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Phases of recovery from open heart surgery : a descriptive study of postoperative patterns in adult cardiac… Jillings, Carol Rossman 1977

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PHASES OF RECOVERY FROM OPEN HEART SURGERY: A DESCRIPTIVE STUDY OF POSTOPERATIVE PATTERNS IN ADULT CARDIAC SURGERY PATIENTS PRIOR TO DISCHARGE FROM HOSPITAL B.S., U n i v e r s i t y of San F r a n c i s c o , 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA by CAROL ROSSMAN JILLINGS In the School of Nursing A p r i l , 1977 Carol Rossman J i l l i n g s , 1977 I I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t o f t h e r e -quirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C olumbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f ^-fUxflLnQj The U n i v e r s i t y o f B r i t i s h Columbia Vancouver, B. C. ,V6T 1W5 Date Qfxril AStfTl ABSTRACT PHASES OF RECOVERY FROM OPEN HEART SURGERY: A DESCRIPTIVE STUDY OF POSTOPERATIVE PATTERNS IN ADULT CARDIAC SURGERY PATIENTS PRIOR TO DISCHARGE FROM HOSPITAL T h i s d e s c r i p t i v e study was d e s i g n e d t o i n v e s t i g a t e the p r oblem o f i n a d e q u a t e e m o t i o n a l r e c o v e r y from open h e a r t s u r g e r y . T h i s problem has been d e f i n e d by a number o f e a r l i e r r e s e a r c h e r s who have noted adverse e m o t i o n a l r e a c t i o n s t o the e x p e r i e n c e o f c a r d i a c s u r g e r y i n b o t h t h e e a r l y p o s t o p e r a t i v e and the p o s t - d i s c h a r g e p e r i o d s . T h i s i n v e s t i g a t i o n had as i t s purpose the e x a m i n a t i o n o f t h e p r e - d i s c h a r g e r e c o v e r y of p a t i e n t s , and the i n v e s t i g a t o r i n t e n d e d t o note whether t h e r e e x i s t e d a common p a t t e r n o f r e c o v e r y among the p a t i e n t s s t u d i e d (hence, a p a t t e r n of e m o t i o n a l response t o s u r g e r y ) . I t was a n t i c i p a t e d t h a t t h e d i s c o v e r y o f s i m i l a r i t i e s o f b e h a v i o u r might g i v e i n -s i g h t i n t o the res p o n s e s t o open h e a r t s u r g e r y and p r o v i d e i n f o r m a t i o n i m p o r t a n t t o the s t u d y of l o n g - t e r m r e h a b i l i t a -t i o n . Twenty a d u l t p a t i e n t s s c h e d u l e d f o r open h e a r t s u r g e r y were s e l e c t e d as t h e sample f o r s t u d y . The p r i n -c i p a l s e t t i n g f o r the i n v e s t i g a t i o n was the C a r d i a c S u r g e r y U n i t o f a l a r g e m e t r o p o l i t a n h o s p i t a l . S u b j e c t s were i n t e r -viewed one t o two days p r i o r t o s u r g e r y and the n e v e r y two i i i t o t h r e e days p o s t o p e r a t i v e l y u n t i l t h e t ime o f d i s c h a r g e . The i n v e s t i g a t o r o b t a i n e d q u a l i t a t i v e d a t a w i t h the a i d o f a d a t a c o l l e c t i o n t o o l , n o t i n g t h e p h y s i o l o g i c a l s t a t u s o f t h e s u b j e c t s b u t f o c u s i n g most d i r e c t l y on v e r b a l and non-v e r b a l b e h a v i o u r s e x h i b i t e d . The l a t t e r o b s e r v a t i o n s i n -c l u d e d f o c u s o f c o n v e r s a t i o n , p a t t e r n s o f communication, a f f e c t , o r i e n t a t i o n , l e v e l o f a n x i e t y , and a c t i v i t y . F o l l o w i n g a n a l y s i s o f t h e d a t a , i t was n o t e d t h a t a common p a t t e r n o f r e c o v e r y was i n d e e d e v i d e n t . Three phases of r e c o v e r y — S o m a t i c , T r a n s i t i o n and R e s o l u t i o n -c o u l d be d e s c r i b e d f o r each s u b j e c t i n t h e sample. The phases i n d i c a t e d t h e s u b j e c t s ' g e n e r a l r e s p o n s e s t o s u r g e r y and t h e i r p r o g r e s s i o n toward i n c r e a s e d a c t i v i t y and i n d e -pendence a t t h e time o f d i s c h a r g e . I n e f f e c t , t h e phases s e r v e d t o d e f i n e t h e h o s p i t a l c o u r s e o f e m o t i o n a l r e c o v e r y from open h e a r t s u r g e r y . The l e n g t h and o n s e t of t h e s e t h r e e phases were s i m i l a r f o r p a t i e n t s w i t h an u n c o m p l i -c a t e d r e c o v e r y but v a r i e d w i t h p a t i e n t s who e x p e r i e n c e d major p h y s i o l o g i c d i f f i c u l t i e s . The i m p l i c a t i o n s o f a r e c o v e r y p a t t e r n have been d i s c u s s e d r e l a t i v e t o n u r s i n g c a r e o f the c a r d i a c s u r g i c a l p a t i e n t and s p e c i f i c recommendations f o r n u r s i n g i n t e r -v e n t i o n have been made. S u b j e c t a r e a s worthy of f u r t h e r i n v e s t i g a t i o n have been enumerated by t h e i n v e s t i g a t o r i n l i g h t o f t h e c o n c l u s i o n s o f t h e p r e s e n t s t u d y . i v TABLE OF CONTENTS LIST OF TABLES v i i ACKNOWLEDGMENTS v i i i C h apter I . INTRODUCTION 1 Background o f the Study 2 Statement o f t h e Problem 1. 2 Assumptions i . . . 3 D e f i n i t i o n o f Terms 4 L i m i t a t i o n s 5 I I . REVIEW OF LITERATURE RELATED TO THE PROBLEM . . . 6 Emotions and C a r d i a c D i s e a s e 6 The S t r e s s o f C a r d i a c Surgery 7 E m o t i o n a l Outcomes o f C a r d i a c S u r g e r y 8 P o s t c a r d i o t o m y D e l i r i u m 9 A d a p t a t i o n t o S u r g e r y ; Phases o f Recovery . . . 12 P r e o p e r a t i v e F a c t o r s and P o s t o p e r a t i v e Outcomes; Long-Term Outcomes 13 Summary . . . . . 16 I I I . THE RESEARCH DESIGN 21 I n t r o d u c t i o n : An Overview 21 The Research S e t t i n g 21 Sample S e l e c t i o n 22 M e t h o d o l o g i c a l C o n s i d e r a t i o n s and P r o c e d u r e s R e l a t i v e t o Data C o l l e c t i o n 27 Data Coding and A n a l y s i s P r o c e d u r e s 30 R e l i a b i l i t y and V a l i d i t y I s s u e s 31 IV. FINDINGS OF THE INVESTIGATION 34 The Recovery P a t t e r n of the I n d i v i d u a l S u b j e c t : Three Phases 34 A. Somatic Phase 35 B. T r a n s i t i o n Phase 37 C. R e s o l u t i o n Phase 42 D i f f e r e n c e s i n t h e Recovery P a t t e r n 48 D i s c u s s i o n o f C u r r e n t F i n d i n g s w i t h Respect t o E a r l i e r Research 51 v I V . FINDINGS OF THE INVESTIGATION (c o n t i n u e d ) D i s c u s s i o n o f C u r r e n t F i n d i n g s w i t h Respect t o S e l e c t e d T h e o r e t i c a l C o n s t r u c t s 5 3 Summary 5 6 V. C O N C L U S I O N AND RECOMJMENDATIONS 58 Major C o n c l u s i o n s D e r i v e d from t h e F i n d i n g s . 5 8 I m p l i c a t i o n s f o r N u r s i n g 6 0 Recommendations f o r C a r d i o v a s c u l a r N u r s i n g P r a c t i c e 6 3 S u g g e s t i o n s f o r F u r t h e r Research 6 3 BIBLIOGRAPHY 6 6 APPENDIX 74 A. I n t e r v i e w G u i d e l i n e s : P r e o p e r a t i v e P e r i o d . 7 5 B. I n t e r v i e w G u i d l i n e s : P o s t o p e r a t i v e P e r i o d . 7 6 C. Data C o l l e c t i o n T o o l 7 8 D. Data A n a l y s i s Worksheet 8 2 E. An Overview o f t h e Recovery P a t t e r n . . . . 8 3 v i LIST OF TABLES TABLE 1. Characteristics of the Sample 24 2. An I l l u s t r a t i o n of the Three Phases of Recovery as Noted with One Subject Under Study 46 v i i 1 ACKNOWLEDGMENTS v. I would l i k e to express my sincere thanks to my thesis advisors, Mrs. Helen E l f e r t (Chairperson) and Mrs. Ethel Warbinek, for t h e i r valuable guidance and support i n the execution of t h i s research project. Thanks are also due to Miss Rose Murakami, without whom my i n i t i a l obser-vations would not have been pursued as topics of inquiry. I also extend my appreciation to the Canadian Heart Founda-t i o n , which provided f i n a n c i a l support for the investiga-t i o n . It must not be forgotten that research requires assistance from a variety of sources outside the scope of the University. The support of the following individuals i s g r a t e f u l l y acknowledged: Mrs. Sharon Johnson and the sta f f of the Cardiac Surgery Unit, for t h e i r co-operation with the investigation; Mrs. Loreen Moakes, for her expert assistance with the preparation of t h i s manuscript; and, f i n a l l y , my husband and my parents, who have never f a i l e d to encourage my academic endeavours. v i i i CHAPTER I INTRODUCTION Background of the Study Throughout the past two decades much medical and nursing research has been devoted to the study of the patient undergoing cardiac surgery. Early researchers examined the outcomes of closed surgical procedures i n the 1950's; with the evolution of "open heart" procedures em-ploying cardiopulmonary bypass, the investigators of the s i x t i e s and seventies have focused on the physiological and psychological sequelae of open heart surgery, seek-ing to define postoperative outcomes and to determine th e i r possible causality. In the course of c l i n i c a l fieldwork i n the area of cardiac surgery, the investigator has noted a possible pat-tern of recovery i n patients who have undergone open heart surgery; t h i s "pattern", indicating possible phases of adaptation to the surgical experience, bears further inves-. t i g a t i o n i n order to determine whether open heart surgery patients have certain commonalities of experience and re-action during recovery from surgery. Phases of the post-operative period have been noted by Abram (1965) and Kimball (1969b), delineating a range of behaviours from apathy and egocentricity to the an t i c i p a t i o n of discharge , 1 from h o s p i t a l . To dat e no r e s e a r c h e r has d e s c r i b e d phases o f r e c o v e r y i n d e t a i l o r d i s c o v e r e d t h e i r s i g n i f i c a n c e f o r n u r s i n g i n t e r v e n t i o n w i t h t h e c a r d i a c s u r g i c a l p a t i e n t . Statement of t h e Problem A number of s t u d i e s have been noted w h i c h d e a l w i t h t h e p o s t o p e r a t i v e c o u r s e o f the c a r d i a c s u r g i c a l p a t i e n t , r a n g i n g from t h e d i s c u s s i o n o f d e l i r i u m and u n u s u a l s e n s o r y and t hought d i s t u r b a n c e s i n t h e immediate p o s t o p e r a t i v e p e r i o d ( K o r n f e l d , 1965; E g e r t o n and Kay, 1964; H e l l e r , 1970; B l a c h l y and S t a r r , 1964; E l l i s , 1972) t o t h e e x a m i n a t i o n o f l o n g - t e r m p s y c h o l o g i c a l outcomes of t h e s u r g i c a l p r o c e d u r e (Frank, 1972; H e l l e r , 1974; B l a c h l y and B l a c h l y , 1968). The l a t t e r s t u d i e s appear t o h o l d f a r - r e a c h i n g i m p l i c a t i o n s f o r c l i n i c a l n u r s i n g s i n c e t h e y p o i n t o u t an absence, i n many c a s e s , o f s u c c e s s f u l e m o t i o n a l r e c o v e r y from open h e a r t s u r g e r y . B l a c h l y and B l a c h l y (1968), i n an e v a l u a t i o n o f the v o c a t i o n a l and e m o t i o n a l s t a t u s o f open h e a r t s u r g e r y p a t i e n t s , found o n e - t h i r d t o o n e - h a l f of a sample o f 263 p a t i e n t s c o m p l a i n i n g of i n c r e a s e d n ervousness and i r r i t a b i l -i t y p o s t o p e r a t i v e l y , as compared w i t h t h e i r p r e o p e r a t i v e d i s p o s i t i o n . A st u d y conducted by H e l l e r e t a l . (1974) showed the i n c i d e n c e of a n x i e t y , d e p r e s s i o n , low s e l f - e s t e e m s o m a t i c p r e o c c u p a t i o n and w i t h d r a w a l i n open h e a r t s u r g e r y p a t i e n t s i n t e r v i e w e d one y e a r f o l l o w i n g s u r g e r y . On t h e b a s i s of t h i s r e s e a r c h , i t i s noted t h a t a s u b s t a n t i a l numbe of open h e a r t s u r g e r y p a t i e n t s f a i l t o make adequate emo-t i o n a l a djustment t o and r e c o v e r y from t h e i r s u r g i c a l ex-p e r i e n c e . The i n v e s t i g a t o r i n t e n d s t o examine t h i s problem 3 i n the sense t h a t " e m o t i o n a l a d j u s t m e n t " may be i n f l u e n c e d o r p r e d i c t e d by phases o f r e c o v e r y i n the p r e - d i s c h a r g e p e r i o d . I n l i g h t of the above problem s t a t e m e n t , the pu r -pose o f t h i s d e s c r i p t i v e s t u d y i s t o i d e n t i f y , p o s t o p e r -a t i v e l y , b e h a v i o u r s w h i c h a re common t o open h e a r t s u r -g e r y p a t i e n t s and which might t h u s s e r v e as e x p r e s s i o n s o f p a t i e n t needs, p e r c e p t i o n s and e x p e r i e n c e s . I f a d a p t i v e o r r e a c t i v e phases can be i d e n t i f i e d i n t h e p o s t o p e r a t i v e c a r d i a c p a t i e n t , t h e n n u r s i n g i n t e r v e n t i o n s may u l t i m a t e l y be d e s i g n e d which a i d i n me e t i n g p a t i e n t s 1 e m o t i o n a l needs and f a c i l i t a t e a d justment ( s h o r t - and long-term) t o the e x p e r i e n c e o f s u r g e r y . The i n v e s t i g a t o r does not i n t e n d t o propose such i n t e r v e n t i o n s , b u t w i l l a t t e m p t t o d i s c o v e r q u a l i t a t i v e , e m p i r i c a l d a t a w h i c h d e s c r i b e i n d e t a i l the b e h a v i o u r s o b s e r v e d i n and common t o p a t i e n t s r e c o v e r i n g from open h e a r t s u r g e r y . Assumptions I t i s assumed t h a t p a t i e n t s a re i n d e e d r e q u i r e d t o make some form o f adjustment t o the s t r e s s o f a s u r g i c a l p r o c e d u r e such as open h e a r t s u r g e r y . I t i s a l s o assumed t h a t such an e m o t i o n a l adjustment b e g i n s t o t a k e p l a c e as the p a t i e n t commences h i s r e c o v e r y from s u r g e r y , and t h a t t h i s r e c o v e r y may b e g i n as soon as the p o s t - a n e s t h e t i c r e -co v e r y p e r i o d . The i n v e s t i g a t o r makes t h e s e assumptions on the b a s i s t h a t o t h e r r e s e a r c h e r s (Abram, 1965; K i m b a l l , 1969; F r a n k , 1972; H e l l e r , 1974; B l a c h l y and B l a c h l y , 1968) have t a k e n f o r g r a n t e d t h e need f o r e m o t i o n a l adjustment 4 t o the impact o f open h e a r t s u r g e r y . The assumption i s a l s o made t h a t p a t i e n t s e x h i b i t no d i f f e r e n c e i n r e a c t i o n t o the e x p e r i e n c e o f open h e a r t s u r -gery by v i r t u e o f t h e i r s ex. E x p e r i e n c e s of t h e r e c o v e r y p e r i o d a r e not unique t o e i t h e r males o r f e m a l e s , as e v i -denced by the st u d y o f S v e i n s s o n (1975). D e f i n i t i o n o f Terms The f o l l o w i n g