r example, although an i n t e r v i e w s c r i p t was used to c r e a t e c o n s i s t e n c y across data c o l l e c t i o n i n t e r v i e w s , t h e r e was  significant variation  expressed themselves. introspective,  i n the depth t o which women  While  some women were  intensely  other women focused on t e l l i n g more  descriptive  s t o r i e s of t h e i r experience. D e s p i t e t h i s l i m i t a t i o n , my efforts to establish  r a p p o r t w i t h c o - r e s e a r c h e r s , i n terms of  t r u s t , comfortableness,  and r e s p e c t , helped t o f a c i l i t a t e  women's s t o r y t e l l i n g . A second qualitative  limitation relates  t o t h e g e n e r a l i z a b i l i t y of  r e s e a r c h . As one of t h e goals of q u a l i t a t i v e  r e s e a r c h i s t o examine the fundamental processes of a s p e c i f i c group of i n d i v i d u a l s ,  i t does not support t h e g e n e r a l i z a t i o n  of study r e s u l t s t o other groups of i n d i v i d u a l s . of t h i s study was not t o g e n e r a l i z e study r e s u l t s female MI p a t i e n t s ,  to a l l  but t o examine the experience of a s m a l l  sample of women h o s p i t a l i z e d In a d d i t i o n ,  The purpose  with MI.  the sample of women i n t h i s study was one  153 p r i m a r i l y of convenience.  Due t o the l i m i t e d numbers of women  h o s p i t a l i z e d with MI, a l l female MI p a t i e n t s were assessed i n order t o determine  study e l i g i b i l i t y and then approached t o  p a r t i c i p a t e i n t h e study. Subsequently, r e s e a r c h e r s was non-Caucasian.  o n l y 1 of the 10 co-  Study f i n d i n g s may have  d i f f e r e d with more d i v e r s e m u l t i - c u l t u r a l r e p r e s e n t a t i o n . An a d d i t i o n a l l i m i t a t i o n r e l a t e s t o t h e manner i n which c o - r e s e a r c h e r s were asked t o r e l a t e t h e i r experience of MI. A s k i n g c o - r e s e a r c h e r s t o r e l a t e t h e i r MI experience i n t h e form of a s t o r y with a beginning, a middle, and an end, p r o v i d e d them with a framework with which they c o u l d o r g a n i z e the sequence of t h e i r i l l n e s s events. Although women adapted these g u i d e l i n e s t o accommodate t h e i r s t o r y t e l l i n g ,  this  s e q u e n t i a l approach may have o c c u r r e d a t t h e c o s t o f a l l o w i n g women t o determine  t h e i r own process around how t o a l l o w t h e i r  experience t o emerge. The f i n a l l i m i t a t i o n i n v o l v e s t h e v a l i d a t i o n i n t e r v i e w s . Due  t o t h e u n p r e d i c t a b l e nature of heart d i s e a s e , I was  concerned  t h a t c o - r e s e a r c h e r s may have d i e d b e f o r e t h e  completion of data a n a l y s i s . As a r e s u l t , i n t e r v i e w s were conducted  validation  following interview transcription  and a p r e l i m i n a r y review of t h e data. Moreover, these i n t e r v i e w s r e f l e c t e d a c o n f i r m a t i o n of the i n f o r m a t i o n o b t a i n e d from t h e women, as opposed t o the v a l i d a t i o n of t h e i d e n t i f i e d nine themes. Implications f o r Counselling Practice The f i n d i n g s of t h i s study suggest t h a t t h e concerns experienced by women with MI a r e o f t e n v a r i e d and complex, and  154 o f t e n extend beyond the d i s e a s e process i t s e l f . H e a l t h  care  p r o f e s s i o n a l s need t o work t o g e t h e r i n order t o p r o v i d e women w i t h care t h a t i s s p e c i f i c and germane t o t h e i r i s s u e s and needs throughout  particular  t h e process of treatment and  r e c o v e r y from MI. C o u n s e l l i n g p s y c h o l o g i s t s working i n t h i s area need t o adopt r o l e s both as c o u n s e l l o r s and as educators. A key i m p l i c a t i o n i n t h i s study i s the important  role f o r  c o u n s e l l o r s t o a s s i s t other h e a l t h care p r o f e s s i o n a l s , p a r t i c u l a r l y d o c t o r s and nurses, i n d e v e l o p i n g the communication s k i l l s t h a t w i l l b e t t e r enable them t o understand  t h e process of women's i l l n e s s experience and t r e a t  t h e i r p a t i e n t s . T h i s t r a i n i n g may i n c l u d e r a p p o r t b u i l d i n g , empathy, and r e f l e c t i v e l i s t e n i n g s k i l l s ,  as w e l l as  h i g h l i g h t i n g the p s y c h o s o c i a l i m p l i c a t i o n s of e x p e r i e n c i n g a l i f e t h r e a t e n i n g event  such as MI. Not o n l y w i l l t h i s  enable  h e a l t h care p r o f e s s i o n a l s t o be a b l e t o implement more p a t i e n t centered care, but may a l s o p r o v i d e them with t h e a b i l i t y t o b e t t e r understand  p a t i e n t ' s responses  and behaviors  i n the  context of t h e i r i l l n e s s and treatment. Another important  area of education f o r c o u n s e l l o r s i s t o  s e n s i t i z e h e a l t h care p r o f e s s i o n a l s t o the p o t e n t i a l needs of female MI p a t i e n t s . F o r example, t o educate d o c t o r s on t h e importance of women's need t o a c q u i r e concrete i n f o r m a t i o n , as w e l l as t o b a r r i e r s t h a t have o f t e n prevented women from c h a l l e n g i n g o r more f i r m l y seeking i n f o r m a t i o n from t h e i r d o c t o r s . These b a r r i e r s may i n c l u d e p r e v i o u s experiences o f b e i n g d i s c o u n t e d by p h y s i c i a n s , experiences  of m i s d i a g n o s i s ,  the power imbalance o f t e n p r e v a l e n t i n t r a d i t i o n a l male  155 doctor-female p a t i e n t r e l a t i o n s h i p s ( i s s u e s of powerlessness), the i n a b i l i t y t o a s s e r t one's r i g h t s ( f e a r s around a s k i n g ) , a l a c k of f a m i l i a r i t y with medical language t o know what questions  t o ask,  and women's concerns around not t a k i n g up  too much time o r space with p h y s i c i a n s .  