terms are o p e r a t i o n a l l y d e f i n e d f o r c l a r i t y i n the d i s c u s s i o n o f d a t a p r e s e n t e d . A d a p t a t i o n : a s t a t e o f s u c c e s s f u l c o p i n g w h i c h i m p l i e s t h a t t h e i n d i v i d u a l has m o d i f i e d h i s u s u a l b e h a v i o u r p a t -t e r n t o some e x t e n t i n o r d e r t o d e a l w i t h change. E m o t i o n a l r e c o v e r y : s u c c e s s f u l a d a p t a t i o n t o the s t r e s s o f open h e a r t s u r g e r y , i n d i c a t e d by t h e p a t i e n t ' s a c c e p t a n c e of the outcome o f s u r g e r y and by h i s o r her r e t u r n t o p r e -s u r g e r y o r p r e - i l l n e s s f u n c t i o n as an i n d i v i d u a l and/or f a m i l y member. Open h e a r t s u r g e r y : c a r d i a c s u r g e r y employing c a r d i o p u l m o -n a r y bypass. P a t i e n t needs: any o f the p h y s i o l o g i c a l , p s y c h o l o g i c a l o r s o c i a l r e q u i r e m e n t s o f t h e h o s p i t a l i z e d i n d i v i d u a l . Phase: a st a g e of the p a t i e n t ' s r e c o v e r y a t w h i c h b e h a v i o u r s e x h i b i t e d by t h e p a t i e n t a re s i m i l a r and form a p a t t e r n ; the phase may be i n d i c a t e d by v e r b a l and n o n v e r b a l b e h a v i o u r s of t h e p a t i e n t o r s i m i l a r c a t e g o r i e s o f b e h a v i o u r as shown : 5 by t h e d a t a . P s y c h o l o g i c a l a d j u s t m e n t : i n t h i s s t u d y , c o n g r u e n t w i t h " e m o t i o n a l r e c o v e r y " ; a s t a t e o f s u c c e s s f u l c o p i n g i n w h i c h a p a t i e n t ' s p s y c h o s o c i a l needs a r e met and i n w h i c h h i s r e -sponse t o s u r g e r y i s t h a t o f a p o s i t i v e a d a p t a t i o n . L i m i t a t i o n s T h i s s t u d y does n o t h y p o t h e s i z e o r measure a r e -l a t i o n s h i p between th e independent and dependent v a r i a b l e s , b u t m e r e l y aims t o d i s c o v e r and d e s c r i b e phases of r e c o v e r y from open h e a r t s u r g e r y i n terms of p a t i e n t b e h a v i o u r s . Needs of t h e p a t i e n t d u r i n g t h e r e c o v e r y p e r i o d may be i n -f e r r e d from t h e d a t a and w i l l be d i s c u s s e d i f r e l e v a n t t o d a t a a n a l y s i s and subsequent c o n c l u s i o n s . The s e l e c t e d sample i s l i m i t e d t o p a t i e n t s under-g o i n g open c a r d i a c p r o c e d u r e s w i t h the use o f c a r d i o p u l -monary by p a s s . The s t u d y does n o t i n v e s t i g a t e any p o s s i b l e c o r r e l a t i o n between th e t y p e o f s u r g i c a l p r o c e d u r e and the o c c u r r e n c e o f phases of r e c o v e r y from s u r g e r y , nor does i t examine t h e r e l a t i o n s h i p between o t h e r v a r i a b l e s , such as age, sex o r d i a g n o s i s and t h e e x i s t e n c e of a p o s t - s u r g i c a l p a t t e r n . CHAPTER I I REVIEW OF LITERATURE RELATED TO THE PROBLEM The t o p i c o f p s y c h o l o g i c a l outcomes of c a r d i a c s u r -g ery has been examined e x t e n s i v e l y by a number vof r e s e a r c h -e r s , some of whom were noted e a r l i e r i n t h e d e f i n i t i o n o f t h e problem under s t u d y . Many i n v e s t i g a t o r s have sought one o r more answers t o t h e problem of l a c k o f e m o t i o n a l r e -c o v e r y from open h e a r t s u r g e r y , and s e v e r a l t r e n d s o r f o c i can be i d e n t i f i e d when summarizing t h e i r e f f o r t s . Emotions and C a r d i a c D i s e a s e I n an a t t empt t o s t u d y e m o t i o n a l a d j ustment t o o r r e -c o v e r y from open h e a r t s u r g e r y , one must f i r s t l o o k t o t h e e a r l y l i t e r a t u r e d e a l i n g w i t h emotions and c a r d i a c d i s e a s e . R e i s e r (1951) was one o f s e v e r a l a u t h o r s who commented on t h e a n x i e t y c onnected w i t h h e a r t d i s e a s e and on the. need t o i n t e g r a t e the awareness of h e a r t d i s e a s e i n t o t h e p a t i e n t ' s s e l f - c o n c e p t . He i d e n t i f i e d a djustment problems such as g u i l t , d e p r e s s i o n and dependency w h i c h , a l t h o u g h n o t ap-p l i e d a t t h e t ime t o the c a r d i a c s u r g e r y p a t i e n t , a r e r e l e -v a n t i n t h e c o n s i d e r a t i o n o f p r e o p e r a t i v e e m o t i o n a l a d j u s t -ment and i t s p o s s i b l e i n f l u e n c e on p o s t o p e r a t i v e outcomes. R e i s e r (1959) l a t e r a p p l i e d t h e s e c o n c e p t s t o c a r d i a c s u r -g e r y , d i s c u s s i n g p o s t o p e r a t i v e d e f e n s e mechanisms, such as 6 dependency, depression and reactions to altered body image. His descriptive data gave a c l e a r insight into the emotional picture of cardiac surgery, and paved the way for future q u a l i t a t i v e and quantitative research. The Stress of Cardiac Surgery With the advent of closed cardiac procedures i n the early f i f t i e s , Fox (1954) discussed psychological observa-tions made with patients undergoing m i t r a l valve repairs. Fox's study focused on the stress of cardiac surgery, open-ing up a new trend i n postoperative research. His i n v e s t i -gation was limited i n scope, however, because i t considered b a s i c a l l y the preoperative reactions to stress (immobility, h y s t e r i c a l amnesia, denial) and did not examine post-surgical reactions in d e t a i l . Findings concerned with personal re-sponses to i l l n e s s and i t s l i m i t a t i o n s tended to r e i t e r a t e e a r l i e r l i t e r a t u r e on the subject of emotions and cardiac disease; i n his discussion of defense mechanisms, such as denial,,immobilization and anxiety, Fox noted s i m i l a r pre-operative defenses among the patients studied but f a i l e d to shed much l i g h t on emotional reactions following surgery. In 1956, Kaplan published the results of a descriptive study which dealt with both pre- and postoperative coping mechan-isms. Once again, the patients selected for study were undergoing closed cardiac procedures for repair of the mi-t r a l valve. Kaplan noted that c e r t a i n preoperative coping mechanisms reappeared aft e r surgery, even though the pre-senting symptoms of heart disease had been a l l e v i a t e d . He 8 found that some patients rea d i l y tended to return to a "pre-sickness pattern of l i v i n g " i f they had not t o a l l y adjusted to t h e i r i l l n e s s before surgery; others, he noted, developed new symptoms (transient muscle pain or psychotic symptoms for example) i n order to u t i l i z e an i l l n e s s to avoid anxiety-provoking s i t u a t i o n s . His observations of t h i s r e h a b i l i t a -tion issue were among the f i r s t insights into the " f a i l u r e to make adequate emotional recovery," and his investigation brought about many questions for further research into re-sponses to cardiac surgery. Emotional Outcomes of Cardiac Surgery Following Kaplan's study, the research focus i n the problem area s h i f t e d i t s emphasis to the examination of emo-t i o n a l outcomes of cardiac surgery. Meyer, (1961) discussed preoperative fear and anxiety and then c l e a r l y described postoperative behaviours and experiences of the patients i n his sample. He found a catastrophe reaction, described as "frozen t e r r o r , " i n a number of early postoperative patients and discovered them to be immobile, apathetic and i n d i f f e r e n t to t h e i r surroundings. His descriptive methodology and de-t a i l e d case studies gave a clear picture of emotional change post open heart surgery, although he did not relate his observations to any e x i s t i n g t h e o r e t i c a l or conceptual framework such as those of loss or anxiety. In 1963, Knox examined the p s y c h i a t r i c aspects of mitra l valvotomy and found psychological sequelae to be present i n a s i g n i f i c a n t number of patients studied. One 9 purpose of thi s study was to determine the frequency of psychological disorders following cardiac surgery; the re-sults noted a decreased incidence of actual psychosis, as compared with the findings of e a r l i e r researchers, but did not describe behaviours which i n fac t were present i n post-operative patients (termed "psychological sequelae") or hypothesize "normal" constituents of an uneventful or un-complicated postoperative course. Dealing with t h i s same theme, Galdston (197 0) noted a psychotic reaction to successful cardiac surgery i n his case study of a woman undergoing a o r t i c valvotomy. Galdston related a theory of "intrapsychic stress" to an outbreak of agitated depression with t h i s patient and discussed the patient's prolonged s e l f - i n t e r e s t and dependence due to her preoperative l i f e s t y l e within the confines of congenital heart disease. Although the author gave a det a i l e d descrip-tion of the patient's post-surgical course, i t i s d i f f i c u l t to say whether his results are generalizable to a larger patient population and i f , i n fa c t , they represent some type of common behavioural reaction or response to the sur g i c a l procedure. Postcardiotomy Delirium The search for a common denominator i n adverse post-operative reactions added yet another dimension to the prob-lem of "inadequate emotional adjustment and recovery." In 1964, Egerton and Kay conducted a study dealing with spe-c i f i c psychological disturbances associated with open heart 10 surgery and found 17 of 60 adult patients to experience de-l i r i u m postoperatively. Depression and hysteria were also noted i n some patients, p e r s i s t i n g i n a few cases u n t i l the post-discharge period. These researchers were the f i r s t to discuss abnormal sensory input as a possible e t i o l o g i c a l factor i n adverse postoperative emotional outcomes; they also discussed the possible r e l a t i o n of cardiopulmonary by-pass and sleep deprivation to post-surgery psychoses. The findings of Egerton and Kay were consistent with t h e i r i n -tent of discovering the frequency of psychological d i s t u r -bance and enumerating possible causes of psychotic reactions to surgery. This study led the way for numerous other r e-searchers who sought to further describe postoperative re-actions of open heart surgery patients. Blachly and Starr (1964) followed Egerton and Kay's study with an examination of "postcardiotomy delirium". They characterized t h i s phenomenon as having a possible re-l a t i o n to perceptual deprivation, sleep deprivation, cen-t r a l nervous system damage secondary to hypothermia or the pump oxygenator, or microemboli. These investigators u t i -l i z e d a well-planned psychiatric evaluation technique to assess the mental status of parti c i p a n t s , and noted that de-l i r i u m was related to the seriousness of preoperative i l l -ness and the degree of stress s u r g i c a l l y and po s t - s u r g i c a l l y . They did not, however, describe the phenomenon i n greater d e t a i l as to onset, length or common behaviours of patients experiencing delirium; "degree of stress" was not operation-a l i z e d by the investigators i n order to give a clearer p i c -11 t u r e o f p o s s i b l e c a u s a l i t y . S t u d i e s which f o l l o w e d t h i s e x a m i n a t i o n o f p s y c h o l o g i c a l c o m p l i c a t i o n s o f open h e a r t s u r g e r y i n c l u d e d t h o s e o f K o r n f e l d (1965) , H e l l e r (1970) and Tufo (1970), a l l o f whom were concerned w i t h f a c t o r s c o n t r i -b u t i n g t o the i n c i d e n c e of adverse e m o t i o n a l outcomes. K o r n f e l d (1965) d i s c u s s e d d e l i r i u m i n g r e a t e r d e s c r i p t i v e d e t a i l and r e l a t e d i t s o c c u r r e n c e t o p h y s i o l o g i c a l f a c t o r s , e n v i r o n m e n t a l f a c t o r s and a n x i e t y . H e l l e r and a s s o c i a t e s (1970) c o n f i r m e d t h e s e f i n d i n g s i n a l a t e r s t u d y and Tufo (1970) noted p o s i t i v e n e u r o l o g i c a l f i n d i n g s w h i c h c o r r e -l a t e d w i t h mental f u n c t i o n i n the p o s t o p e r a t i v e p e r i o d . B r a c e l a n d (1974) appeared t o agree w i t h c a u s a t i o n by o r -g a n i c and s e n s o r y f a c t o r s i n a r e c e n t r e v i e w of r e s e a r c h r e l a t i v e t o e m o t i o n a l outcomes o f open h e a r t s u r g e r y . The t r e n d w i t h r e g a r d t o d e f i n i n g untoward psycho-l o g i c a l outcomes of open h e a r t s u r g e r y appears t o have be-come s t a t i c f o r a p e r i o d , when the f o c u s was narrowed t o the e x a m i n a t i o n o f p o s t c a r d i o t o m y p s y c h o s i s . The a t t e m p t s o f e a r l i e r r e s e a r c h e r s t o d e f i n e o r d e s c r i b e p o s t o p e r a t i v e p a t t e r n s of b e h a v i o u r o r common r e a c t i o n s seem t o have been l o s t f o r a time due t o i n t e n s e i n t e r e s t i n t h i s phenomenon. N u r s i n g l i t e r a t u r e was n o t w i t h o u t i t s emphasis on e n v i r o n -m e n t a l o r s e n s o r y f a c t o r s r e l a t e d t o r e c o v e r y from open h e a r t s u r g e r y , and s e v e r a l s t u d i e s d e a l i n g w i t h s l e e p de-p r i v a t i o n and d i s o r i e n t a t i o n e v o l v e d from t h i s c u r i o s i t y (Walker, 1972; Woods, 1972; E l l i s , 1972; Budd, 1974; and L a s a t e r , 1975). A l l of t h e r e s e a r c h i n t h i s a r e a has been u s e f u l t o p r a c t i t i o n e r s and r e s e a r c h e r s a l i k e , i n terms of 12 modification of the environment of the intensive care unit and the design of nursing care a c t i v i t i e s which are aimed at reducing the patient's anxiety and maintaining r e a l i t y o r i e n t a t i o n . However, i t seems that no one factor can be designated as basic to the occurrence of postcardiotomy delirium, and i t i s therefore necessary to re - d i r e c t the l i t e r a t u r e review (and research interests i n general) to-ward a d i f f e r e n t angle of investigation of the problem. Adaptation to Surgery; Phases of Recovery Blacher (1972) noted that the emotional impact of cardiac surgery may be an additional factor necessary i n the explanation of psychosis following open heart surgery. In discussing t h i s point, he directed the researcher's think-ing back to the i n i t i a l investigations of emotional out-comes and t i e d them together with research focusing s o l e l y on delirium. In t h e i r search for further explanation of emotional recovery from open heart surgery, two researchers of the s i x t i e s discussed adaptation to surgery and to the threat imposed by an operation on a v i t a l organ. Abram (1965) was the f i r s t of these researchers to discuss the cardiac patient's emotional response and reaction to surgery and to the threat of death inherent i n open heart surgery. In his descriptive study, Abram consistently noted the ca-tastrophe reaction mentioned by Meyer (1961), as well as two other phases characterized by mild depression and "gradual l i f t i n g of the a f f e c t " (Abram, 1965, p.662). He also described the incidence of psychotic reactions i n two 13 p a t i e n t s . H i s stu d y was t h e f i r s t t o d e s c r i b e , i n d e t a i l , a m e a n i n g f u l p i c t u r e o f t h e open h e a r t s u r g e r y p a t i e n t ' s c o u r s e o f r e c o v e r y . He a l s o r e l a t e d h i s f i n d i n g s t o t h e t h r e a t o f d e a t h and c o n s i d e r e d e n v i r o n m e n t a l f a c t o r s and t h e i r i n f l u e n c e upon the p a t i e n t ' s response t o s u r g e r y and h i s e x p e r i e n c e o f t h e r e c o v e r y p e r i o d . The second r e s e a r c h e r t o d e a l d e s c r i p t i v e l y w i t h emo-t i o n a l r e a c t i o n t o and r e c o v e r y from open h e a r t s u r g e r y was K i m b a l l (1969b). I n t h e f i r s t o f many s t u d i e s d e a l i n g w i t h the e x p e r i e n c e o f open h e a r t s u r g e r y , h i s purpose was t o de-te r m i n e the s p e c i f i c e x p e r i e n c e s o f p a t i e n t s u n d e r g o i n g c a r -d i a c s u r g e r y . K i m b a l l conducted t h o r o u g h p r e - and p o s t o p e r -a t i v e i n t e r v i e w s t o a s s e s s m e n t a l s t a t u s , u t i l i z e d o t h e r m e d i c a l and n u r s i n g d a t a s o u r c e s i n c o n t a c t w i t h the p a t i e n t and succeeded i n g a t h e r i n g a w e a l t h o f d e s c r i p t i v e d a t a con-c e r n i n g " t y p e s " of p a t i e n t s p r e s e n t i n g f o r open h e a r t s u r -g e r y . L i k e Abram, he noted phases o f r e c o v e r y which ex-tended from an i n i t i a l c a t a s t r o p h e response t o t r a n s f e r a n x i e t y t o d e p r e s s i o n t o the a n t i c i p a t i o n o f d i s c h a r g e . The d e s c r i p t i o n of phases o r p a t t e r n s p r o v i d e d a " m i s s i n g l i n k " w h i c h added n e c e s s a r y i n f o r m a t i o n f o r t h e s t u d y and e x p l a n a -t i o n o f p o s t open h e a r t s u r g e r y b e h a v i o u r s . The imp o r t a n c e o f phases t o t h e i n v e s t i g a t i o n of t h e problem a t hand w i l l be d i s c u s s e d i n t h e f i n a l summary o f t h e l i t e r a t u r e . P r e o p e r a t i v e F a c t o r s and P o s t o p e r a t i v e Outcomes; Long-Term Outcomes  In o r d e r t o b r i n g t h e problem of i n a d e q u a t e e m o t i o n a l r e c o v e r y from open h e a r t s u r g e r y i n t o i t s p r o p e r p e r s p e c t i v e , i t i s n e c e s s a r y t o d i s c u s s c u r r e n t r e s e a r c h t r e n d s and i n -t e r e s t s . A number o f c l i n i c a l r e s e a r c h e r s a r e now i n v e s -t i g a t i n g the r e l a t i o n s h i p between p r e o p e r a t i v e p e r s o n a l i t y f a c t o r s t o p o s t o p e r a t i v e outcomes. Weiss (1966), Kennedy (1966), Layne (1971), H e n r i c h s (1969, 1971), Q u i n l a n (1974) K i m b a l l (1969b, 1970, 1972, 1973) and W i l l n e r (1976) have found a p o s i t i v e c o r r e l a t i o n between l a c k o f p r e o p e r a t i v e p s y c h o l o g i c a l a d j u s t m e n t and ad v e r s e p o s t o p e r a t i v e o u t -comes. Both K i m b a l l and H e n r i c h s have u t i l i z e d p s y c h i a t -r i c e v a l u a t i o n s i n o r d e r t o measure degrees o r ty p e s o f e m o t i o n a l d i s t u r b a n c e and have n o t e d fewer p o s t - s u r g i c a l c o m p l i c a t i o n s w i t h w e l l - a d j u s t e d , l e s s d i s t r e s s e d preope-r a t i v e p a t i e n t s ; p r e o p e r a t i v e d e n i a l , h i g h a n x i e t y o r de-p r e s s i o n have been i d e n t i f i e d as " r i s k f a c t o r s " r e l a t e d t o e m o t i o n a l response t o s u r g e r y . Even more r e l e v a n t t o t h e i s s u e o f e m o t i o n a l r e -co v e r y o r a d a p t a t i o n t o open h e a r t s u r g e r y i s t h e c u r r e n t l i t e r a t u r e d e a l i n g w i t h p o s t - d i s c h a r g e r e s p o n s e s and o u t -comes. R e s e a r c h e r s d e a l i n g w i t h t h i s t o p i c have d i s c u s s e d l o n g - t e r m adjustment o r s e q u e l a e o f c a r d i a c s u r g e r y . I n 1968, B l a c h l y and B l a c h l y e v a l u a t e d the v o c a t i o n a l and e m o t i o n a l s t a t u s of 263 p o s t - s u r g i c a l p a t i e n t s and found t h a t f o r t y - o n e p e r cen t o f t h e sample, w h i l e f e e l i n g t h a t they b e n e f i t e d from s u r g e r y , f e l t u nable t o work and com-p l a i n e d o f nervousness o r d e p r e s s i o n ; t h e s e r e s e a r c h e r s s u g g e s t e d an e s t a b l i s h e d c a r d i a c r e h a b i l i t a t i o n program as a means of a s s i s t i n g p a t i e n t s t o a f u l l e r r e c o v e r y . They f a i l e d , however, t o mention any v a l u e o f a f u r t h e r i n v e s -15 t i g a t i o n i n t o e m o t i o n a l u p s e t s o r causes o f r e l u c t a n c e t o r e t u r n t o the w o r k i n g f o r c e . I n t h e e a r l y s e v e n t i e s , b o t h L u c i a (1970) and Frank (1972) found improved r e h a b i l i t a t i o n and f u n c t i o n a l s t a t u s i n p a t i e n t s s t u d i e d a f t e r open h e a r t s u r g e r y , g i v i n g o p t i m i s t i c r e s u l t s of a s u c c e s s f u l r e c o v e r y p e r i o d . The s u b j e c t o f e m o t i o n a l a d j ustment t o and r e c o v e r y from open h e a r t s u r g e r y was examined f u r t h e r by Frank (1972b), who a l s o found p a t i e n t s t o be s a t i s f a c t o r i l y r e -h a b i l i t a t e d , e x h i b i t i n g g r a t i f i c a t i o n r e g a r d i n g the s u r g i c a l r e s u l t s and n o t i n g improvement i n t h e i r f u n c t i o n a l c a p a c i t y (both p h y s i o l o g i c a l and s o c i a l ) . Frank noted t h a t h i s sam-p l e may have been b i a s e d , however, i n view o f the f a c t t h a t h i s p a t i e n t p o p u l a t i o n were a l l members o f the "Mended H e a r t s I n c o r p o r a t e d " , a " s e r v i c e - m i n d e d and h e a l t h - o r i e n t e d " o r g a n i z a t i o n o f former c a r d i a c s u r g i c a l p a t i e n t s . I n 1974, H e l l e r and a s s o c i a t e s p u b l i s h e d the r e s u l t s o f a n o t h e r f o l l o w - u p s t u d y o f open h e a r t s u r g e r y p a t i e n t s and d i s c o v e r e d l e s s s u c c e s s f u l r e h a b i l i t a t i o n i n a sample o f 142 p a t i e n t s i n t e r v i e w e d one y e a r p o s t o p e r a t i v e l y . T h i s s t u d y n o ted p h y s i c a l improvement and p s y c h o l o g i c a l d e c l i n e i n t he p a t i e n t s i n t e r v i e w e d and i d e n t i f i e d a n x i e t y , d e p r e s -s i o n , low s e l f - e s t e e m , dependency, s o m a t i c p r e o c c u p a t i o n and w i t h d r a w a l i n many o f the p a r t i c i p a n t s ; i m p a i r e d s e x u a l and m a r i t a l f u n c t i o n i n g was a l s o documented. A p p r o x i m a t e l y o n e - t h i r d o f the p a t i e n t s i n H e l l e r ' s sample e x h i b i t e d " p s y c h o l o g i c a l h i n d r a n c e s t o o p t i m a l r e c o v e r y " . These r e -s u l t s make c l e a r once a g a i n the problem under i n v e s t i g a t i o n : t h e f a i l u r e of many open h e a r t s u r g e r y p a t i e n t s t o make ade-16 quate emotional recovery from surgery. Heller's study i s unique i n that i t gives s p e c i f i c d i r e c t i o n for further i n -vestigation of t h i s problem, considering i t from a pre-discharge perspective rather than from the popular "pre-operative factors" or "postcardiotomy delirium" angles. In his recommendation for the promotion of optimal recovery by hospital s t a f f , he alludes to the previous findings on emo-tions and cardiac disease and the stress of cardiac surgery; his suggestions also leave an opening for more intensive de-s c r i p t i v e research (following Abram and Kimball) to examine the pre-discharge recovery period. I t i s from t h i s d i r e c -t i o n that the purpose of the present study evolves. Summary The preceding l i t e r a t u r e review has i l l u s t r a t e d a variety of approaches to the problem of inadequate emotional recovery from open heart surgery. Throughout the past twenty-five years, the problem has been examined with re-gard to preoperative observations of influencing or caus-ative factors, immediate postoperative aberrant behaviours, such as delirium and related thought disturbances, and post-discharge vocational and emotional outcomes. It has been demonstrated that many post open heart surgery pa-t i e n t s return to an adequate l e v e l of s o c i a l and emotional function, either when within the bounds of the hospital or afte r t h e i r return home; however, the discoveries of Blachly and Blachly (1968) and Heller (1974), i n d i c a t i n g a s i g n i f -icant lack of post-discharge recovery from open heart sur-17 gery, cannot be discounted and point to the need for exam-ination of the problem from a new and d i f f e r e n t focal point. The question of whether or not there exists a c r i t i c a l period (influencing long-term outcomes of surgery) i n the patient's hospital recovery remains to be answered. The i n -vestigator has chosen to d i r e c t the purpose of t h i s study i n that vein; to i d e n t i f y behaviours which are common to open heart surgery patients which may indicate phases or patterns figuring s i g n i f i c a n t l y i n the patient's emotional recovery from open heart surgery. It seems that both 7Abram (1965) and Kimball (1969b) have uncovered some general pat-terns of recovery, delineating Meyer's "catastrophe re-action" (1961), as well as a period of mild depression f o l -lowed by preparation for discharge. These descriptions point to the possible existence of phases of emotional re-covery from the entire open heart surgical experience, but they have not been described or followed up i n s u f f i c i e n t d e t a i l to document t h e i r possible significance for long-term recovery. The study of phases of recovery has impor-tance for nursing care of cardiac surgical patients i n both the hospital and community settings, since i t may a s s i s t i n more accurate assessment of the needs of these i n d i v i d u a l s . The discovery of phases or patterns has taken place with regard to diseases or conditions other than those of the cardiovascular system and has provided valuable tools for nursing assessment and intervention. Lenneberg and Rowbotham (1970), i n a descriptive study of the r e h a b i l i t a -tion of ileostomy patients, have i d e n t i f i e d f i v e phases of the r e h a b i l i t a t i o n process which are indicators of the pa-t i e n t ' s adjustment to his s i t u a t i o n . The description of these phases includes the emotional reactions of patients to the impact of surgery and a changed body image. Crate (1965) has discussed a model of adaptation to chronic i l l -ness which i s formulated to aid the nurse i n recognizing the adaptation process and the feelings which the patient experiences at d i f f e r e n t stages of adaptation; i t a s s i s t s also i n the development of nursing interventions aimed at a s s i s t i n g the patient to an optimal l e v e l of adaptation to chronic i l l n e s s . In a s i m i l a r manner, Kubler-Ross (1969) has provided a guideline for assessing successful adapta-t i o n to death and dying, and has discussed phases of ad-justment which provide guideposts for intervention with -patients and f a m i l i e s . In the cardiovascular f i e l d , s imilar e f f o r t s have begun in the areas of r e h a b i l i t a t i v e stages following myocardial i n f a r c t i o n (Granger, 197 4) and the i d e n t i f i c a t i o n of patient needs following aortic^ valve re-placement (Lumpp, 1968). The former a r t i c l e discusses both adaptive and maladaptive behaviours presenting i n three phases of r e h a b i l i t a t i o n extending from the period i n the coronary care unit u n t i l three years post-discharge; t h i s discussion i s not based upon an independent research study, but draws from other research e f f o r t s i n the area of cor-onary patient r e h a b i l i t a t i o n and the concepts of "loss theory" and " c r i s i s theory". The study by Lumpp describes a myriad of patient needs and discusses t h e i r frequencies of manifestation with respect to four phases (preoperative-19 ICU-postoperative-pre-discharge) of h o s p i t a l i z a t i o n . Most r e c e n t l y B o i s v e r t (1976) has sought to enumerate the post-operative concerns of coronary bypass patients and has un-covered themes related to fatigue, pain, a c t i v i t y l e v e l , dependence-independence, and other aspects of the thera-peutic regime. From the evidence of other researchers, i t seems reasonable to expect that further detailed descrip-t i o n of phases or patterns of the postoperative open heart patient w i l l constitute a useful and meaningful addition to e x i s t i n g knowledge of the problems related to emotional re-covery. Descriptive methodology has been chosen for the i n -vestigation of the problem because i t i s f e l t that empir-i c a l , q u a l i t a t i v e data are relevant and necessary to the investigator's purpose. The q u a l i t a t i v e approach of Glaser and Strauss (1967) , seems an i d e a l means of investigating the postoperative course of recovery since the object i s documentation of behaviours and subsequent exploration, analysis and conceptualization related to data obtained. Glaser and Strauss' method of "Observation-Classification-Generalization" w i l l be e s s e n t i a l to the i d e n t i f i c a t i o n of any pattern of recovery which may be found, and t h e i r approach seems compatible with other examinations of the problem by Blachly and Blachly (1968) , Heller (1974) , Abram (1965) , Meyer (1961) and Kimball (1969b) . It i s expected that the empirical, inductive approach w i l l be most useful i n providing s p e c i f i c information about emotional recovery, just as i t has yielded a meaningful picture of patterns i n 20 t h e c h r o n i c a l l y o r t e r m i n a l l y i l l i n d i v i d u a l . CHAPTER III THE RESEARCH DESIGN Introduction: An Overview The c o l l e c t i o n of data required to investigate the research problem took place over a period of four months. The approach to this investigation was inductive and em-p i r i c a l data were obtained and analyzed i n the manner of Glaser and Strauss (1967). It should be mentioned that the investigator did not follow exactly these authors 1 "constant comparative" method of data c o l l e c t i o n and analysis; because a pattern or possible phases were sought, i t was f e l t that concurrent data c o l l e c t i o n and analysis might bias the ob-server/interviewer. However, Glaser and Strauss' method of data recording, coding and categorizing was adhered to and proved useful i n the examination of the vast quantity of empirical data obtained. The Research Setting This investigation of recovery from open heart sur-gery took place in the Cardiac Surgery Unit of a large metropolitan hospital i n Vancouver, B r i t i s h Columbia. An average of six open cardiac surgeries are performed weekly i n t h i s i n s t i t u t i o n . The Cardiac Surgery Unit i s comprised of f i f t e e n beds and contains a patient population l i m i t e d to individuals undergoing either open heart surgery, pacemaker 21 22 i n s e r t i o n or cardiac catheterization procedures. Patients admitted for open heart surgery enter the hospital one to two days p r i o r to surgery and are given intensive preop-erative i n s t r u c t i o n by the unit s t a f f members. The preop-erative teaching plan includes an overview of the patho-physiology of cardiac disease (sp e c i f i c to the i n d i v i d u a l patient's diagnosis), the proposed surgical procedure, post-operative routines i n the post-anesthetic recovery and i n -tensive care areas and an introduction to the physiotherapy regimen (coughing, deep breathing, progressive ambulation). Following surgery, patients remain i n the post-anesthetic recovery area for approximately twenty-four hours and are then transferred to the intensive care unit, where the average length of stay i s three to four days. Patients then return to the Cardiac Surgery Unit for the remainder of t h e i r h o s p i t a l stay; one to two days p r i o r to discharge they re-ceive written discharge instructions accompanied by verbal explanation of the physician's orders. The t o t a l h o spital stay ranges from thirteen to sixteen days for patients with an uncomplicated recovery period. Sample Selection The sample for investigation has been selected from the group of patients admitted to the Cardiac Surgery Unit; a convenient non-random sample of open heart surgery pa-t i e n t s has been chosen, with a t o t a l of twenty patients p a r t i c i p a t i n g i n the study. Subjects selected for study were required to meet the following c r i t e r i a : 1) between the ages of nineteen and s i x t y - f i v e , i n c l u s i v e ; 2) undergo-ing a cardiac s u r g i c a l procedure employing the pump oxy-genator; 3) English-speaking. Both males and females were included i n the sample. A s p e c i f i c diagnosis was not a c r i -t e rion for sample selection; subjects included i n the inves-t i g a t i o n had diagnoses of congenital or acquired heart d i -sease (rheumatic or a r t e r i o s c l e r o t i c ) . Five patients i n the sample had undergone previous cardiac surgery at some point i n t h e i r h i s t o r y . Three patients i n i t i a l l y selected f o r study have been excluded from the sample for analysis be-cause of death, extended complications and unrelated com-p l i c a t i o n s , respectively. A l l p a r t i c i p a n t s were given a f u l l explanation of the investigation p r i o r to obtaining t h e i r written consent to inclusion in the study sample. The c h a r a c t e r i s t i c s of the sample are included i n Table 1. The twenty participants are l i s t e d with corre-sponding information about age, sex, diagnosis and surgical procedure. The length of each subject's postoperative hos-p i t a l stay i s indicated, as i s the number of contacts made by the investigator for the purpose of data c o l l e c t i o n . Thirteen males and seven females were included i n the sample. The mean age of participants was 51.5 years. The average length of the postoperative period i n hospital was fourteen days TABLE 1 CHARACTERISTICS OF THE SAMPLE PATIENT'S INITIAL AGE SEX DIAGNOSIS SURGICAL PROCEDURE TOTAL POSTOPERATIVE DAYS IN HOSPITAL TOTAL CONTACTS MADE BY INVESTIGATOR* A 43 M coronary artery disease double aorto-coronary bypass 12 6 B 51 M mitral stenosis mitral valve replacement 15 8 C 55 M ao r t i c stenosis aortic valve replacement 13 7 D 62 M **coronary artery disease single aorto-coronary bypass 13 7 F 33 F **mitral stenosis m i t r a l i n s u f f i c i e n c y m i t r a l valve replacement 11 5 G 57 F **mitral stenosis mitral valve replacement 15 8 I 52 M coronary artery disease single aorto-coronary v bypass 11 6 J 61 M coronary artery disease single aorto-coronary bypass 11 5 •includes pre-operative interview **had previous cardiac surgery TABLE 1 (continued) CHARACTERISTICS OF THE SAMPLE TOTAL TOTAL! POSTOPERATIVE CONTACTS PATIENT 1S INITIAL AGE SEX DIAGNOSIS SURGICAL PROCEDURE ' DAYS IN HOSPITAL MADE BY INVESTIGATOR' K 56 M coronary artery disease; l e f t v e n t r i c u l a r aneurysm single aorto-coronary bypass; resection of ventricular aneurysm 29 14 L 47 M coronary disease artery t r i p l e aorto-coronary bypass 16 9 M 51 F **mitral coronary disease stenosis artery mitral valve replace-ment; single aorto-coronary bypass 19 10 N 55 F coronary disease artery single aorto-coronary bypass 14 7 0 47 M coronary disease artery single aorto-coronary bypass 18 9 P 58 F coronary disease artery double aorto-coronary bypass 12 6 •includes pre-operative interview **had previous cardiac surgery to TABLE 1 (continued) CHARACTERISTICS OF THE SAMPLE PATIENT'S INITIAL AGE SEX DIAGNOSIS SURGICAL PROCEDURE TOTAL POSTOPERATIVE DAYS IN HOSPITAL TOTAL CONTACTS MADE BY INVESTIGATOR* 0 41 M coronary artery disease double aorto-coronary bypass 13 6 R 61 F m i t r a l regur-g i t a t i o n mitral valve replacement 15 7 S 45 F **mitral stenosis; m i t r a l i n s u f f i c i e n c y m i t r a l valve replacement 14 8 U 44 M coronary artery disease single aorto-coronary bypass 12 6 V 46 M coronary artery disease single aorto-coronary bypass 12 6 W 64 M coronary artery disease; l e f t v e n t r i c u l a r aneurysm single aorto-coronary bypass; excision of aneurysm 17 8 •includes pre-operative interview **had previous cardiac surgery M e t h o d o l o g i c a l C o n s i d e r a t i o n s and P r o c e d u r e s R e l a t i v e t o Data C o l l e c t i o n  The e m p i r i c a l , i n d u c t i v e approach has been chosen as the methodology o f t h i s i n v e s t i g a t i o n . The d e s c r i p t i v e "grounded t h e o r y " method o f G l a s e r and S t r a u s s (1967) was found t o l e n d i t s e l f t o the i n v e s t i g a t o r ' s p urpose: t h e d i s c o v e r y o f phases o r p a t t e r n s i n p o s t o p e r a t i v e c a r d i a c s u r g i c a l p a t i e n t s . Because the d i s c o v e r y o f a p a t t e r n i s e x p l o r a t o r y i n n a t u r e and may u l t i m a t e l y c o n s t i t u t e new knowledge, d e t a i l e d d a t a o f a q u a l i t a t i v e n a t u r e were de-s i r e d . The e m p i r i c a l approach t o the problem and purpose a t hand i s c o n s i d e r e d t o have f o u r components (Mann, 1968): o b s e r v a t i o n , c l a s s i f i c a t i o n , g e n e r a l i z a t i o n and the o p e r a -t i o n a l d e f i n i t i o n o f c o n c e p t s . These components c o n s t i t u t e g u i d e l i n e s f o r the i n v e s t i g a t o r i n a l l s t e p s o f the r e s e a r c h p r o c e s s ; t h e y g i v e d i r e c t i o n f o r t h e phases o f d a t a c o l l e c t -i o n , c o d i n g and a n a l y s i s and, i n and o f t h e m s e l v e s , form a p r o c e s s o f d e s c r i p t i v e s t u d y . I n t h i s i n v e s t i g a t i o n d a t a c o l l e c t i o n was conducted i n the manner d e s c r i b e d , b e g i n n i n g w i t h t h e p r o c e s s o f ob-s e r v a t i o n . P a r t i c i p a n t s i n the s t u d y were p u r p o s e f u l l y i n -t e r v i e w e d and o b s e r v e d w i t h the i n t e n t o f g a t h e r i n g r e l e -v a n t d a t a r e g a r d i n g t h e r e c o v e r y p e r i o d of t h e open h e a r t s u r g e r y p a t i e n t . I n o r d e r t o f a c i l i t a t e and s y s t e m a t i z e o b s e r v a t i o n and the i n t e r v i e w p r o c e d u r e , a d a t a c o l l e c t i o n t o o l was d e v e l o p e d by the i n v e s t i g a t o r . The t o o l a l l o w e d f o r p r e - s o r t i n g o f d a t a o b t a i n e d from d i a l o g u e w i t h and o b s e r v a t i o n o f s t u d y p a r t i c i p a n t s ; t h i s was, i n e f f e c t , a p r e l i m i n a r y c o d i n g p r o c e d u r e w h i c h s e p a r a t e d d a t a i n t o 28 d i s t i n c t observational categories for both the pre- and postoperative periods. The preoperative portion of the data-gathering instrument included demographic data, d e t a i l s of the medical history, the patient's perception of his i l l -ness and i t s l i m i t a t i o n s and psychosocial data giving i n -sight into s i g n i f i c a n t forces or factors i n the l i f e of the i n d i v i d u a l . An assessment of communication patterns was also made, considering verbal behaviour (par t i c i p a t i o n i n conversation, i n i t i a t i o n of or response to questions, char-a c t e r i s t i c s of speech) and nonverbal behaviour characteris-t i c s (eye contact, gestures, body movement during interview). A general comment regarding the anxiety l e v e l of the patient was also included preoperatively; anxiety l e v e l was rated mild, moderate or severe according to the scales of Peplau (1963) and Hays (1961) . Thus, verbal and nonverbal behav-iours were indicators of anxiety; parameters included alertness, perception, degree of physical or emotional d i s -tress and concentration. The postoperative portion of the data c o l l e c t i o n tool was composed of more s p e c i f i c categories of behaviour, focusing most d i r e c t l y on the patient's verbal and non-verbal behaviour. The focus of the individual's conversa-t i o n was considered to be of prime importance i n assessing the recovery period, p a r t i c u l a r l y i n the determination of a l e v e l or stage of recovery. This emphasis was made in view of Abram (1965) and Kimball's (1969b) observations of the postoperative behaviour of cardiac s u r g i c a l patients. Con-sequently, the questions posed by the investigator at t h i s p o i n t were v e r y g e n e r a l , s e r v i n g o n l y t o d i r e c t t he d i a l o g u e t o t he t o p i c d e s i r e d by t h e s u b j e c t and t o encourage h i s ex-p a n s i o n o f i d e a s and f e e l i n g s t o the utmost. A d d i t i o n a l p o s t o p e r a t i v e d a t a - i n c l u d e d documentation of n o n v e r b a l b e - 1 h a v i o u r s ( a l s o i n t e g r a l o b s e r v a t i o n s made by Abram and K i m b a l l ) , d e t e r m i n a t i o n of t h e l e v e l o f c o n s c i o u s n e s s and e x a m i n a t i o n f o r a l t e r a t i o n s i n the thought p r o c e s s e s o f t h e s u b j e c t . The l a t t e r d a t a were n o t e d u s i n g the d e s c r i p t i v e c h a r a c t e r i s t i c s g i v e n by Bates (1974) and Mechner (1975). F i n a l l y , p h y s i o l o g i c a l parameters were i n c l u d e d i n t h e d a t a g a t h e r i n g i n s t r u m e n t , k e e p i n g i n mind the p o s s i b l e o r g a n i c i n f l u e n c e s upon t h e s u b j e c t ' s p o s t o p e r a t i v e b e h a v i o u r . The p a t i e n t r e c o r d and c o n s u l t a t i o n w i t h u n i t s t a f f were u t i -l i z e d as complementary d a t a s o u r c e s t o o b t a i n t h i s i n f o r m a -t i o n . A complete copy o f t h e d a t a c o l l e c t i o n t o o l , accom-p a n i e d by i n t e r v i e w g u i d e l i n e s , i s p r o v i d e d i n Appendices A, B and C. The d a t a c o l l e c t i o n was completed f o r each p a r t i c -i p a n t on the o c c a s i o n o f each v i s i t by t h e i n v e s t i g a t o r . P r e o p e r a t i v e i n t e r v i e w s took p l a c e one t o two days p r i o r t o the proposed s u r g e r y , f o l l o w i n g t h e i n t r o d u c t i o n t o t h e p a t i e n t and the e x p l a n a t i o n o f t h e s t u d y . The p o s t o p e r a t i v e i n t e r v i e w s c h e d u l e commenced on t h e p a t i e n t ' s f i r s t p o s t -o p e r a t i v e day, a p p r o x i m a t e l y t w e n t y - f o u r hours f o l l o w i n g s u r g e r y . The s e t t i n g f o r t h e i n i t i a l p o s t o p e r a t i v e i n t e r -v i ew v a r i e d ' b e t w e e n p o s t - a n e s t h e t i c r e c o v e r y and t h e i n t e n -s i v e c a r e u n i t , depending upon t h e p a t i e n t ' s t i m e o f t r a n s -f e r . D u r i n g the f i r s t p o s t o p e r a t i v e week, v i s i t s were made e v e r y t h r e e days. I n t e r v i e w s became more f r e q u e n t d u r i n g t h e second week f o l l o w i n g s u r g e r y when p a t i e n t s were seen e v e r y two days. In a l l c a s e s , i n t e r v i e w s ranged from f i v e t o f o r t y - f i v e m inutes i n l e n g t h , depending upon the pa-t i e n t ' s c o n d i t i o n and t o l e r a n c e ; the most l e n g t h y s e s s i o n s were c o n s e q u e n t l y toward t h e end o f the p a r t i c i p a n t ' s hos-p i t a l s t a y . I n cases where the p a t i e n t ' s c o n d i t i o n was poor or i f he e x p e r i e n c e d f a t i g u e , the i n v e s t i g a t o r ' s v i s i t was postponed u n t i l the f o l l o w i n g day t o a l l o w the p a t i e n t t o r e s t ; such an a l t e r a t i o n i n s c h e d u l e was found t o be most n e c e s s a r y i n the i n t e n s i v e c a r e s e t t i n g . Data Coding and A n a l y s i s P r o c e d u r e s \ F o l l o w i n g t h e d a t a c o l l e c t i o n phase o f t h e i n v e s t i -g a t i o n , the raw d a t a were s o r t e d and coded i n t o c a t e g o r i e s o f b e h a v i o u r . A "data a n a l y s i s w o r k s h e e t " (Appendix D) was dev e l o p e d i n o r d e r t o condense the volume of raw d a t a i n t o a w o r k a b l e f o r m a t . M a r g i n a l n o t a t i o n s were made i n t h e d a t a themselves t o i n d i c a t e i l l u s t r a t i v e case examples f o r l a t e r use i n the d i s c u s s i o n of f i n d i n g s . As t h i s " j o i n t c o d i n g and a n a l y s i s " e v o l v e d ( G l a s e r and S t r a u s s , 1967, p. 107), c a t e g o r i e s and t h e i r components appeared, o f f e r i n g a n a r r rower u n i t o f a n a l y s i s . " O r i e n t a t i o n " , " a n x i e t y " and " a f -f e c t " were t h r e e o f the c a t e g o r i e s w h i c h emerged. Data f o r each p a r t i c i p a n t were r e v i e w e d and the i n d i v i d u a l and group p a t t e r n s of r e c o v e r y were c o n s i d e r e d . The t o p i c o f c o n v e r -s a t i o n , c o u p l e d w i t h n o n v e r b a l b e h a v i o u r and o b s e r v a t i o n s o f g e n e r a l a c t i v i t y , became t h e most s i g n i f i c a n t c o n s i d e r -a t i o n s b o t h f o r t h e i n d i v i d u a l s u b j e c t and f o r the e n t i r e sample. Components o r p r o p e r t i e s of t h e s e c a t e g o r i e s i n -c l u d e d n e g a t i v e s o m a t i c f e e l i n g s , boredom, humor, and p o s i -t i v e s o m a t i c f e e l i n g s . These p r o p e r t i e s were c o l o r - c o d e d i n t he margin o f the a n a l y s i s w orksheet (next t o the p o s t -o p e r a t i v e day) i n o r d e r t h a t the d a t a might be q u i c k l y r e -viewed f o r t h e i n c i d e n c e and f r e q u e n c y of c e r t a i n behav-i o u r s . F o r example, a r e d d o t denoted a l l n e g a t i v e s o m a t i c s t a t e m e n t s ; when the i n v e s t i g a t o r r e v i e w e d the wo r k s h e e t s o f th e e n t i r e sample, the r e d d o t s i n the margin c o u l d be counted t o dete r m i n e the t o t a l number o f n e g a t i v e s o m a t i c r e s p o n s e s f o r a l l p a t i e n t s on a c e r t a i n p o s t o p e r a t i v e day. These " r e c o v e r y i n d i c a t o r s " s e r v e d as t h e b a s i s f o r d e l i n -e a t i o n o f t h e r e c o v e r y p a t t e r n t o be d i s c u s s e d i n Chapter IV. R e l i a b i l i t y and V a l i d i t y I s s u e s At t h i s p o i n t i t i s n e c e s s a r y t o address t h e i s s u e s of r e l i a b i l i t y and v a l i d i t y o f t h e d a t a base d e r i v e d from t h e p r o c e d u r e s o u t l i n e d i n t h e p r e c e d i n g s e c t i o n . Observa-t i o n s made by t h e i n v e s t i g a t o r i n the c o u r s e o f d a t a c o l l e c -t i o n were v e r i f i e d wherever p o s s i b l e w i t h the s t a f f n u r s e s and t h e m e d i c a l and n u r s i n g r e c o r d s , i n o r d e r t o ensure r e -l i a b i l i t y of. the f i n d i n g s . N o t a t i o n s were made by t h e i n -v e s t i g a t o r i n d i c a t i n g s p e c i f i c b e h a v i o u r s d e s c r i b e d by o t h e r h e a l t h p e r s o n n e l i n t h e c o u r s e o f h e a l t h c a r e d e l i v e r y . When a p p r o p r i a t e , s t a f f were d i r e c t l y q u e s t i o n e d about t h e i r assessment o r o b s e r v a t i o n s o f p a r t i c u l a r b e h a v i o u r s . D u r i n g t h e a c t u a l i n t e r v i e w p r o c e s s , the i n v e s t i g a t o r made note o f key words, t o p i c s and o b s e r v a t i o n s i n o r d e r t o m a i n t a i n a c-c u r a t e r e c a l l of e v e n t s . The d a t a c o l l e c t i o n t o o l was com-p l e t e d i m m e d i a t e l y f o l l o w i n g t h e i n t e r v i e w i n o r d e r t o m i n i -mize e r r o r s o f memory. Audio o r v i d e o r e c o r d i n g s were not u t i l i z e d as a means o f d e t e r m i n i n g r e l i a b i l i t y because o f the p o t e n t i a l d i f f i c u l t y o f o p e r a t i n g such equipment i n the c r i t i c a l c a r e a r e a s and due t o the p o s s i b l e h a r d s h i p t a p i n g might impose upon t h e p a t i e n t . The s y s t e m a t i c approach t o d a t a c o l l e c t i o n and a n a l y s i s l e n d s a degree o f r e l i a b i l i t y t o t he s t u d y , however ( R i l e y , 1963, p. 7 3 ) . A s t a n d a r d i z e d p r o c e d u r e f o r the c o l l e c t i o n and a n a l y s i s o f d a t a a f f o r d s a more c o n s i s t e n t approach t o the r e s e a r c h p r o c e s s and i s t h e r e b y more e x p l i c i t i n r e l a y i n g the methodology t o o t h e r i n v e s t i g a t o r s . The v a l i d i t y o f the methodology and t h e r e s u l t s ob-t a i n e d i s a " n e g l i g i b l e problem" ( a c c o r d i n g t o D e u t s c h e r , 1970, p. 213) when t h e d e s i g n o f the s t u d y i s c o n s i d e r e d . D e u t s c h e r s t a t e s t h a t "the problem o f v a l i d i t y d i s a p p e a r s when we have d i r e c t o b s e r v a t i o n o f the a c t u a l phenomenon ( d i r e c t b e h a v i o u r a l o b s e r v a t i o n ) we are a t t e m p t i n g t o approximate w i t h our measuring i n s t r u m e n t . " A p r e l i m i n a r y t e s t o f v a l i d i t y was conducted w i t h a p i l o t s t u d y (sample s i z e : two s u b j e c t s ) u s i n g the d a t a g a t h e r i n g i n s t r u m e n t . In a d d i t i o n , t h i s s t u d y p r o v i d e d an o p p o r t u n i t y t o a s s e s s t h e i n t e r v i e w s c h e d u l e . At the c o n c l u s i o n o f t h e p i l o t s t u d y , t h e d a t a g a t h e r e d appeared t o be adequate f o r t h e d e t e r m i n a t i o n o f p o s t o p e r a t i v e p a t t e r n s and were c o n s i s t e n t 33 w i t h t h e i n v e s t i g a t o r ' s purpose o f o b t a i n i n g b e h a v i o u r a l ob-s e r v a t i o n s a t v a r y i n g s t a g e s o f r e c o v e r y from c a r d i a c s u r -g e r y . f CHAPTER IV FINDINGS OF THE INVESTIGATION Upon i n t e n s i v e e x a m i n a t i o n o f the i n v e s t i g a t o r ' s f i e l d n o t e s and the d a t a a n a l y s i s w o r k s h e e t s , i t i s found t h a t a p a t t e r n o f r e c o v e r y i n d e e d e x i s t s f o r open h e a r t s u r -g e r y p a t i e n t s . A s e r i e s o f a d a p t i v e o r r e c o v e r y b e h a v i o u r s has been e x t r a c t e d from b o t h t h e raw and coded d a t a and i n -d i c a t e s c o m m o n a l i t i e s i n t h e p o s t o p e r a t i v e e x p e r i e n c e s o f the twenty s u b j e c t s s t u d i e d . A l l s u b j e c t s were found t o demonstrate s p e c i f i c v e r b a l and n o n v e r b a l b e h a v i o u r s w h i c h o c c u r r e d w i t h a degree of o r d e r and w i t h h i g h f r e q u e n c y a t c e r t a i n p o i n t s i n t h e p o s t o p e r a t i v e c o u r s e . D i f f e r e n c e s i n the time o f o c c u r r e n c e o r i n b e h a v i o u r s o b s e r v e d a t c e r t a i n i n t e r v a l s may be a t t r i b u t e d t o the i n c i d e n c e o f c o m p l i c a -t i o n s (and t h u s t h e p o s t o p e r a t i v e time f a c t o r w i t h c e r t a i n s u b j e c t s ) . The Recovery P a t t e r n o f t h e I n d i v i d u a l S u b j e c t : Three Phases As i t i s d e s c r i b e d h e r e , t h e r e c o v e r y p a t t e r n o f the i n d i v i d u a l r e p r e s e n t s a summation of t h e commonly o c c u r r i n g b e h a v i o u r s o b s e r v e d i n s t u d y p a r t i c i p a n t s . The o v e r a l l p a t t e r n can be viewed as h a v i n g t h r e e components o r phases; each phase i s a s u b - p a t t e r n o r group of s i m i l a r be-h a v i o u r s w h i c h i n d i c a t e a t r e n d t h a t i s unique and s e p a r a t e 34 35 from the other phases described. A. Somatic Phase The i n i t i a l phase, l a b e l l e d the "Somatic Phase") has i t s onset as the in d i v i d u a l commences recovery from open heart surgery. This phase has been observed to extend from the post-anesthetic recovery period through the t h i r d day of the patient's convalescence. Variations i n length i n -clude a duration of up to four days (or the entire period i n the intensive care unit) or an extension for nearly one week with a c r i t i c a l l y i l l subject. This phase was c l e a r l y observed i n a l l subjects under study. The occurrence of the Somatic Phase coincides with the aggressive aspects of the medical and nursing regime. Within the time period described above, the patient exper-iences constant monitoring of physiological function and i s confined to a controlled a c t i v i t y l e v e l . He i s frequently medicated for pain and receives intravenous narcotic analge-s i c s . He undergoes vigorous chest physiotherapy and i s i n constant contact with a variety of health professionals. V i s i t o r s are r e s t r i c t e d to members of the patient's imme-diate family and the length of contact i s usually limited to promote the patient's r e s t . As one might i n f e r , the Somatic Phase has as i t s major c h a r a c t e r i s t i c a preoccupation with bodily state and function. This preoccupation has both p o s i t i v e and nega-t i v e aspects, depending upon i t s expression by the subject. With nearly half of the subjects interviewed, the response to questioning about t h e i r progress i n thi s early stage was a n e g a t i v e one. The o t h e r p o r t i o n o f the sample r e p o r t e d t h a t t h e y were "doing OK" o r " f e e l i n g p r e t t y good." A t t i m e s , t h e s e comments were g i v e n i n c o m b i n a t i o n w i t h one a n o t h e r ; f o r example, a response s t a t i n g f a t i g u e o r n o t i n g extreme d i s c o m f o r t might f o l l o w a p o s i t i v e comment such as ' "I'm d o i n g p r e t t y w e l l . " I n g e n e r a l , however, a l l s u b j e c t s i n t e r v i e w e d had a b a s i c c o n v e r s a t i o n a l f o c u s d e a l i n g w i t h some a s p e c t o f p h y s i c a l w e l l - b e i n g , whether i t be o p t i m i s m , d i s c o m f o r t , f a t i g u e o r a d i s l i k e of t u b i n g s and m o n i t o r i n g d e v i c e s . Some i n d i v i d u a l s summarized t h e i r s i t u a t i o n w i t h a t o t a l l y n e g a t i v e comment such as "I'm d o i n g t e r r i b l e " o r "I'm r e a l l y dead b u t I'm s t i l l f i g h t i n g , " i n d i c a t i n g a de-gree o f d i s c o m f o r t o r a n x i e t y . P a t i e n t s a t t h i s s t a g e o f r e c o v e r y r a r e l y mentioned i n d i v i d u a l s o t h e r than themselves i n c o n v e r s a t i o n ; i n cases where o t h e r p a t i e n t s were men-t i o n e d , e n q u i r i e s most o f t e n d i d not appear u n t i l t he l a t t e r p o r t i o n o f t h e s u b j e c t ' s s t a y i n t h e c r i t i c a l c a r e a r e a . I f t he s u b j e c t s were asked about f a m i l y members o r f r i e n d s , the response i n a l l c a s e s was s u c c i n c t ("they come i n eve r y day" o r " f i n e " ) . The appearance o f p a t i e n t s i n the Somatic Phase g e n e r a l l y gave a p i c t u r e o f f a t i g u e and d i s c o m f o r t . Pa-t i e n t s were l e t h a r g i c and p a l e , and th e y o f t e n showed s i g n s o f p a i n o r e x h a u s t i o n . Speech was mumbled and f a i n t and appeared t o r e q u i r e a g r e a t d e a l of e f f o r t , p a r t i c u l a r l y on the f i r s t p o s t o p e r a t i v e day. S u b j e c t s d i d not r e a d i l y i n i t -i a t e c o n v e r s a t i o n and l i m i t e d t h e i r v e r b a l i z a t i o n t o b r i e f r e s p o n s e s t o the q u e s t i o n s posed by the i n v e s t i g a t o r o r o t h e r h e a l t h p r o f e s s i o n a l s . N o n v e r b a l communication i n -c l u d e d nods, eye c o n t a c t i n response t o c o n v e r s a t i o n and l i m i t e d g e s t u r e s g i v e n as a g r e e t i n g t o p e r s o n s a p p r o a c h i n g th e s u b j e c t . N ine of t h e twenty s u b j e c t s s t u d i e d were a s l e e p a t i n t e r v a l s when c o n t a c t e d d u r i n g the f i r s t t h r e e p o s t o p e r a t i v e days; one p a t i e n t was i n t u b a t e d and u n a b le t o v e r b a l i z e d u r i n g t h i s e n t i r e p e r i o d . Two o f t h e p a t i e n t s c o n t a c t e d d i d not w i s h t o be seen by the i n v e s t i g a t o r be-cause o f t h e i r g e n e r a l i z e d d i s c o m f o r t . A c c o r d i n g t o t h e i n v e s t i g a t o r ' s o b s e r v a t i o n s and d o c u m e n t a t i o n from the p a t i e n t r e c o r d , a l l p a t i e n t s i n t h i s phase o f r e c o v e r y were w e l l - o r i e n t e d and none o f the s t u d y s u b j e c t s e x p e r i e n c e d d i s t u r b a n c e s o f t h o u g h t o r a f f e c t i v e d i s o r d e r s d u r i n g t h i s t i m e p e r i o d . A n x i e t y l e v e l was low f o r most s u b j e c t s ; i f p r e s e n t , a n x i e t y was n o t e d most o f t e n i n r e l a t i o n t o p r o c e d u r e s ( p h y s i c a l o r p h y s i o l o g i c care) and the i n d i v i d u a l ' s t o l e r a n c e o f them. T h i s o b s e r v a t i o n was made w i t h f i v e s u b j e c t s i n t h e i n v e s t i g a t i o n . B. T r a n s i t i o n Phase F o l l o w i n g t h e Somatic Phase, a second t r e n d appears i n the o v e r a l l p a t t e r n o f r e c o v e r y . T h i s second g r o u p i n g o f b e h a v i o u r s s h a l l be i n d i c a t e d as t h e " T r a n s i t i o n Phase". T h i s p e r i o d has been o b s e r v e d t o o c c u r a p p r o x i m a t e l y between the f o u r t h and n i n t h p o s t o p e r a t i v e days; i t was n o t e d t o have a l a t e r o c c u r r e n c e f o r s u b j e c t s e x p e r i e n c i n g p r o l o n g e d c o m p l i c a t i o n s o r a s l i g h t l y l o n g e r s t a y i n h o s p i t a l . Once a g a i n , a l l s u b j e c t s were noted t o demonstrate t o some de-gree the b e h a v i o u r c h a r a c t e r i s t i c s d e s c r i b e d h e r e i n . 