Subsequently, i t i s  important t h a t h e a l t h care p r o f e s s i o n a l s do not assume t h a t women a r e s a t i s f i e d with the q u a l i t y of i n f o r m a t i o n  and care  they have r e c e i v e d d e s p i t e the l a c k , o f feedback o r questions t h a t may suggest t h e c o n t r a r y . As mentioned e a r l i e r , p a r t of t h i s work may i n v o l v e the implementation of a c t i v e and  listening  communication s k i l l s t r a i n i n g s e s s i o n s with h e a l t h  care  professionals. Because one of the key areas of concern i d e n t i f i e d by coresearchers  was the i s s u e of needing i n f o r m a t i o n ,  it is  important t h a t c o u n s e l l o r s adopt t h e r o l e of educator with female c l i e n t s with heart d i s e a s e . R e s u l t s  from the c u r r e n t  study suggest t h a t there would be great value  i n providing  i n d i v i d u a l as w e l l as group c o u n s e l l i n g f o r women t h a t have s u f f e r e d from MI. T h i s would e n t a i l having i n f o r m a t i o n c l e a r understanding of t h e process of MI recovery  and a  including  p h y s i c a l and emotional r e a c t i o n s t h a t a r e o f t e n c h a r a c t e r i s t i c to t h i s experience. As w e l l , i t would important f o r c o u n s e l l o r s t o have some awareness of the more e x i s t e n t i a l i s s u e s t h a t women may experience r e l a t e d t o l o s s , t r a n s i t i o n , the e v a l u a t i o n o r r e - e v a l u a t i o n of s i g n i f i c a n t r e l a t i o n s h i p s , the process of r e b u i l d i n g of i d e n t i t y , i s s u e s of s e l f esteem, and  i s s u e s surrounding m o r t a l i t y and death. As mentioned  e a r l i e r , with r e s p e c t t o t h e work of M i l l e r e t a l . (1988), t h e  156 extent of i n f o r m a t i o n i n t e r v e n t i o n s p r o v i d e d by c o u n s e l l o r s would be based on the i n d i v i d u a l needs of each c l i e n t . I n i t i a t i n g the development of h o s p i t a l and community based support  and/or psychoeducational  groups would not o n l y p r o v i d e  women with a forum i n which t o l e a r n more about t h e p h y s i c a l and emotional  e f f e c t s of t h e i r i l l n e s s , but would p r o v i d e  women with the o p p o r t u n i t y t o share t h e i r experiences  of MI  with others and help a l l e v i a t e f e e l i n g s of i s o l a t i o n . Important t o the development of such a group would not o n l y be i n f o r m a t i o n germane t o t h e female c a r d i a c p a t i e n t , but a l s o a group format t h a t would accommodate women's needs and f a c i l i t a t e t h e i r group experience. Belenky, C l i n c h y , Goldberger,  and T a r u l e (1986) propose t h a t women l e a r n and  g a i n knowledge i n a d i f f e r e n t manner than do men. Moreover, Belenky e t a l . suggests  t h a t women tend t o l e a r n best i n  c o l l a b o r a t i v e groups and i n s i t u a t i o n s t h a t p r o v i d e t h e o p p o r t u n i t y f o r e x p e r i e n t i a l l e a r n i n g t h a t i s geared  towards a  p e r s o n a l o r i e n t a t i o n . I n c o r p o r a t i n g these f a c t o r s i n t o t h e d e s i g n of group work f o r women l i v i n g with h e a r t d i s e a s e would l i k e l y be v a l u a b l e i n terms of f a c i l i t a t i n g women's group experience  as w e l l as promoting a sense of w e l l - b e i n g .  Conclusion Current  l i t e r a t u r e w i t h i n the area of women and c a r d i a c  h e a l t h f a i l s t o f u l l y capture the nature of women's experience with MI. The purpose of t h i s phenomenological study was t o explore and d e s c r i b e women's experience  o f MI w h i l e  h o s p i t a l i z e d i n order t o more f u l l y understand sense of t h i s l i f e t h r e a t e n i n g  event.  still  how women make  157  Study r e s u l t s demonstrated the presence  of nine common  themes t h a t d e s c r i b e d women's experience of MI and were e v i d e n t i n almost a l l of the c o - r e s e a r c h e r accounts d e s p i t e the uniqueness  and v a r i a b i l i t y of t h e i r e x p e r i e n c e s . These  emergent themes i n c l u d e d t h e f o l l o w i n g e x p e r i e n c e s :  illness  awareness, f e e l i n g e m o t i o n a l l y overwhelmed, f e a r and worry, l o s s , d i f f i c u l t y a s k i n g f o r o r r e c e i v i n g help from o t h e r s , t h e need f o r i n f o r m a t i o n , care and support, making sense o f t h e MI experience, and p l a n n i n g f o r the f u t u r e . Although  s i m i l a r themes have d i r e c t l y emerged or been  subsumed under other themes i n p r e v i o u s r e s e a r c h conducted on p o s t - h o s p i t a l d i s c h a r g e , t h e examination  of women's experience  of MI from a s u b j e c t i v e p e r s p e c t i v e d u r i n g h o s p i t a l i z a t i o n has not p r e v i o u s l y been documented. Subsequently,  how women  experienced s e v e r a l of these themes i n c l u d i n g l o s s , t h e d i f f i c u l t y a s k i n g f o r o r r e c e i v i n g help from o t h e r s , t h e need f o r i n f o r m a t i o n , and care and support, appeared  d i f f e r e n t l y as  a r e s u l t of o c c u r r i n g d u r i n g the acute phase of i l l n e s s . As a r e s u l t , v a l u a b l e i n f o r m a t i o n was gleaned about c o - r e s e a r c h e r ' s experiences and needs while h o s p i t a l i z e d with MI, and r e f l e c t s an aspect of the recovery process t h a t has been overlooked by previous research. In g e n e r a l , the primary c o n t r i b u t i o n of t h i s study to t h e examination  relates  of an area t h a t has not p r e v i o u s l y been  researched, thereby adding an e x t e n s i v e d e s c r i p t i o n t o t h e small e x i s t i n g body of l i t e r a t u r e on women and MI, and p r o v i d i n g t h e b a s i s f o r f u t u r e r e s e a r c h . The r i c h n e s s of women's s u b j e c t i v e s t o r i e s serves t o help h e a l t h care  158 professionals  more f u l l y understand the importance of b e i n g  s e n s i t i v e t o the e x p e r i e n t i a l q u a l i t y of the MI experience, t o the unique nature of women's r e c o v e r y from MI, f o r a balance between c u r i n g  and c a r i n g  and t o the need  i n hospital care.  159  References American Heart A s s o c i a t i o n . (1980). Heartbook: A guide t o p r e v e n t i o n and treatment o f c a r d i o v a s c u l a r d i s e a s e . New York: E.P. Dutton. Ayanian, J.Z., & E p s t e i n , A.M. (1991). D i f f e r e n c e s i n t h e use of procedures between women and men h o s p i t a l i z e d f o r coronary h e a r t d i s e a s e . The New England J o u r n a l o f Medicine, 325(4), 221-225. Baggs, J . G., & Karch, A. M. (1987). Sexual c o u n s e l l i n g o f women with coronary heart d i s e a s e . Heart and Lung, 16(2), 154-159. Bass, C., & Wade, C. (1982). Type A b e h a v i o r : Not s p e c i f i c a l l y pathogenic? Lancet, 11, 1147-1150. Belenky, M.F., C l i n c h y , B.M., Goldberger, N.R., & T a r u l e , J.M. (1986). Women's ways o f knowing: Development o f s e l f , v o i c e , and mind. New York: B a s i c Books. Benner, P., & Wrubel J . (1989). The primacy o f c a r i n g : S t r e s s and c o p i n g i n h e a l t h and i l l n e s s . Menlo Park, CA: AddisonWesley. Ben-Sira, Z. (1980). A f f e c t i v e and i n s t r u m e n t a l components i n the p h y s i c i a n - p a t i e n t r e l a t i o n s h i p : An a d d i t i o n a l dimension of i n t e r a c t i o n t h e o r y . J o u r n a l of H e a l t h and S o c i a l Behavior, 21, 170-180. B e n - S i r a , Z., & E l i e z e r , R. (1990). The s t r u c t u r e o f readjustment a f t e r heart a t t a c k . S o c i a l Science and Medicine, 30, 523-536. Boogard M.A.K. (1984). R e h a b i l i t a t i o n o f the female p a t i e n t a f t e r m y o c a r d i a l i n f a r c t i o n . N u r s i n g C l i n i c s of North America, 19, 433-441. Boogard, M.A.K., & B r i o d y , M.E. (1985). Comparison o f t h e r e h a b i l i t a t i o n o f men and women p o s t - m y o c a r d i a l i n f a r c t i o n . J o u r n a l o f Cardiopulmonary R e h a b i l i t a t i o n , 5, 379-384. B u l l e r , M.K., & B u l l e r , D.B. (1987). P h y s i c i a n s ' communication s t y l e and p a t i e n t s a t i s f a c t i o n . J o u r n a l of H e a l t h and S o c i a l Behavior, 28, 375-388. Burgess, A., Lerner, D., D'Agostino, R., Vokonas, P., Hartman, C , & Gaccione, P. (1987). A randomized c o n t r o l t r i a l o f c a r d i a c r e h a b i l i t a t i o n . S o c i a l Science and Medicine, 24, 354-370.  160 Burgoon, J.K., Pfau, M., P a r r o t t , R., B i r k , T., Coker, T., & Burgoon, M. (1987). Compliance-gaining s t r a t e g i e s , and compliance i n communication between p h y s i c i a n s and p a t i e n t s . Communication Monographs, 54, 307-324. Byrne, D.G. (1987a). P e r s o n a l i t y , l i f e events and c a r d i o v a s c u l a r d i s e a s e . J o u r n a l o f Psychosomatic Research, 331, 661-671. Byrne, D.G. (1987b). The b e h a v i o r a l management o f t h e c a r d i a c p a t i e n t . Norwood, NJ: Ablex. Byrne, D.G. (1990). P s y c h o l o g i c a l aspects o f outcomes and i n t e r v e n t i o n s f o l l o w i n g heart a t t a c k . In D.G. Byrne & R.H. Rosenman (Eds.), A n x i e t y and the heart (pp. 369-396). New York: Hemisphere. C h i r i k o s , T.N., & N i c k e l , J.L. (1984). Work d i s a b i l i t y from coronary heart d i s e a s e . Women and Health, 9_, 55-74. C o g l i a n e s e , M.E., S g l l a n o , J.A., & B i l o d e a u , S.E. (1992, Summer). Women and heart d i s e a s e . Heartbeat, p. 4. Cohen, F., & Lazarus, R.S. (1979). Coping with the s t r e s s e s o f i l l n e s s . In G. C. Stone, F. Cohen, & N.E. A d l e r (Ed.), Health psychology: A handbook (pp.217-254). San F r a n c i s c o : Jossey-Bass. C o l a i z z i , P. (1978). P s y c h o l o g i c a l r e s e a r c h as t h e phenomenologist views i t . In R. V a l l e & M. King (Eds.), E x i s t e n t i a l - p h e n o m e n o l o g i c a l a l t e r n a t i v e s f o r psychology (pp. 48-71). New York: Oxford P r e s s . Compas, B.E., & Orosan, P.G. (1993). C o g n i t i v e a p p r a i s a l s and coping with s t r e s s : I m p l i c a t i o n s f o r understanding women and employment s t r e s s . In B.C. Long & S.E. Kahn (Eds.), Women, work, and coping. Montreal: M c G i l l Queen's U n i v e r s i t y Press. Conn, V.S., T a y l o r , S.G., & Abele, P.B. (1991). Myocardial i n f a r c t i o n s u r v i v o r s : Age and gender d i f f e r e n c e s i n p h y s i c a l h e a l t h , p s y c h o s o c i a l s t a t e and regimen adherence. J o u r n a l o f Advanced Nursing, 16, 1026-1034. Conrad, P. (1990). Q u a l i t a t i v e r e s e a r c h on c h r o n i c i l l n e s s : A commentary on method and conceptual development. S o c i a l Science and Medicine, 30, 1257-1263. Croog, S.H. (1983). Recovery, and r e h a b i l i t a t i o n o f heart p a t i e n t s : P s y c h o s o c i a l a s p e c t s . In D.S. Krantz, A. Baum, & J.E. Singer, (Eds.), Handbook o f psychology and h e a l t h (Vol 3): C a r d i o v a s c u l a r d i s o r d e r s and behavior (pp. 295-334). H i l l s d a l e , NJ: Lawrence Erlbaum.  161 Degre-Coustry, C , & G r e v i s s e , M. (1982). P s y c h o l o g i c a l problems i n r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n . Advances i n C a r d i o l o g y , 29, 126-131. Dunn, P. (1985). Women's p e r c e p t i o n s of t h e i r i l l n e s s experience with myocardial i n f a r c t i o n . Unpublished master's t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C. Dustan, H.P. (1990). Coronary a r t e r y d i s e a s e i n women. Canadian J o u r n a l of C a r d i o l o g y , 16, Supplement B, 19B-21B. Eaker, E.D. (1989). P s y c h o s o c i a l f a c t o r s i n the epidemiology of coronary h e a r t d i s e a s e i n women. P s y c h i a t r i c C l i n i c s of North America, 12, 167-173. Eaker, E.D., Packard, B., & Thorn, T.J. (1989). Epidemiology and r i s k f a c t o r s f o r coronary a r t e r y d i s e a s e i n women. In P.S. Douglas & A.N. B r e s t , (Eds.), Heart d i s e a s e i n womenC a r d i o v a s c u l a r c l i n i c s (pp. 129-145). P h i l a d e l p h i a : FA Davis Co. Eaker, E.D., Packard, B., Wenger, N.K., C l a r k s o n , T.B., & T y r o l e r , H.A. (1986). Coronary h e a r t d i s e a s e i n women: Reviewing the evidence i d e n t i f y i n g the needs [Workshop Summary1. Bethesda, MD: N a t i o n a l I n s t i t u t e s of H e a l t h . Egan, G. (1990). The s k i l l e d h e l p e r . P a c i f i c Grove: Cole.  