3 8 The c o r r e s p o n d i n g m e d i c a l and n u r s i n g regimen i n -c l u d e s an i n c r e a s e d a c t i v i t y l e v e l t h r ough p r o g r e s s i v e ambu-l a t i o n and group p h y s i o t h e r a p y s e s s i o n s , i n c r e a s e d p a r t i c i -p a t i o n i n s e l f c a r e , d i e t as t o l e r a t e d w i t h group meals i n t h e ward l o u n g e , and t h e removal of t u b i n g s , c a r d i a c moni-t o r s and p a r e n t e r a l m e d i c a t i o n s ( w i t h the e x c e p t i o n o f i n -t r a v e n o u s sodium h e p a r i n a d m i n i s t e r e d v i a a " h e p a r i n l o c k " ) . A t t h i s t i m e , t h e p a t i e n t has u s u a l l y r e t u r n e d t o the Car-d i a c S u r g e r y U n i t ; one o f the p a t i e n t s i n t h i s sample was an e x c e p t i o n t o t h i s r o u t i n e and remained i n the i n t e n s i v e c a r e u n i t w h i l e " T r a n s i t i o n Phase" b e h a v i o u r s were o b s e r v e d . B e h a v i o u r s c h a r a c t e r i z i n g the T r a n s i t i o n Phase may be summarized as t h o s e moving away from t h e s o m a t i c , ego-c e n t r i c f o c u s of c o n v e r s a t i o n and a c t i o n toward an i n c r e a s e d awareness o f o t h e r i n d i v i d u a l s ; t h i s t r a n s i t i o n may i n c l u d e a " r e s t " from the d i s c o m f o r t o f p r e v i o u s days and the pa-t i e n t ' s i n w a r d and outward r e f l e c t i o n s upon the e x p e r i e n c e o f s u r g e r y o r upon h i s p a s t and p r e s e n t s t a t e s o f w e l l -b e i n g . S u b j e c t s a t t h i s s t a g e appeared s t r o n g e r w i t h im-p r o v e d c o l o u r and a c t i v i t y t o l e r a n c e . They were more n e a t -l y groomed and u s u a l l y wore e y e g l a s s e s and watches. O f t e n they were c h e e r f u l and more t a l k a t i v e , a l t h o u g h s e v e r a l i n -d i v i d u a l s ( s i x o f the sample) were noted t o be s l e e p i n g ex-t e n s i v e l y . A number of s u b j e c t s n o t e d d e c r e a s e d d i s c o m f o r t a t t h i s t i m e , a l t h o u g h e l e v e n r e s p o n d e n t s c o n t i n u e d t o com-p l a i n o f p e r s i s t e n t p a i n . Four p a t i e n t s c h a r a c t e r i z e d t h e i r p a i n as b e i n g u n r e l a t e d t o s u r g i c a l i n c i s i o n s b u t c o n s i s t -39 i n g o f a g e n e r a l i z e d a c h i n g . N e a r l y h a l f o f t h e sample noted poor s l e e p i n g p a t t e r n s and c o n t i n u e d t o c o m p l a i n o f some degree of f a t i g u e . There was, however, a change i n f o c u s from t h e s e s o m a t i c t o p i c s t o more g l o b a l s t a t e m e n t s of s u b j e c t s ' a t -t i t u d e s or p e r c e p t i o n s . A l t h o u g h t h e s o m a t i c a s p e c t s o f t h e p a t i e n t ' s s i t u a t i o n c o n t i n u e d t o r e c e i v e m e n t i o n , t h i s t o p i c was n o t f o r e m o s t i n e i t h e r o c c u r r e n c e or emphasis. Many p a t i e n t s i n q u i r e d about th e s t a t u s o f o t h e r p a t i e n t s whom t h e y had known p r e o p e r a t i v e l y . S u b j e c t s tended t o t a l k a t g r e a t e r l e n g t h about t h e i r f a m i l i e s o r f r i e n d s , r e c o u n t -i n g s t o r i e s o f v i s i t s made by s i g n i f i c a n t p e r s o n s . The a c -t i v i t y l e v e l was a n o t h e r f o c u s o f c o n v e r s a t i o n , and s e v e r a l s u b j e c t s o u t l i n e d t h e i r d a i l y ward r o u t i n e s o f s e l f c a r e , e x e r c i s e , r e s t and meals. One p a t i e n t d e s c r i b e d h i m s e l f as e x p e r i e n c i n g " l i t t l e b u r s t s o f energy" which h i g h l i g h t e d p e r i o d s o f i n c r e a s e d m o b i l i t y and f u n c t i o n . A second d e f i n i t i v e s h i f t i n s u b j e c t s ' c o n c e r n s was n o t e d i n the r e f l e c t i v e e x p r e s s i o n s o f c e r t a i n i n d i v i d u a l s . A few p a t i e n t s r e c a l l e d e i t h e r c o m p l i c a t i o n s o r t h e c o u r s e o f e v e n t s i n the c r i t i c a l c a r e a r e a s . Three p a t i e n t s c l e a r -l y s t a t e d t h a t t h e y were " g l a d t o be a l i v e " f o l l o w i n g s u r -g e r y and an even g r e a t e r number of p a t i e n t s i n d i c a t e d o p t i -mism a t t h e outcome o f s u r g e r y . These i n d i v i d u a l s were g e n e r a l l y p r o g r e s s i n g w e l l and were happy t o r e t u r n t o t h e C a r d i a c S u r g e r y U n i t . Other s u b j e c t s ( s l i g h t l y over one-f o u r t h o f t h e s a m p l e ) , w h i l e o p t i m i s t i c , e x p r e s s e d the de-s i r e t o have g r e a t e r knowledge of the outcome o f the s u r -40 g i c a l p r o c e d u r e and t h e i r p r o g n o s i s . O f t e n t h e s e i n d i v i d -u a l s were unsure o f t h e i r a c t u a l s t a t u s and r e f e r r e d t o a nebulous "they" (presumably p h y s i c i a n s and nu r s e s ) when d i s -c u s s i n g t h e i r p r o g r e s s - i . e . "they say I'm d o i n g f i n e " o r "they t e l l me I'm OK." I t appeared t h a t a l l s u b j e c t s r e -q u i r e d some manner o f r e f l e c t i o n t o c o n t e m p l a t e t h e e x t e n t o f t h e i r e x p e r i e n c e and t o i n t e g r a t e the p a s t w i t h p r e s e n t e v e n t s o r f e e l i n g s . Some p a t i e n t s r e f l e c t e d on the f u t u r e as w e l l , and began t o wonder a t the dat e o f d i s c h a r g e from h o s p i t a l . One p a t i e n t q u i t e f r e e l y e x p r e s s e d h i s t h o u g h t s about the e x p e r i e n c e o f s u r g e r y and the p o s t o p e r a t i v e p e r i o d : he s t a t e d t h a t he was " o f f Gloud N i n e , down t o Cl o u d S i x " and c l a r i f i e d t h a t the e l e v a t i o n o f mood i n t h e immediate p o s t o p e r a t i v e p e r i o d (which c o i n c i d e d w i t h h i s p e r c e p t i o n of s u r v i v a l and f e e l i n g s of h a v i n g conquered d e a t h ) , had s u b s i d e d , l e a v i n g him w i t h a r e a l i z a t i o n o f h i s own m o r t a l i t y and a t h a n k f u l n e s s f o r a p o s i t i v e outcome. A number o f s u b j e c t s a l s o n o t e d a l o w e r i n g o f mood d u r i n g the p e r i o d d e s c r i b e d as the T r a n s i t i o n Phase. T h i s e x p e r i e n c e was l a b e l l e d by p a t i e n t s "as d e p r e s s i o n " , t h e " b l u e s " o r a "down day." S u b j e c t s who e n c o u n t e r e d t h i s phenomenon c o u l d n o t i d e n t i f y a s p e c i f i c p r e c i p i t a t i n g f a c t o r , n o r c o u l d t h e y d e l i n e a t e any s p e c i f i c f o c u s o f th o u g h t a t the t i m e o f d e p r e s s i o n . One woman l i k e n e d the e x p e r i e n c e t o the p o s t p a r t u m d e p r e s s i o n f o l l o w i n g t h e b i r t h o f h e r c h i l d r e n . Two men d e s c r i b e d t h i s mood as one o f i r -r i t a b i l i t y and i m p a t i e n c e w i t h o t h e r s , s t a f f and f a m i l y members i n c l u d e d . Another man d i s c u s s e d f e e l i n g s o f emp-t i n e s s and h e a v i n e s s , s t a t i n g t h a t he f e l t as i f "the bottom had dropped o u t " of e v e r y t h i n g ; he acknowledged t h a t he wanted t o be a l o n e a t t h i s t i m e and had a need t o " s o r t t h i n g s o u t " . A l l o f t h e i n d i v i d u a l s who e x p e r i e n c e d t h i s p o s t - s u r g i c a l d e p r e s s i o n ( a p p r o x i m a t e l y o n e - t h i r d o f the sample) found t h a t i t s one-day d u r a t i o n d i d n o t c o n s t i t u t e a s e t b a c k . I n s p i t e o f p r e v a i l i n g improvement m a n i f e s t e d d u r i n g t h i s phase, s i x o f t h e s u b j e c t s under s t u d y had a m i l d i n -c r e a s e i n a n x i e t y d u r i n g t h i s t i me p e r i o d . For a l l pa-t i e n t s , t h e l e v e l of a n x i e t y was low and appeared r e l a t e d t o one o f t h e f o l l o w i n g f a c t o r s : p r o l o n g e d i n c i s i o n a l d i s -c o m f o r t , an e p i s o d e of c h e s t p a i n ( a t t r i b u t e d t o s u r g i c a l trauma and not d i a g n o s e d as a n g i n a o r pulmonary embolism) o r g a s t r o i n t e s t i n a l d i s t u r b a n c e s . T h i s a n x i e t y , u s u a l l y n o t e d by t h e p a t i e n t ' s v e r b a l emphasis on t h e p r e c i p i t a t i n g f a c t o r , was a b s ent a t t h e time o f subsequent i n t e r v i e w s w i t h a l l p a t i e n t s c o n c e rned. The s u b j e c t s ' l e v e l o f o r i e n t a t i o n was - g e n e r a l l y good d u r i n g the T r a n s i t i o n Phase, a l t h o u g h f o u r i n d i v i d u a l s e x h i b i t e d a m i l d degree of d i s o r i e n t a t i o n o r p e r i o d i c con-f u s i o n between the n i n t h and e l e v e n t h p o s t o p e r a t i v e days. T h i s d i s o r i e n t a t i o n u s u a l l y i n v o l v e d l a c k o f knowledge of t ime o r p e r s o n o r a d i s r u p t i o n o f s h o r t - t e r m memory p r o -c e s s e s . No s u b j e c t s e x p e r i e n c e d h a l l u c i n a t o r y phenomena, a l t h o u g h two p a t i e n t s r e p o r t e d s t r a n g e dreams and one o f t h e s e men behaved i n a p p r o p r i a t e l y a f t e r awakening. Communication p a t t e r n s i n t h e T r a n s i t i o n Phase were changed d r a m a t i c a l l y from t h o s e o f the Somatic Phase. The s u b j e c t s i n t e r v i e w e d a t t h i s time demonstrated more spon-taneous communication and spoke a t g r e a t e r l e n g t h i n r e -sponse t o q u e s t i o n s . P a t i e n t s a t t h i s s t a g e o f t h e r e c o v e r y p e r i o d were o b s e r v e d t o c o n v e r s e w i t h s t a f f and o t h e r pa-t i e n t s t o a g r e a t e r e x t e n t t h a n p r e v i o u s l y . N o n v e r b a l com-m u n i c a t i o n was a l s o s i g n i f i c a n t a t t h i s t i me - many s u b j e c t s (over h a l f o f t h e sample) p u n c t u a t e d t h e i r speech w i t h ges-t u r e s o r a c t i o n s i n o r d e r t o more c l e a r l y e x p r e s s them-s e l v e s , and eye c o n t a c t was g e n e r a l l y i n c r e a s e d . S e v e r a l p a t i e n t s d i s p l a y e d t h e i r i n c i s i o n s o r v e n i p u n c t u r e s i t e s t o the i n v e s t i g a t o r w h i l e d i s c u s s i n g d i s c o m f o r t ; o t h e r s showed g r e e t i n g c a r d s o r f l o w e r s w h i l e m e n t i o n i n g v i s i t o r s o r t h e i r improved p h y s i c a l s t a t e . As a whole, s u b j e c t s appeared more o u t g o i n g and s o l i c i t o u s of a t t e n t i o n and c o n v e r s a t i o n t h a n i n t h e p r e c e d i n g phase o f r e c o v e r y . C. R e s o l u t i o n Phase The t h i r d and f i n a l phase o f the r e c o v e r y p e r i o d i s t h a t segment i n wh i c h s t u d y p a r t i c i p a n t s showed t h e g r e a t -e s t improvement. T h i s s t a g e i s named t h e " R e s o l u t i o n Phase" because i t i s t h e time d u r i n g w h i c h c o n f l i c t s and problems appear t o a c h i e v e t o t a l o r p a r t i a l s o l u t i o n . A t t h i s t i m e , the p a t i e n t c o n t i n u e s t o improve s t e a d i l y and e x h i b i t s a g r e a t e r degree o f independence i n d a i l y a c t i v i t i e s . He r e a d i e s h i m s e l f f o r d i s c h a r g e by o b t a i n i n g i n f o r m a t i o n w h i c h w i l l a s s i s t him t o p r o g r e s s o u t s i d e of t h e h o s p i t a l e n v i r o n -ment. The r o u t i n e o f t h e C a r d i a c S u r g e r y U n i t a l l o w s the v 43 i n d i v i d u a l t o attempt an i n c r e a s e d d a i l y a c t i v i t y l e v e l t hrough s e l f - c a r e and p h y s i o t h e r a p y . Toward the c o n c l u s i o n o f the h o s p i t a l s t a y , the p a t i e n t r e c e i v e s d i s c h a r g e g u i d e -l i n e s and i n s t r u c t i o n s from t h e p h y s i c i a n and/or members o f th e n u r s i n g s t a f f . T h i s i n f o r m a t i o n i n c l u d e s t o p i c s such as m e d i c a t i o n s , d i e t and a c t i v i t y l e v e l p o s t - d i s c h a r g e . The R e s o l u t i o n Phase has been n o t e d t o o c c u r approx-i m a t e l y t h r e e days p r i o r t o the s u b j e c t ' s d i s c h a r g e from h o s p i t a l . F o r i n d i v i d u a l ' s w i t h an u n e v e n t f u l r e c o v e r y period,-, t h i s phase would b e g i n on o r about the t e n t h p o s t -o p e r a t i v e day. S u b j e c t s i n t e r v i e w e d i n the R e s o l u t i o n Phase were n o t e d t o have improved appearance snd a c t i v i t y t o l e r a n c e as compared w i t h t h e p r e v i o u s s t a g e . A l l p a t i e n t s were n e a t l y groomed^, t a l k a t i v e , a l e r t and o f t e n j o v i a l . Many were found i n the p a t i e n t lounge s o c i a l i z i n g w i t h o t h e r i n -d i v i d u a l s . A l l s u b j e c t s i n d i c a t e d the a n t i c i p a t i o n o f d i s -charge as a major c o n v e r s a t i o n a l f o c u s a t t h i s t i m e . The a n x i e t y l e v e l was low once a g a i n f o r s u b j e c t s o b s e r v e d a t t h i s p o i n t i n t i m e . The m i l d a n x i e t y provoked by the d i s c o m f o r t o f t h e f i r s t two phases had d i s a p p e a r e d . P a t i e n t s who e x h i b i t e d m i l d a n x i e t y d u r i n g t h e R e s o l u t i o n Phase were concerned about r e c e i v i n g i n f o r m a t i o n r e g a r d i n g d i s c h a r g e (on s u b j e c t s such as a c t i v i t y l e v e l , v i s i t s t o the p h y s i c i a n , s e x u a l a c t i v i t y , t r a v e l l i n g ) and most o f t e n t h i s a n x i e t y was r e s o l v e d by t h e p r e - d i s c h a r g e t e a c h i n g . Two o f the s u b j e c t s s t u d i e d c o n t i n u e d t o e x p e r i e n c e m i l d a n x i e t y about t h e i r p r o g n o s i s and t h e s e persons q u e s t i o n e d t h e i r p h y s i c i a n s a p p r o p r i a t e l y r e g a r d i n g t h i s m a t t e r . As was mentioned i n t h e i n i t i a l d i s c u s s i o n o f the R e s o l u t i o n Phase, d i s c h a r g e from h o s p i t a l was t h e p r i m a r y f o c u s o f c o n v e r s a t i o n f o r p a t i e n t s a t t h i s s t a g e o f t h e i r r e c o v e r y . S u b j e c t s were g e n e r a l l y happy t o be a p p r o a c h i n g d i s c h a r g e and a w a i t e d t h e event w i t h o p t i m i s m and a degree o f e n t h u s i a s m . A l l s u b j e c t s posed a number o f q u e s t i o n s c o n c e r n i n g the p o s t - h o s p i t a l p e r i o d and most i n d i v i d u a l s were eager f o r the p h y s i c i a n ' s o r n u r s e ' s t e a c h i n g s e s s i o n . Many p a t i e n t s were o f t h e o p i n i o n t h a t r e c o v e r y would p r o -ceed more q u i c k l y a t home - s e v e r a l p ersons s t a t e d t h a t they c o u l d " r e c o v e r j u s t as w e l l a t home as (they) c o u l d h e r e . " Over h a l f o f t h e s u b j e c t s s t u d i e d had c o n c r e t e p l a n s f o r d a i l y a c t i v i t y and a r e t u r n t o t h e i r j o b s o r u s u a l f u n c t i o n s a t some p r o j e c t e d d a t e . A d d i t i o n a l t o p i c s o f c o n v e r s a t i o n w h i c h s u r f a c e d d u r i n g the R e s o l u t i o n Phase i n c l u d e d the mention of t h e s u b j e c t ' s f a m i l y o r t h e d i s c u s s i o n o f v a r i o u s e v e n t s t o t a l l y u n r e l a t e d t o h o s p i t a l i z a t i o n o r i l l n e s s . A few minor com-p l a i n t s o f p a i n o r f a t i g u e p e r s i s t e d , b u t t h e s e d i d n o t c o n s t i t u t e a major f o c u s o f v e r b a l i z a t i o n . Two p a t i e n t s i n t r o d u c e d a p r o f o u n d t o p i c d e a l i n g w i t h t h e impact o f open h e a r t s u r g e r y on t h e i r e m o t i o n s . I n summarizing t h e i r e x p e r i e n c e s o f c a r d i a c s u r g e r y and the p o s t o p e r a t i v e p e r i o d , t h e s e i n d i v i d u a l s n o t e d t h a t the s u r g e r y had e x e r t e d a s i g -n i f i c a n t e f f e c t upon t h e i r e m o t i o n s , l e a v i n g them w i t h f e e l -i n g s o f a n x i e t y , d e p r e s s i o n , l o n e l i n e s s o r f e a r . . Each sub-j e c t acknowledged t h a t he c u r r e n t l y f e l t improved and i n a b r i g h t e r mood, but agreed t h a t open h e a r t s u r g e r y was a t r e -mendously e m o t i o n a l e x p e r i e n c e f o r him. Both i n d i v i d u a l s f e l t t h a t t h e i r p h y s i c a l needs had been met r e p e a t e d l y d u r -i n g t h e c o u r s e o f r e c o v e r y , b u t noted t h a t t h e i r needs f o r p s y c h o l o g i c a l s u p p o r t were not always s a t i s f i e d . One woman f e l t t h a t she c o u l d n o t r e l y on her f a m i l y f o r such s u p p o r t because t h e y were unable t o d e a l w i t h her need f o r them -she f e l t t h a t t h e y d e n i e d the s e r i o u s n e s s o f her s u r g e r y because i t t h r e a t e n e d the e m o t i o n a l make-up o f the f a m i l y group. T h i s s u b j e c t suggested t h a t t h e nurse would be t h e i d e a l i n d i v i d u a l t o p r o v i d e e m o t i o n a l s u p p o r t , because he o r she would be " n e u t r a l " and not f e e l p e r s o n a l l y t h r e a t -ened by t h e s i t u a t i o n . T h i s d i s c u s s i o n o f t h e R e s o l u t i o n Phase c o n c l u d e s t h e g e n e r a l d e s c r i p t i o n o f t h e r e c o v e r y p a t t e r n . T a b l e 2 i l l u s t r a t e s t h e t h r e e phases o f h o s p i t a l r e c o v e r y as they were e v i d e n c e d i n the b e h a v i o u r o f one o f t h e s u b j e c t s s t u d i e d . Appendix 3 r e p r e s e n t s an o v e r v i e w o f t h e t o t a l r e c o v e r y p a t t e r n . POSTOPERATIVE DAY 1 ( I n t e n s i v e Care U n i t ) 4 ( C a r d i a c S u r g e r y U n i t ) 9 TABLE 2 AN ILLUSTRATION OF THE THREE PHASES OF RECOVERY AS NOTED WITH ONE SUBJECT UNDER STUDY APPEARANCE VERBAL AND NONVERBAL BEHAVIOUR p a l e c o l o u r ; s l e e p i n g s o u n d l y appears t i r e d and i n moderate d i s c o m f o r t ; p a l e ; t o l e r a t i n g a m b u l a t i o n w e l l s l e e p i n g s o u n d l y ; n u r s e s ' notes r e p o r t p a t i e n t w e l l -o r i e n t e d and c o - o p e r a t i v e complains o f p e r s i s t e n t neck p a i n which i n t e r f e r e s w i t h s l e e p ; s t a t e s he i s t i r e d ; s t a t e s i n c i s i o n a l p a i n .de-c r e a s e d ; v o l u n t e e r s i n f o r m a -t i o n ; s l i g h t l y s h o r t o f b r e a t h w i t h speech appears t i r e d and p a l e ; l y i n g q u i e t l y i n bed; h a i r combed s t a t e s he f e e l and i s r e s t i n g p h y s i o t h e r a p y ; s i x t i m e s t h i s a f t e r each mea g r o i n d i s c o m f o about edema a t d i s p l a y s s i t e ; v e r s a t i o n ; ask s b e t t e r to-day f o l l o w i n g w a l ked i n h a l l morning; w a l k s 1; c o m p l a i n s o f r t ; w o r r i e d CVP s i t e -i n i t i a t e s con-s q u e s t i o n s c h e e r f u l , l a u g h i n g a t times o u t l i n e s d a i l y r o u t i n e ; f e e l s b e t t e r ; has had "bad days" where he f e l t t i r e d and i n ti-er, TABLE 2 (continued) AN ILLUSTRATION OF THE THREE PHASES OF RECOVERY AS NOTED WITH ONE SUBJECT UNDER STUDY POSTOPERATIVE DAY 9 (c o n t i n u e d ) APPEARANCE 11 c h e e r f u l ; w alks b r i s k l y ; i n lounge w a t c h i n g / t e l e v i s i o n w i t h a group of p a t i e n t s ; well-groomed VERBAL AND NONVERBAL BEHAVIOUR p a i n - l i t t l e t h i n g s g o t on h i s n e r v e s , l o s t temper; com-p l a i n s of poor s l e e p ; i n i t -i a t e s c o n v e r s a t i o n ; t a l k a t i v e f e e l s much b e t t e r ; l e s s p a i n ; improved s l e e p ; a n x i o u s t o go home; f i n d s s m a l l t h i n g s ( k i n d n e s s , c omfort) mean a l o t t o him; spontaneous con-v e r s a t i o n ; j o k i n g w i t h some p a t i e n t s 13 d i s c h a r g e d from h o s p i t a l 48 D i f f e r e n c e s i n the Recovery P a t t e r n The p r e c e d i n g d i s c u s s i o n has f o c u s e d on t h r e e s t a g e s o f t h e r e c o v e r y p e r i o d which were n o t e d t o r e p r e s e n t a p a t t e r n common t o the twenty s u b j e c t s s t u d i e d . I t i s noteworthy t h a t , w h i l e t h e r e c o v e r y p a t t e r n was f a i r l y con-s i s t e n t , the l e n g t h and time o f o n s e t o f t h e phases a r e named a r b i t r a r i l y . S u b j e c t s who had an u n c o m p l i c a t e d p o s t -o p e r a t i v e p e r i o d were o b s e r v e d t o e x p e r i e n c e a r e c o v e r y p a t t e r n w i t h i n t h e parameters named; s u b j e c t s who expe-r i e n c e d c o m p l i c a t i o n s o f a s e r i o u s n a t u r e e x h i b i t e d s i m i l a r b e h a v i o u r s ( i . e . a p a t t e r n ) , b u t a t d i f f e r i n g p o s t o p e r a t i v e i n t e r v a l s . Thus, i t must be s t a t e d t h a t t h e s i g n i f i c a n c e o f t h e s e r e s e a r c h f i n d i n g s l i e s i n t h e a c t u a l d e s c r i p t i o n o f b e h a v i o u r s c o n s t i t u t i n g a r e c o v e r y p a t t e r n and does not c e n t e r on t h e l e n g t h o f phases o r the p o s t - s u r g i c a l d a t e o f o c c u r r e n c e . P o s t o p e r a t i v e c o m p l i c a t i o n s a r e , o f c o u r s e , the most s i g n i f i c a n t i n t e r v e n i n g v a r i a b l e w i t h r e g a r d t o the cou r s e o f r e c o v e r y . Four o f t h e s u b j e c t s i n t h i s sample e x p e r i e n c e d p o s t o p e r a t i v e c o m p l i c a t i o n s w h i c h were r e s o l v e d w i t h o u t a f f e c t i n g the l e n g t h o f the r e c o v e r y p e r i o d : p o s t -o p e r a t i v e hemorrhage (two s u b j e c t s ) , p y r e x i a and bowel ob-s t r u c t i o n . Two s u b j e c t s had major s e t b a c k s due t o c a r d i a c a r r e s t . One o f t h e s e i n d i v i d u a l s a r r e s t e d on the n i n t h p o s t o p e r a t i v e day and the o t h e r s u b j e c t had m u l t i p l e ven-t r i c u l a r a r r h y t h m i a s ( n e c e s s i t a t i n g n i n e d e f i b r i l l a t i o n s ) i n t he f i r s t f o u r p o s t o p e r a t i v e days; b o t h s u b j e c t s ' con-d i t i o n s e v e n t u a l l y s t a b i l i z e d and each resumed a f a i r l y 49 t y p i c a l p o s t o p e r a t i v e c o u r s e f o l l o w i n g t r e a t m e n t o f c o m p l i -c a t i o n s . The t h r e e phases o f r e c o v e r y were noted i n a s i m -i l a r t i me span f o r t h e f o u r s u b j e c t s whose c o m p l i c a t i o n s had no b e a r i n g on t h e l e n g t h o f h o s p i t a l i z a t i o n ; t h a t i s , t h e phases o c c u r r e d w i t h i n a time span s i m i l a r t o t h a t f o r " u n c o m p l i c a t e d " s u b j e c t s . The two p a t i e n t s who e x p e r i e n c e d p o s t o p e r a t i v e hemorrhage w i t h i n t h e f i r s t t w e n t y - f o u r hours of s u r g e r y p r o g r e s s e d smoothly f o l l o w i n g s u r g i c a l i n v e s t i -g a t i o n o f b l e e d i n g and subsequent t r a n s f u s i o n s . T h e i r r e -c a l l of t h e s e c o m p l i c a t i o n s c o i n c i d e d w i t h t h e l a t t e r p o r -t i o n o f the Somatic Phase and t h e T r a n s i t i o n Phase. One s u b j e c t who remained f e b r i l e f o r a number o f days d i d not e x p e r i e n c e a p r o l o n g e d h o s p i t a l s t a y , b u t was n o t e d t o r e -main i n the T r a n s i t i o n Phase f o r a s l i g h t l y l o n g e r p e r i o d ( a p p r o x i m a t e l y two days g r e a t e r than t h e d u r a t i o n f o r o t h e r p a t i e n t s w i t h the same l e n g t h of s t a y i n h o s p i t a l ) . The p a t i e n t who e x p e r i e n c e d g a s t r o i n t e s t i n a l c o m p l i c a t i o n s r e -mained l o n g e r i n t h e Somatic Phase ( i . e . had a c o n t i n u a l f o c u s on p h y s i c a l s t a t e and d i s c o m f o r t ) u n t i l t h e t h i r t e e n t h p o s t o p e r a t i v e day; he t h e n proceeded t h r o u g h t h e second and t h i r d phases q u i t e r a p i d l y as t h e time o f d i s c h a r g e approached. The two s u b j e c t s w i t h a p r o l o n g e d h o s p i t a l s t a y due t o c a r d i a c a r r e s t a l s o demonstrated b e h a v i o u r s w h i c h con-s t i t u t e d t h r e e r e c o v e r y phases, b u t the d u r a t i o n o f each st a g e was q u i t e d i f f e r e n t from the u n c o m p l i c a t e d r e c o v e r y c o u r s e d e s c r i b e d e a r l i e r . The s u b j e c t who had m u l t i p l e a r -50 r e s t s remained i n t h e i n t e n s i v e c a r e u n i t f o r seventeen days p o s t - s u r g e r y and was i n t u b a t e d w i t h v e n t i l a t o r a s s i s t a n c e t o r e s p i r a t i o n u n t i l the t e n t h p o s t o p e r a t i v e day. F o l l o w -i n g t h i s p e r i o d , t h e p a t i e n t showed a low i n c i d e n c e o f som a t i c c o m p l a i n t s and moved q u i c k l y i n t o the d i s c u s s i o n o f h i s e x p e r i e n c e s i n t h e c r i t i c a l c a r e s e t t i n g , h i s w i f e ' s s u p p o r t o f him d u r i n g t h i s t i me and h i s p r o g r e s s i n a c t i v i t y l e v e l ( R e s o l u t i o n P h a s e ) . F o l l o w i n g t r a n s f e r t o t h e C a r d i a c S u r g e r y U n i t , t h i s s u b j e c t c o n t i n u e d t o p r o g r e s s w e l l u n t i l t he t ime o f d i s c h a r g e on the t w e n t y - n i n t h p o s t o p e r a t i v e day. The second s u b j e c t who s u s t a i n e d a c a r d i a c a r r e s t demons s t r a t e d a d i f f e r e n t p o s t o p e r a t i v e c o u r s e . She p r o g r e s s e d i n the t y p i c a l f a s h i o n u n t i l t he time o f a s y s t o l e on t h e n i n t h p o s t o p e r a t i v e day, and then r e v e r t e d t o t h e Somatic Phase w i t h the r e c u r r e n c e o f f a t i g u e , a r e s t r i c t e d a c t i v i t y l e v e l and more v i g o r o u s m e d i c a l and n u r s i n g t r e a t m e n t . As she r e c o v e r e d f u r t h e r t h i s s u b j e c t r e p e a t e d h er former r e -c o v e r y p a t t e r n , moving t h r o u g h the Somatic and T r a n s i t i o n , Phases and, f i n a l l y , e x p e r i e n c i n g t h e components o f t h e Re-s o l u t i o n Phase. I n summary, t h e n , i t appears t h a t t h e i n c i d e n c e o f c o m p l i c a t i o n s may p r e c i p i t a t e a more l e n g t h y r e c o v e r y p a t -t e r n (and thus d i f f e r e n c e s i n the t i m e o f o c c u r r e n c e o f th e b e h a v i o u r s l a b e l l e d as p h a s e s ) . The a l t e r a t i o n o f p a t -t e r n i n t h i s sample has been s i g n i f i c a n t o n l y i n terms of the t i m i n g o r l e n g t h o f c e r t a i n p a t t e r n s , and has shown no d i f f e r e n c e s which would negate the e x i s t e n c e of common-a l i t i e s i n the r e c o v e r y e x p e r i e n c e . 51 D i s c u s s i o n o f C u r r e n t F i n d i n g s w i t h Respect t o E a r l i e r R esearch  The r e c o v e r y p a t t e r n d e s c r i b e d h e r e i n appears t o c o r r o b o r a t e the r e s e a r c h f i n d i n g s o f Abram and K i m b a l l , b o t h o f whom noted s p e c i f i c t y p e s o r c l a s s e s o f e m o t i o n a l r e -sponses t o open h e a r t s u r g e r y . Abram (1965, p. 662-663) noted a " c a t a s t r o p h e r e a c t i o n " i n which p a t i e n t s were des-c r i b e d as "immobile, a p a t h e t i c , i n d i f f e r e n t and ' f l a t ' i n a f f e c t . " T h i s p e r i o d had a few d a y s 1 d u r a t i o n and was f o l -lowed by an e p i s o d e o f m i l d d e p r e s s i o n and a subsequent e l e -v a t i o n o f mood. P s y c h o t i c r e a c t i o n s ( h a l l u c i n a t i o n s , de-l u s i o n s ) were n o t e d i n two o f Abram's s u b j e c t s who remained i n t h e e a r l y c a t a s t r o p h e s t a t e f o r a p r o l o n g e d p e r i o d . K i m b a l l (1969b, p. 352-354) d e s c r i b e d p o s t o p e r a t i v e b e h a v i o u r s a t g r e a t l e n g t h , d e l i n e a t i n g t h r e e p e r i o d s which spanned b o t h t h e p o s t o p e r a t i v e c o u r s e and t h e d i s c h a r g e p e r i o d up t o f i f t e e n months p o s t - h o s p i t a l i z a t i o n . The f i r s t two o f t h e s e p e r i o d s c o r r e s p o n d w i t h t h e phases o f r e c o v e r y d e s c r i b e d i n t h i s t h e s i s . K i m b a l l f i r s t mentioned the e a r l y p o s t o p e r a t i v e p e r i o d w h i c h encompassed t h e f i f t h t o se v e n t h p o s t o p e r a t i v e days (the time K i m b a l l ' s s u b j e c t s s p e n t i n t h e i n t e n s i v e c a r e u n i t ) . I n t h i s t i me p e r i o d , he n o t e d f o u r t y p e s o f r e s p o n s e s : unremarkable ( p a t i e n t s w e l l -o r i e n t e d and c o - o p e r a t i v e w i t h h e a l t h p r o f e s s i o n a l s ; ad-m i t t e d d i s c o m f o r t ) , ' c a t a s t r o p h i c ( p a t i e n t s i m m o b i l e , pas-s i v e , a l e r t and aware), e u p h o r i c ( p a t i e n t s c o n f i d e n t , b r i g h t , r e s p o n s i v e ) and a l t e r e d s t a t e s o f c o n s c i o u s n e s s ( d e l i r i u m ; u n r e s p o n s i v e o r s e m i - c o n s c i o u s p a t i e n t s ) . The f i r s t