Brooks  Friedman, M., & Rosenman, R.H. (19 74). Type A b e h a v i o r and your h e a r t . New York: Knopf. G i l l i g a n , C. (1982).- In a d i f f e r e n t v o i c e : P s y c h o l o g i c a l t h e o r y and women's development. Cambridge, MA: Harvard U n i v e r s i t y Press. G i o r g i , A. (1975). An a p p l i c a t i o n of Phenomenological method. In A. G i o r g i , C. T. F i s c h e r , & E. L. Murray, (Eds.), Duquesne S t u d i e s i n Phenomenological Psychology ( V o l . 2, pp. 82-103). P i t t s b u r g , PA: Duquesne U n i v e r s i t y P r e s s . G i o r g i , A. (1985). Sketch of a p s y c h o l o g i c a l phenomenological method. In A . G i o r g i , (Ed.), Phenomenology and p s y c h o l o g i c a l r e s e a r c h (pp. 9-22). P i t t s b u r g , PA: Duquesne U n i v e r s i t y Press. Hackett, T.P., & Cassem, N.H. (1984). P s y c h o l o g i c aspects of r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n and coronary a r t e r y bypass surgery. In N.K. Wenger, & H.K. H e l l e r s t e i n , (Eds.), R e h a b i l i t a t i o n of the coronary p a t i e n t (pp. 437451). New York: John Wiley & Sons.  162  H a l l , J.A., I r i s h , J.Y., Roter, D.L., E h r l i c h , CM., & M i l l e r , L.H. (1994). Gender, i n medical encounters: An a n a l y s i s of p h y s i c i a n and p a t i e n t communication i n a primary care s e t t i n g . H e a l t h Psychology, 13(5), 384-392. Haynes, S.G., & F e i n l e i b , M. (1980). Women, work and coronary heart d i s e a s e : P r o s p e c t i v e f i n d i n g s from t h e Framingham heart study. American J o u r n a l of P u b l i c H e a l t h , 7.0(2), 133141. Haynes, S.G., F e i n l e i b , M., & Kannel, W.B. (1980). The r e l a t i o n s h i p of p s y c h o s o c i a l f a c t o r s t o coronary h e a r t d i s e a s e i n t h e Framingham study: I I I 8-year i n c i d e n c e of CHD. American J o u r n a l of Epidemiology, 111, 37-52. Hycner, R.H. (1985). Some g u i d e l i n e s f o r t h e phenomenological a n a l y s i s of i n t e r v i e w d a t a . Human S t u d i e s , 8, 279-303. I s l e s , C.G., Hole, D.J., Hawthorne, V.M., & Lever, A.F. (1992). R e l a t i o n between coronary r i s k and coronary m o r t a l i t y i n women of the Renfrew and P a i s l e y survey: Comparison w i t h men. The Lancet, 339, 702-706. Jensen, L.A., & A l l e n , M.N. (1994). A s y n t h e s i s of q u a l i t a t i v e r e s e a r c h on w e l l n e s s - i l l n e s s . Q u a l i t a t i v e H e a l t h Research, 4(4), 349-369. Johansson, S., Vedin, A., & Wilhelmsson, C. (1983). M y o c a r d i a l i n f a r c t i o n i n women. Epidemiology Review, 5, 67-95. Johnson, J.L., & Morse, J.M. (1990). Regaining c o n t r o l : The process of adjustment a f t e r m y o c a r d i a l i n f a r c t i o n . Heart and Lung, 19, 126-135. Kannel, W.B. (1990). CHD r i s k f a c t o r s : A Framingham study update. H o s p i t a l P r a c t i c e , 25., 119-130. Kannel, W.B., & Abbott, R.D. (1987). Incidence and p r o g n o s i s of myocardia i n f a r c t i o n i n women: The Framingham Study. In E.D. Eaker, B. Packer, N.K. Wenger, T. C l a r k s o n , & H.A. T y r o l e r (Eds.), Coronary a r t e r y d i s e a s e i n women (pp. 208214). New York: Haymarket-Doyma. Kannel, W.B., & Gordon, T. (1973). The Framingham Study: An E p i d e m i o l o g i c a l I n v e s t i g a t i o n of C a r d i o v a s c u l a r D i s e a s e s . ( S e c t i o n 28). DHEW P u b l i c a t i o n No.(NIH) 74-618). Washington, DC: U.S. Government P r i n t i n g O f f i c e . Keckeisen, M.E., & Nyamathi, A.M. (1990). Coping and adjustment t o i l l n e s s i n t h e acute m y o c a r d i a l i n f a r c t i o n p a t i e n t . J o u r n a l of C a r d i o v a s c u l a r Nursing, 5, 25-33. Kimmel, D.C. (1990). Adulthood and aging: An i n t e r d i s c i p l i n a r y , developmental view. New York: Wiley.  163 King, K.B. (1985). Measurement of c o p i n g s t r a t e g i e s , concerns, and emotional responses i n p a t i e n t s undergoing coronarya r t e r y bypass g r a f t i n g . Heart and Lung, 14, 579-586. Kleinman, A. (1988). The i l l n e s s n a r r a t i v e s : S u f f e r i n g , h e a l i n g , and t h e human c o n d i t i o n . New York: B a s i c Books. Knaack, P. (1984). Phenomenological r e s e a r c h . Western J o u r n a l of N u r s i n g Research, 6, 107-114. Kvale, S. (1983). The q u a l i t a t i v e r e s e a r c h i n t e r v i e w : A phenomenological and a hermeneutical mode of understanding. J o u r n a l of Phenomenological Psychology, 14, 171-196. Lazarus, R.S., & Lazarus, B.N. (1994). P a s s i o n and reason: Making sense of our emotions. New York: Oxford U n i v e r s i t y Press. Lazarus, R.S., & Folkman, S. (1984). S t r e s s , a p p r a i s a l , and coping. New York: S p r i n g e r . L i p o w s k i , Z. J . (1969). P s y c h o s o c i a l aspects of d i s e a s e . Annals of I n t e r n a l Medicine, 6, 1197-1207. MacMillan, J.H., & Schumacher, S. (1989). Research i n education: A conceptual i n t r o d u c t i o n . (2nd ed.). Harper Collins. Mayou, R. (1984). P r e d i c t i o n of emotional and s o c i a l outcome a f t e r a heart a t t a c k . J o u r n a l of Psychosomatic Research, 28, 17-25. Mayou, R., F o s t e r , A., & W i l l i a m s o n , B. (1978). P s y c h o s o c i a l adjustment i n p a t i e n t s one year a f t e r myocardial i n f a r c t i o n . J o u r n a l of Psychosomatic Research, 22, 447-453. M i l l e r , P., Wikoff, R., G a r r e t t , M., McMahon, M., & Smith, T. (1990). Regimen compliance two years a f t e r i n f a r c t i o n . N u r s i n g Research, 39, 333-336. M i l l e r , S.M., Brody, D.S., & Summerton, J . (1988). S t y l e s of coping with t h r e a t : I m p l i c a t i o n s f o r h e a l t h . J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology, 54, 142-148. Moos, R.H. (1979). S o c i a l - e c o l o g i c a l p e r s p e c t i v e s on h e a l t h . In G.C. Stone, N.E. A d l e r , & F. Cohen (Eds.), H e a l t h psychology (pp. 217-254). San F r a n c i s c o : Jossey-Bass. Morse, J.M., & Johnson, J.L. (1991). The i l l n e s s e x p e r i e n c e : Dimensions of s u f f e r i n g . Newbury Park, CA: Sage. Murdaugh, C. (1990). Coronary a r t e r y d i s e a s e i n women. J o u r n a l of C a r d i o v a s c u l a r Nursing, 4 ( 4 ) , 35-50.  164 Oakley, A. (1981). I n t e r v i e w i n g women: A c o n t r a d i c t i o n i n terms. In H. Roberts, & P. Kegan (Eds.), Doing f e m i n i s t r e s e a r c h (pp. 30-61). London: Routledge. Oakley, A. (1993). Essays on women, medicine, and h e a l t h . Edinburgh: Edinburgh U n i v e r s i t y P r e s s . O l d r i d g e , N. (1988). C a r d i a c r e h a b i l i t a t i o n , s e l f r e s p o n s i b i l i t y , and q u a l i t y of l i f e . J o u r n a l of Cardiopulmonary R e h a b i l i t a t i o n , 6., 153-156. Osborne, J.W. (1990). Some b a s i c e x i s t e n t i a l - p h e n o m e n o l o g i c a l r e s e a r c h methodology f o r c o u n s e l l o r s . Canadian J o u r n a l of C o u n s e l l i n g , 24(2), 79-91. Packard, B. (1992). C l i n i c a l aspects of coronary h e a r t d i s e a s e i n women. In N.K. Wenger, & H.K. H e l l e r s t e i n (Eds.), R e h a b i l i t a t i o n of the coronary p a t i e n t (3rd ed.) (pp. 217230). New York: C h u r c h i l l L i v i n g s t o n e . Papadopoulos, C , Beaumont, C , S h e l l e y , S. I., & L a r r i m o r e , P.(1983). M y o c a r d i a l i n f a r c t i o n and sexual a c t i v i t y of t h e female p a t i e n t . A r c h i v e s of I n t e r n a l Medicine. 143(8), 1528-1530. P a r c h e r t , M.A., & Creason, N. (1989). The r o l e of n u r s i n g i n the r e h a b i l i t a t i o n of women w i t h c a r d i a c d i s e a s e . J o u r n a l of C a r d i o v a s c u l a r Nursing, 3.(4), 57-64. Peberdy, M.A., & Ornato, J.P. (19 92). Coronary a r t e r y d i s e a s e i n women. Heart Disease and Stroke, 1, 315-319. Pennebaker, J.W. (1993). P u t t i n g s t r e s s i n t o words: H e a l t h , l i n g u i s t i c , and t h e r a p e u t i c i m p l i c a t i o n s . Behaviour, Research, and Therapy, 31, 539-548. Pennebaker, J.W., K i e c o l t - G l a s e r , J.K., & G l a s e r , R. (1988). D i s c l o s u r e of traumas and immune f u n c t i o n : H e a l t h i m p l i c a t i o n s f o r psychotherapy. J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 56, 239-245. Rankin, S.H. (1990). D i f f e r e n c e s i n r e c o v e r y from c a r d i a c surgery: A p r o f i l e of male and female p a t i e n t s . Heart and Lung, 19, 481-485. Rankin, S.H. (1995). P s y c h o s o c i a l adjustments of coronary a r t e r y d i s e a s e p a t i e n t s and t h e i r spouses: N u r s i n g i m p l i c a t i o n s . N u r s i n g C l i n i c s of North America, 27 ( 1 ) , 271-282. Rodin, J . , & I c k o v i c s , J.R. (1990). Women's h e a l t h : Review and r e s e a r c h agenda as we approach the 21st century. American P s y c h o l o g i s t , 45, 1018-1034.  165 Rosenberg, L., M i l l e r , D.R., Kaufman, D.W., Helmrich, S.P., Van de Carr, S., S t o l l e y , P.D., & Shapiro, S.(1983). M y o c a r d i a l i n f a r c t i o n i n women under 50 years of age. J o u r n a l of American M e d i c a l A s s o c i a t i o n , 250, 2801-2806. Scherwitz, L., McKelvain, R., & Laman, C. (1983). Type A behavior, s e l f - i n v o l v e m e n t , and coronary a t h l e r c l e r o s i s . Psychosomatic Medicine, 45, 47-57. Sharpe, P.A., C l a r k , N.M., & Janz, N.K. (1991). D i f f e r e n c e s i n the impact and management of heart d i s e a s e between o l d e r women and men. Women and Health, 17.(2), 25-43. Slone, D., Shapiro, S., Kaufman, D.W., Rosenberg, L., M i e t t i n e n , O.S., & S t o l l y , P.D. (1981). R i s k of MI i n r e l a t i o n t o c u r r e n t and d i s c o n t i n u e d use of o r a l c o n t r a c e p t i v e s . New England J o u r n a l of Medicine, 5, 420424. Slone, D., Shapiro, S., Rosenberg, L., Kaufman, D.W., Hartz, S.C., R o s s i , A.C., S t o l l e y , P.D., & M i e t t i n e n , O.S. (1978). R e l a t i o n of c i g a r e t t e smoking t o myocardial i n f a r c t i o n i n young women. New England J o u r n a l of Medicine, 298, 12731276. Smith, H.C. (1992). Return t o work. In N.K. Wenger, & H.K. H e l l e r s t e i n (Eds.), R e h a b i l i t a t i o n of t h e coronary p a t i e n t (3rd ed., pp. 511-520). New York: C h u r c h i l l L i v i n g s t o n e . Stampfer, M.J., C o l d i t z , G.A., W i l l e t t , W.C, Manson, J.E., Rosner, B., S p e i z e r , F.E., & Hennekens, C H . (1991). Postmenopausal estrogen therapy and c a r d i o v a s c u l a r d i s e a s e : Ten-year follow-up from the nurses' h e a l t h study. New England J o u r n a l of Medicine, 325, 756-762. S t a t i s t i c s Canada, (1994). M o r a l i t y - Summary l i s t of causes of death ( R e v i s e d ) . Canadian Centre f o r Health Information, Ottawa: Government of Canada. S t e i n g a r t , R.M., Packer, M., Hamm, P., C o g l i a n e s e , M.E., Gersh, B., & Geltman, E.M. (1991). Sex d i f f e r e n c e s i n t h e management of coronary a r t e r y d i s e a s e . The New England J o u r n a l of Medicine, 325(4) , 226-230. Stern, M.J., P a s c a l e , L., & McLoone, J.B. (1976). P s y c h o s o c i a l a d a p t a t i o n f o l l o w i n g an acute myocardial i n f a r c t i o n . J o u r n a l of Chronic Disease, 29, 513-526. S t e r n , M.J., P a s c a l e , L., & Ackerman, A. (1977). L i f e adjustment p o s t - m y o c a r d i a l i n f a r c t i o n : Determining p r e d i c t i v e v a r i a b l e s . A r c h i v e s of I n t e r n a l Medicine, 137, 1680-1685.  166 S t r e e t , R.L., & Wiemann, J.M. (1987). P a t i e n t s ' s a t i s f a c t i o n with p h y s i c i a n s i n t e r p e r s o n a l involvement, expressiveness, and dominance. In McLaughlin M. (Ed.), Communication Yearbook ( V o l . 10), (pp. 591-612). B e v e r l y H i l l s , CA: Sage. Sykes, D.H. (1994). Coping with a heart a t t a c k : P s y c h o l o g i c a l processes. The I r i s h J o u r n a l of Psychology, 15 (1), 54-66. T a y l o r , S.E. (1983). Adjustment t o t h r e a t e n i n g American P s y c h o l o g i s t , 38, 1161-1173.  events.  Thoresen, C.E., & G r a f f Low, K. (1990). Women and the Type A behavior p a t t e r n : Review and commentary. J o u r n a l of S o c i a l Behavior and P e r s o n a l i t y , 5_, 117-133. von  E c k a r t s b e r g , R. (1971). On e x p e r i e n t i a l methodology. In G i o r g i , A., F i s c h e r , W., & von E c k a r t s b e r g , R. (Eds.), Duguesne s t u d i e s i n phenomenological psychology ( V o l . 1 ) , (pp. 66-79). P i t t s b u r g : Duquesne U n i v e r s i t y P r e s s .  Weisman, C.S., & Teitelbaum, M.A. (1985). P h y s i c i a n gender and the p h y s i c i a n - p a t i e n t r e l a t i o n s h i p : Recent evidence and r e l e v a n t q u e s t i o n s . S o c i a l Science and Medicine, 20, 11191127. Wenger, N.K. (1989). Coronary heart d i s e a s e i n women: C l i n i c a l syndromes, prognosis and d i a g n o s t i c t e s t i n g . In Douglas P.S. & B r e s t A.N. (Eds.), Heart d i s e a s e i n women C a r d i o v a s c u l a r c l i n i c s (pp. 173-186). P h i l a d e l p h i a , PA: FA Davis. Wenger, N. K. (1990). Gender, coronary a r t e r y d i s e a s e , and coronary bypass surgery. Annals of I n t e r n a l Medicine, 112, 561-567. Wenger, N.K. (1992). Coronary heart d i s e a s e i n women: A 'new' problem. H o s p i t a l P r a c t i c e , 27, 59-62. White, M., & Epston, D. (1990). N a r r a t i v e means t o t h e r a p e u t i c ends. NY: Norton. W i n e f i e l d , H.R., & M a r t i n , C.J. (1981). Measurement and p r e d i c t i o n of recovery a f t e r myocardial i n f a r c t i o n . I n t e r n a t i o n a l J o u r n a l of P s y c h i a t r y i n Medicine, 11, 154.  145-  Young, R.F., & Kahana, E. (1993). Gender, recovery from l a t e l i f e heart a t t a c k , and medical care. Women and Health, 20(1), 11-31.  167 APPENDIX A Interview  Format  Interview Time: 30-90 minutes f o r each i n t e r v i e w . G u i d i n g Question: What has i t been l i k e f o r you t o have had a heart  attack?  P r e l i m i n a r y Meeting Introduce  myself as a graduate student  i n Counselling  Psychology a t UBC, and as a C a r d i o l o g y T e c h n o l o g i s t a t the h o s p i t a l . Introduce  and e x p l a i n the r a t i o n a l e f o r the study,  requirements of study p a r t i c i p a t i o n , c o n f i d e n t i a l i t y and anonymity, and answer any questions expected by c o - r e s e a r c h e r s . informed First  about what i s i n v o l v e d o r  Give i n f o r m a t i o n l e t t e r and o b t a i n  consent. Arrange a time f o r the f i r s t  interview.  Interview  I acquainted  co-researchers  with the nature and  approximate d u r a t i o n of the f i r s t  i n t e r v i e w . As w e l l , I  a d v i s e d each woman t o inform me i f she d i d not f e e l w e l l , t h a t she c o u l d take a break i f necessary, from answering any questions  t h a t she c o u l d  refrain  t h a t she d i d not f e e l  comfortable  with, and t h a t she c o u l d ask me t o t u r n o f f the audio-tape i f she d i d not want a p a r t i c u l a r p a r t of the i n t e r v i e w  recorded.  Script During t h i s meeting, I am i n t e r e s t e d i n d e v e l o p i n g an o v e r a l l p e r s p e c t i v e , based on your experiences, been l i k e f o r you t o have had a heart  of what i t has  attack.  I would l i k e you t o t h i n k back t o when you f i r s t  realized  t h a t you were having a heart a t t a c k , your experience  when you  a r r i v e d a t the h o s p i t a l , and what your experience l i k e s i n c e . While you t h i n k about t h i s experience,  has been also think  168  about the f e e l i n g s t h a t you have had, what your thoughts  have  been, and how you have behaved. I t i s important t o remember t h a t t h e r e a r e no r i g h t or wrong ways of e x p e r i e n c i n g your i l l n e s s - what i s important this  i s how you p e r s o n a l l y experienced  event. Could you now begin t o d e s c r i b e t o me some of these  experiences, as though you were t e l l i n g a s t o r y t h a t has a beginning, a middle, and an end. T e l l i n g your s t o r y l i k e  this  may help you d e s c r i b e the sequence of events and your experiences s i n c e t h e heart a t t a c k . While you t e l l your s t o r y , I encourage you t o i n c l u d e as many d e t a i l s as p o s s i b l e t h a t a r e r e l a t e d t o your thoughts,  feelings,  and b e h a v i o r s , as they occur d u r i n g each p a r t of  your MI experience. You may have experienced f e e l i n g s , thoughts,  different  or b e h a v i o r s , d u r i n g t h e beginning,  middle, and end of your  experience.  While the c o - r e s e a r c h e r s were t e l l i n g t h e i r s t o r i e s , I asked each woman t h e f o l l o w i n g q u e s t i o n s i n order t o help f a c i l i t a t e t h e d e s c r i p t i o n of her MI experience, as w e l l as t o help d i s c o v e r any p e r s o n a l meanings a s s o c i a t e d with t h e experience. When necessary, prompts s i m i l a r t o those below were used t o help c o - r e s e a r c h e r s f u r t h e r  listed  articulate,  e l a b o r a t e , o r . c l a r i f y t h e i r d e s c r i p t i o n s and responses t o questions.. At t h e end of each i n t e r v i e w , c o - r e s e a r c h e r s were asked demographic type q u e s t i o n s i n order t o g a i n a b e t t e r sense o f t h e i r s o c i a l and c u l t u r a l context  (see Appendix B ) .  169  Questions (a) When were you f i r s t  aware t h a t you were having a heart  attack? (b) What does i t mean t o you t o have experienced a heart attack? (c)  What i s the s i g n i f i c a n c e of the event?  (d) T e l l me more about your f e e l i n g s , your thoughts,  and your  behaviors s i n c e having the heart a t t a c k . (e) How do you f e e l about r e t u r n i n g home? (f)  Is t h e r e anything e l s e you would l i k e t o t e l l me about  your experience of having a heart a t t a c k ? Prompts T e l l me more about t h a t . What were your f e e l i n g s when t h a t happened? What went through your mind when t h a t happened? What d i d you do when t h a t happened? What d i d t h a t mean t o you? How d i d t h a t a f f e c t you? Once the c o - r e s e a r c h e r f i n i s h e d t e l l i n g her s t o r y , I asked she wanted t o add any other r e l e v a n t d e t a i l s t o her s t o r y t h a t would help me understand  her experience of MI, but  t h a t I had not asked about. As w e l l , I asked each woman what her experience was t o be i n t e r v i e w e d and t o t a l k about her MI experience. The i n t e r v i e w was f i n i s h e d o n l y when the cor e s e a r c h e r had o f f e r e d her f i n a l comments. A t t h i s p o i n t , the audio-tape was turned o f f . Before ending the s e s s i o n , I b r i e f l y d e s c r i b e d my forthcoming process of t r a n s c r i b i n g and r e v i e w i n g the  170 i n t e r v i e w i n order t o g a i n a b e t t e r understanding  of the  co-  r e s e a r c h e r ' s s t o r y and f o r p r e l i m i n a r y themes. I thanked the c o - r e s e a r c h e r f o r s h a r i n g her p e r s o n a l s t o r y , and arranged  to  c o n t a c t her f o r the second i n t e r v i e w . Second  Interview  I presented the c o - r e s e a r c h e r with my p r e l i m i n a r y understanding  of her s t o r y from the t r a n s c r i b e d i n t e r v i e w .  Next, I e x p l a i n e d to the c o - r e s e a r c h e r t h a t she has  the  o p p o r t u n i t y to c l a r i f y any m a t e r i a l t h a t appears vague or incomplete,  or p r o v i d e me w i t h a d d i t i o n a l i n f o r m a t i o n t h a t  w i l l help me  f u r t h e r understand  At t h i s time,  her i l l n e s s  I a l s o asked the c o - r e s e a r c h e r f o r  p e r m i s s i o n t o c o n t a c t her b r i e f l y  i n the near f u t u r e i f I  needed t o seek f u r t h e r c l a r i f i c a t i o n m a t e r i a l . The  experience.  c o - r e s e a r c h e r was  r e g a r d i n g the i n t e r v i e w  informed t h a t a copy of the  study r e s u l t s w i l l be a v a i l a b l e upon request once data a n a l y s i s i s complete.  171 APPENDIX B Background Information Form 1.  Please i n d i c a t e your age.  2.  Where do you c u r r e n t l y l i v e ?  3.  Please i n d i c a t e your h i g h e s t education  level:  (a) p u b l i c s c h o o l (b) high school (c) some c o l l e g e o r u n i v e r s i t y courses  (d) undergraduate u n i v e r s i t y degree  (e) master's degree o r above. 4.  M a r i t a l status?  5.  Number of c h i l d r e n :  (a) l i v i n g a t home  b) not l i v i n g a t  home. 6.  How do you c u r r e n t l y spend your time? (a) employed (b) unemployed (c) homemaker (d) r e t i r e d  (e) v o l u n t e e r ( f ) other (please e x p l a i n ) .  7.  What i s your c u r r e n t o r p r e v i o u s  8.  What i s your own o r f a m i l y income?  9.  What i s your e t h n i c background?  10.  occupation?  Have you had any p r e v i o u s i l l n e s s e s ? B r i e f l y d e s c r i b e what i l l n e s s and when were you h o s p i t a l i z e d a t t h i s time?  11.  Does your i l l n e s s experience remind you of another experience you have had i n your  life?  Co-researchers were a l s o asked the f o l l o w i n g q u e s t i o n r e l a t i n g t o a r e s e a r c h p r o j e c t proposed t o p r o v i d e p s y c h o e d u c a t i o n a l support s e r v i c e s t o women l i v i n g w i t h heart d i s e a s e . *  I f you had the o p p o r t u n i t y t o be p a r t of a support group f o r women l i v i n g with heart d i s e a s e what s o r t s of i s s u e s or concerns do you t h i n k would be important t o address?  172 APPENDIX C INFORMED  CONSENT  Title:  Women's Experience with M y o c a r d i a l I n f a r c t i o n : A phenomenological approach  Investigator:  Michele Bowers (M.A. Candidate) 687-6828  Contact  Dr. Maria K i e s s 631-5297  Person:  You have been asked t o p a r t i c i p a t e i n a r e s e a r c h study. P a r t i c i p a t i o n i n t h i s study i s e n t i r e l y v o l u n t a r y . You may decide not t o p a r t i c i p a t e o r may withdraw from the study a t any time without a f f e c t i n g your normal medical treatment. Purpose Most of t h e r e s e a r c h t h a t has focused on women and heart a t t a c k , has not examined women's i l l n e s s experience from a p a t i e n t p e r s p e c t i v e . As a r e s u l t , t h e r e i s l i t t l e understanding of women's p e r c e p t i o n s of t h e i r experience with heart a t t a c k , and how women make meaning of t h i s experience. The purpose of t h i s study i s t o examine t h e nature of women's i l l n e s s experience with heart a t t a c k from t h e i r p e r s p e c t i v e , i n order t o e x p l o r e and d e s c r i b e these experiences and t o understand how women make sense of heart a t t a c k . Procedures I f you decide t o take p a r t i n t h i s study, you w i l l be c o n t a c t e d by the r e s e a r c h e r t h r e e times. The f i r s t meeting w i l l take p l a c e a f t e r you have been t r a n s f e r r e d from t h e coronary care u n i t t o the heart f l o o r . The f i r s t i n t e r v i e w w i l l take p l a c e a day or two a f t e r t h e i n i t i a l meeting, but b e f o r e you a r e d i s c h a r g e d from the h o s p i t a l . The i n t e r v i e w w i l l take p l a c e i n your h o s p i t a l room, and w i l l take between t h i r t y and s i x t y minutes t o complete. You w i l l be asked t o d e s c r i b e what your experience of having a heart a t t a c k has been l i k e . T h i s i n t e r v i e w w i l l be audio taped. The second i n t e r v i e w w i l l take p l a c e v i a telephone once you r e t u r n home from t h e h o s p i t a l . The study should not take up any more time beyond t h e time taken f o r the i n t e r v i e w s . There w i l l not be any i n t e r r u p t i o n of your r e g u l a r medical treatment o r medications.  Page 1 of 2  173 Risks and S i g n i f i c a n t Side E f f e c t s There are no a n t i c i p a t e d r i s k s or s i g n i f i c a n t s i d e e f f e c t s r e s u l t i n g from p a r t i c i p a t i o n i n t h i s study. Potential Benefits T h i s study should add to our understanding of how women make sense of t h e i r experience with heart a t t a c k . You may f i n d i t h e l p f u l to have the o p p o r t u n i t y t o d i s c u s s some of your f e e l i n g s and concerns r e l a t e d to having a heart a t t a c k and being h o s p i t a l i z e d . Monetary Compensation There w i l l be no monetary compensation f o r p a r t i c i p a t i o n i n t h i s study. Confidentiality Any i n f o r m a t i o n r e s u l t i n g from t h i s r e s e a r c h study w i l l be kept s t r i c t l y c o n f i d e n t i a l and w i l l be a c c e s s i b l e o n l y t o M i c h e l e Bowers and the members of her t h e s i s committee which comprise of f a c u l t y members at the U n i v e r s i t y of B r i t i s h Columbia. Audio tapes w i l l not be used f o r any purpose other than f o r Michele Bowers' t h e s i s . These tapes w i l l be s t o r e d s e c u r e l y , and coded by number only as the names of study p a r t i c i p a n t s and any i d e n t i f y i n g i n f o r m a t i o n w i l l not be i n c l u d e d i n the f i n a l r e p o r t .  I f you have any q u e s t i o n s or concerns at any time d u r i n g the study, you may c o n t a c t Michele Bowers at 687-6828.  *************** I have read the above i n f o r m a t i o n and I have had an o p p o r t u n i t y to ask questions to help me understand what my p a r t i c i p a t i o n would i n v o l v e . I f r e e l y consent t o p a r t i c i p a t e i n the study and acknowledge r e c e i p t of a copy of the consent form.  Signature of P a r t i c i p a n t  Date  Signature of Witness page 2 of 2  174  APPENDIX D P a r t i c i p a n t Information L e t t e r One of our t e c h n i c a l s t a f f (ECG t e c h ) , Michele Bowers, i s a l s o graduate student a t U n i v e r s i t y of B r i t i s h Columbia i n c o u n s e l l i n g psychology. Michele i s conducting a r e s e a r c h study, at St. Paul's h o s p i t a l i n c o n s u l t a t i o n with c a r d i o l o g i s t Dr. Maria K i e s s . The r e s e a r c h p r o j e c t examines Women's experience w i t h myocardial i n f a r c t i o n . Michele i s i n t e r e s t e d i n l e a r n i n g more about women's experience with heart a t t a c k , and would be i n t e r e s t e d i n l i s t e n i n g t o your thoughts and f e e l i n g s r e g a r d i n g your experience. She f e e l s t h a t the knowledge gained from your p a r t i c i p a t i o n i n t h i s study c o u l d make a v a l u a b l e c o n t r i b u t i o n t o the f u t u r e care of female c a r d i a c p a t i e n t s . I f you d e c i d e t o p a r t i c i p a t e , Michele w i l l meet with you t o e x p l a i n the p r o j e c t i n more d e t a i l a f t e r you have been t r a n s f e r r e d from the CCU t o the heart ward. I f you are i n t e r e s t e d i n v o l u n t e e r i n g f o r the study, M i c h e l e w i l l arrange a time, w h i l e you are s t i l l h o s p i t a l i z e d , when you can d i s c u s s your experience of having a heart a t t a c k . During t h i s i n t e r v i e w , she w i l l ask you what some of your thoughts and f e e l i n g s have been d u r i n g t h i s experience. There are no r i s k s i f you p a r t i c i p a t e i n t h i s study, and i n no way w i l l p a r t i c i p a t i n g i n the study a f f e c t your c u r r e n t or f u t u r e medical treatment. Some women may f i n d i t h e l p f u l t o be a b l e t o t a l k about t h e i r experiences of heart a t t a c k . Any i n f o r m a t i o n gathered d u r i n g t h i s r e s e a r c h study w i l l be kept s t r i c t l y c o n f i d e n t i a l and w i l l be a c c e s s i b l e o n l y t o M i c h e l e Bowers, Dr. K i e s s , and the other t h r e e UBC p r o f e s s o r s on her r e s e a r c h team. If you t h i n k you might want t o p a r t i c i p a t e i n the study or would l i k e more i n f o r m a t i o n , I would l i k e t o get your p e r m i s s i o n t o forward your name t o M i c h e l e . Thank-you!  175 APPENDIX E Co-researcher  Background  Information  Age Lydia:  75  Kiko:  65  Kaye:  73  Gina:  44  Anne:  63  Brynn:  51  Roslynn:  47  Noreen :  58  Penny:  40  Hilda:  64  M a r i t a l Status and Number of C h i l d r e n Lydia:  Single/0  Kiko:  Widowed/2/2 step  Kaye:  Widowed/1  Gina:  Married/2  Anne:  Married/2  Brynn:  Remarried/3  Roslynn:  Divorced/2  Noreen :  Widowed/7  Penny:  Married/0  Hilda:  Married/9  Education Lydia:  college equivalent  Kiko:  high  school  Kaye:  some c o l l e g e  Gina:  high  school  Anne:  high s c h o o l  Brynn:  university  Roslynn:  university  Noreen :  some high  Penny:  post secondary certificate  Hilda:  high  school  school  176  Current Employment Lydia:  retired/nurse  Kiko:  retired/produce wholesaler  Kaye:  p r o p e r t y manager  Gina:  retail  Anne:  homemaker  Brynn:  unemployed/nurse  Roslynn:  engineer/management  Noreen:  cook-waitress  Penny:  housing a p p r a i s e r .  Hilda:  retired/cookbaker  clerk  Ethnicity Lydia:  Canadian  Kiko:  Japanese/Canadian  Kaye:  Canadian  Gina:  Canadian  Anne:  Canadian  Brynn:  Canadian  Roslynn:  Canadian/Belgium  Noreen:  Canadian  Penny:  Canadian  Hilda:  Canadian  C u r r e n t l y Residence Lydia:  urban  city  Kiko:  urban  Kaye:  urban  city  Gina:  rural  Anne:  rural  city  Brynn:  urban  Roslynn:  urban  city  Noreen:  rural  Penny:  rural  city  Hilda:  rural  city  city  city  177  Previous  Illness  Lydia:  mastectomy; pulmonary f i b r o s i s ;  appendectomy  Kiko:  g a l l s t o n e s removed; u t e r a l  Kaye:  high blood p r e s s u r e ; coronary bypass surgery  Gina:  t o n s i l l e c t o m y ; hysterectomy;  Anne:  neck c y s t s removed; benign tumour removed; 3 Mis; coronary bypass surgery  Brynn:  d y s p l a s i a ; g a l l bladder removed  Roslynn:  2 Mis; kidney stone removed  Noreen:  appendectomy; c a r d i a c arrhythmia  Penny:  vertigo  Hilda:  appendectomy; high blood  clotting  sciatica  pressure  

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