t h r e e 52 o f t h e s e r e s p o n s e s concur w i t h f i n d i n g s d e s c r i b i n g the So-m a t i c Phase, b o t h i n the s p e c i f i c > o b s e r v a t i o n s n o t e d and i n the c h a r a c t e r i s t i c p a t t e r n s o f communication e x h i b i t e d by s u b j e c t s ( m o n o s y l l a b i c r e s p o n s e s , l i t t l e s p o n t a n e i t y o r e l a b o r a t i o n ) . K i m b a l l ' s f o u r t h o b s e r v a t i o n o f a l t e r e d s t a t e s o f c o n s c i o u s n e s s does n o t a p p l y t o o b s e r v a t i o n s made o f t h i s sample. K i m b a l l n e x t d e s c r i b e d an i n t e r m e d i a t e p e r i o d w h i c h commenced w i t h t h e p a t i e n t ' s t r a n s f e r from the i n t e n s i v e c a r e u n i t . He noted t h r e e c l a s s e s o f b e h a v i o u r i n t h i s p e r i o d , b e g i n n i n g w i t h a n x i e t y r e g a r d i n g t r a n s f e r from the i n t e n s i v e c a r e a r e a t o the g e n e r a l s u r g i c a l u n i t . De-p r e s s i o n was d e s c r i b e d n e x t and was c h a r a c t e r i z e d by w i t h -d r a w a l and c o m p l a i n t s r e g a r d i n g the p h y s i c a l o r e n v i r o n -m ental s t a t e . E x t e n s i v e s l e e p was no t e d i n many s u b j e c t s a t t h i s t i m e . F o l l o w i n g t h e p e r i o d o f d e p r e s s i o n , K i m b a l l o b s e r v e d an e l e v a t i o n o f mood and an a n t i c i p a t i o n o f d i s -charge w i t h c o n c u r r e n t p l a n n i n g on the p a r t o f t h e p a t i e n t . He a l s o noted an i n c r e a s e i n a n x i e t y l e v e l p r i o r t o d i s -c h a r g e ; a t t h i s time p a t i e n t s had a number o f i n q u i r i e s about t h e f u t u r e and some i n d i v i d u a l s e x p r e s s e d a need f o r more h o s p i t a l time " t o a d j u s t " . K i m b a l l ' s i n t e r m e d i a t e p e r i o d appears t o approximate the T r a n s i t i o n Phase n o t e d by t h i s i n v e s t i g a t o r , i n wh i c h c o n t i n u e d s o m a t i c c o m p l a i n t s , abundant s l e e p , d e p r e s s i o n and mood e l e v a t i o n s were ob-s e r v e d ; a n x i e t y r e g a r d i n g the t r a n s f e r from the c r i t i c a l c a r e a r e a was n o t ob s e r v e d i n t h i s sample, perhaps; due t o the c l o s e p r o x i m i t y o f the i n t e n s i v e c a r e and c a r d i a c s u r -53 g e r y u n i t s . The l a t t e r p o r t i o n o f K i m b a l l ' s d e s c r i p t i o n c o n c e r n i n g the a n t i c i p a t i o n o f d i s c h a r g e and p r e - d i s c h a r g e a n x i e t y c o r r e s p o n d c l o s e l y w i t h the b e h a v i o u r s n o t e d i n the R e s o l u t i o n Phase. An i n t e r e s t i n g d i f f e r e n c e between th e i n v e s t i g a t o r ' s d a t a and t h o s e o f K i m b a l l i s t h a t f o u r o f the s u b j e c t s d i s c u s s e d here e x h i b i t e d d i s o r i e n t a t i o n i n t h i s l a t e r p e r i o d (from t h e n i n t h t h r o u g h t h i r t e e n t h p o s t -o p e r a t i v e d a y ) ; t h i s f i n d i n g i s n o t i n agreement w i t h K i m b a l l ' s o b s e r v a t i o n s o r w i t h t h e f i n d i n g s o f o t h e r r e -s e a r c h e r s who have n o t e d e a r l y p o s t o p e r a t i v e changes i n o r i e n t a t i o n . D i s c u s s i o n o f C u r r e n t F i n d i n g s w i t h Respect t o S e l e c t e d T h e o r e t i c a l C o n s t r u c t s . The f i n d i n g s o f t h i s i n v e s t i g a t i o n have been d i s -c u s s e d i n view o f t h e p r e m i s e t h a t t h e r e e x i s t t h r e e phases o f r e c o v e r y from open h e a r t s u r g e r y . Thus f a r , t h e s e f i n d -i n g s have been d e s c r i b e d and t h e n compared w i t h s i m i l a r f i n d i n g s made by o t h e r r e s e a r c h e r s . I n o r d e r t o c a r r y t h e a n a l y s i s one s t e p f u r t h e r , t h e r e c o v e r y p a t t e r n w i l l now be compared w i t h t h e o r e t i c a l c o n s t r u c t s w h i c h appear r e l a t e d t o c e r t a i n o f the o b s e r v e d b e h a v i o u r s o r phenomena. T h i s comparison does not r e p r e s e n t an attempt t o e x p l a i n o r q u a l i f y t h e e x i s t e n c e o f phases o f r e c o v e r y ; r a t h e r , i t s e r v e s o n l y t o e n l i g h t e n the r e a d e r by d e n o t i n g s i m i l a r - ; i t i e s between the f i n d i n g s o f t h i s i n v e s t i g a t o r and the t h e o r e t i c i a n s p r e s e n t e d . I f hypotheses were d e v e l o p e d from t h e s e s i m i l a r i t i e s , f u r t h e r r e s e a r c h would be n e c e s s a r y t o d e t e r m i n e i f the c o n c e p t s o r t h e o r i e s p r o v i d e an e x p l a n a -54 t i o n f o r the r e c o v e r y p a t t e r n . The t h e o r y o f l o s s has i m p l i c a t i o n s f o r any s u r g i c a l p a t i e n t o r i n d i v i d u a l w i t h a l i f e - t h r e a t e n i n g i l l n e s s . L o s s i t s e l f may e n t a i l the l o s s o f a body p a r t o r f u n c t i o n , l o s s o f membership o r s t a t u s , f a i l u r e o f a p l a n o r v e n t u r e o r change's i n l i f e s t y l e ( E n g e l , 1964 , p. 295). Each of t h e s e forms o f l o s s can be r e l a t e d t o t h e c a r d i a c s u r g i c a l p a t i e n t who may f a c e the l o s s o f a f a m i l y o r s o c i a l r o l e , the l o s s o f b o d i l y f u n c t i o n o r changes i n p l a n s and l i f e s t y l e . The p a t i e n t may e i t h e r f a c e t h e s e t h r e a t s a t t h e t ime o f s u r -g e r y , o r he may have a l r e a d y e x p e r i e n c e d them a t t h e t i m e of o n s e t and t h r o u g h o u t th e d u r a t i o n o f h e a r t d i s e a s e . Ac-c o r d i n g t o E n g e l (1964) , Lindemann (1965) and P e r e t z (1970a, 1970b), g r i e v i n g i s the r e a c t i o n t o l o s s w h i c h a l l o w s f o r response t o the l o s s and, h o p e f u l l y , t o i t s u l t i m a t e r e -s o l u t i o n . J a n i s (1965, p. 1363) s t a t e s t h a t i l l n e s s o r h o s p i t a l i z a t i o n c o n s t i t u t e a "danger o f m u t i l a t i o n o r a n n i -h i l a t i o n (which) g i v e s r i s e t o a c u t e e m o t i o n a l shock"; con-s e q u e n t l y , t h e g r i e f r e a c t i o n i s n o t uncommon i n h o s p i t a l -i z e d p a t i e n t s . J a n i s a l s o mentions the g r i e v i n g p r o c e s s s p e c i f i c a l l y i n r e l a t i o n t o c o n v a l e s c e n c e : " E s p e c i a l l y i n t h e p h y s i c a l l y i n j u r e d and d i s e a s e d p e r s o n s , t h e r e i s a w e l l -known sequence such t h a t a c c e p t a n c e o f t h e m e d i c a l regimen and p s y c h o l o g i c a l r e a d j u s t m e n t d u r i n g t h e c o u r s e of normal c o n v a l e s c e n c e g r a d u a l l y o c c u r s f o l l o w i n g an i n i t i a l p e r i o d o f o v e r t g r i e v i n g and p r e o c c u p a t i o n w i t h l o s s " . C l o s e l y r e l a t e d t o the c o n c e p t o f l o s s i s t h e i d e a of s e l f - c o n c e p t . T h i s second concept i n c l u d e s such f a c t o r s y 55 as s e l f - e s t e e m and body image. Once a g a i n , the temporary l o s s of f u n c t i o n and dependency i n h e r e n t i n r e c o v e r y from a major s u r g i c a l p r o c e d u r e may c o n t r i b u t e t o a l t e r a t i o n s o f an i n d i v i d u a l ' s s e l f - e s t e e m . Changes i n body image due t o p a i n , l o s s o f f u n c t i o n o r p h y s i c a l trauma (the i n c i s i o n and o t h e r wounds) may a l s o be e v i d e n t i n t h e p a t i e n t u n d e r g o i n g open h e a r t s u r g e r y and can l e a d t o w i t h d r a w a l from o t h e r p ersons w i t h a f o c u s on one's p h y s i c a l s e l f . R o l e t h e o r y may add meaning t o any d i s c u s s i o n of t h e c a r d i a c s u r g i c a l p a t i e n t as he e x p e r i e n c e s l o s s o r changes i n the s e l f - c o n c e p t . An i n d i v i d u a l ' s r o l e p e r f o r m -ance depends upon h i s c oncept o f " r o l e " ( A g u i l e r a , 1970, p. 6 2 ) : how he p e r c e i v e s i t s e f f e c t upon the s e l f - c o n c e p t , how t h e r o l e i s i n f l u e n c e d by l i f e g o a l s and v a l u e s , and how he v iews s o c i e t y ' s e x p e c t a t i o n s ' o f a p a r t i c u l a r r o l e . P a t i e n t s who undergo open h e a r t s u r g e r y appear t o make numerous r o l e changes d u r i n g the c o u r s e o f t h e i r i l l n e s s and i t s s u r g i c a l t r e a t m e n t . P r e o p e r a t i v e l y , t h e y may ex-p e r i e n c e r o l e a l t e r a t i o n s w h i c h a r e r e l a t e d t o p h y s i c a l , s o c i a l and f a m i l y f u n c t i o n and w h i c h r e s u l t f r om t h e l i m -i t a t i o n s imposed by i l l n e s s . The assumption o f the s i c k r o l e (Suchman, 1972) i s one o f t h e p o s s i b l e r o l e a l t e r a t i o n s t h a t any p a t i e n t e x p e r i e n c e s . F o l l o w i n g t r e a t m e n t i n t h e p a t i e n t r o l e , t h e i n d i v i d u a l may resume h i s f o r m e r r o l e o f " h e a l t h " o r , i n t h e case o f c h r o n i c i l l n e s s , assume t h e " c h r o n i c a l l y i l l " o r " r e h a b i l i t e e " r o l e s . T h i s second r o l e change i s o f t e n as d i f f i c u l t as t h e i n i t i a l a c c e p t a n c e o f t h e s i c k r o l e . F o r t h e c a r d i a c p a t i e n t , the p o s t - s u r g i c a l r o l e change ( i n response t o a s u r g i c a l s u c c e s s ) may evoke a n x i e t y . The p a t i e n t may be f e a r f u l of assuming independ-ence because o f a p r i o r dependency upon " c a r i n g " o t h e r s o r he may l a c k c o n f i d e n c e i n p e r f o r m i n g p h y s i c a l and s o c i a l a c t i v i t i e s o r i n the r e s u m p t i o n o f s o c i a l r e l a t i o n s h i p s . D u r i n g c o n v a l e s c e n c e , the s e l f - c o n c e p t f i g u r e s s i g n i f i c a n t l y i n the t r a n s i t i o n from dependency t o independency (Brown and R a w l i n s o n , 1975). Summary The f i n d i n g s o f t h i s i n v e s t i g a t i o n o f t h e r e c o v e r y p a t t e r n s o f c a r d i a c s u r g i c a l p a t i e n t s have i n d i c a t e d t h a t , f o r t h i s sample, t h r e e phases of r e c o v e r y were p r e s e n t . These phases were c h a r a c t e r i z e d by s p e c i f i c v e r b a l and non-v e r b a l b e h a v i o u r s w h i c h were s i m i l a r f o r most p a t i e n t s a t a p a r t i c u l a r s t a g e of the p o s t o p e r a t i v e p e r i o d . I n t h e i r t o -t a l i t y , t h e phases r e p r e s e n t e d a r e c o v e r y p r o c e s s e x t e n d i n g from th e immediate p o s t o p e r a t i v e p e r i o d u n t i l the t ime of d i s c h a r g e from h o s p i t a l . As s e p a r a t e e n t i t i e s , t h e y ap-p eared t o be an i n d i c a t i o n o f t h e p a t i e n t ' s a f f e c t , a c t i v -i t y l e v e l , communication p a t t e r n and o v e r a l l needs a t d i f f -e r e n t i n t e r v a l s d u r i n g c o n v a l e s c e n c e . The phases were found t o r e p r e s e n t a common p a t t e r n between a l l s u b j e c t s s t u d i e d ; t h e i r t i m e of o c c u r r e n c e and d u r a t i o n have been a r b i t r a r i l y d e s c r i b e d a c c o r d i n g t o the "average" and t ime d i f f e r e n c e s have been noted t o o c c u r w i t h p a t i e n t s h a v i n g s e r i o u s p h y s i o l o g i c a l c o m p l i c a t i o n s . A p o s s i b l e r e l a t i o n s h i p be-tween the r e c o v e r y p a t t e r n and the t h e o r i e s o f l o s s and 57 r o l e performance was e x p l o r e d , b u t t h i s r e l a t i o n s h i p has been n e i t h e r examined nor c o n c l u s i v e l y d e monstrated by t h i s i n v e s t i g a t i o n . CHAPTER V CONCLUSIONS AND RECOMMENDATIONS T h i s i n v e s t i g a t i o n has been aimed a t t h e d i s c o v e r y o f p o s t - s u r g i c a l r e c o v e r y p a t t e r n s o f p a t i e n t s who have undergone open h e a r t s u r g e r y . A p a t t e r n has, i n f a c t , been noted and d e l i n e a t e d h e r e i n . I t i s note w o r t h y t h a t the phases d e s c r i b e d r e p r e s e n t c o m m o n a l i t i e s among the twenty s u b j e c t s s t u d i e d and t h a t t h e s e s i m i l a r i t i e s c o i n c i d e w i t h t h e o b s e r v a t i o n s o f two e a r l i e r r e s e a r c h e r s , Abram and i K i m b a l l . However, c a u t i o n must be e x e r c i s e d i n g e n e r a l i z -i n g t h e f i n d i n g s t o t h e p o p u l a t i o n o f open h e a r t s u r g e r y p a t i e n t s i n N o r t h America due t o the l i m i t e d , non-random sample s e l e c t e d f o r e x a m i n a t i o n by t h i s i n v e s t i g a t o r . M ajor C o n c l u s i o n s D e r i v e d from t h e F i n d i n g s The problem w h i c h has been c o n s i d e r e d t h r o u g h o u t t h i s i n v e s t i g a t i o n has been t h a t o f i n a d e q u a t e e m o t i o n a l a d j u s t m e n t t o open h e a r t s u r g e r y . T h i s p r oblem has been m a n i f e s t e d i n b o t h t h e p o s t - s u r g i c a l and p o s t - d i s c h a r g e r e -c o v e r y p a t t e r n s o f c a r d i a c p a t i e n t s . The l a t t e r p a t t e r n o f r e c o v e r y i s c u r r e n t l y the s u b j e c t o f i n t e n s i v e i n v e s t i g a -t i o n on many f r o n t s . I t has a l r e a d y been noted t h a t B l a c h l y and B l a c h l y (1968) and H e l l e r (1974) have d i s c o v e r e d a d v e r s e p s y c h o l o g i c a l outcomes f o l l o w i n g t h e p h y s i o l o g i c a l r e c o v e r y 58 from open h e a r t s u r g e r y . A more r e c e n t s t u d y by B i g e l o w (1977) has uncovered s i m i l a r r e a c t i o n s ( p a r t i c u l a r l y d e p r e s s -i o n and a n x i e t y ) i n p a t i e n t s f o l l o w i n g d i s c h a r g e . D a v i d (1977) has a l s o n o t e d t h a t f o r t y p e r c e n t o f h i s sample o f 1655 s u b j e c t s have f a i l e d t o r e t u r n t o work. These d i s -c o v e r i e s i n d i c a t e t h a t the problem under c o n s i d e r a t i o n con-t i n u e s t o e x i s t f o r a g r e a t number of c a r d i a c s u r g i c a l p a t i e n t s . I t appears t h a t , f o r many i n d i v i d u a l s , t h e r e -h a b i l i t a t i o n phase i s u n s u c c e s s f u l and does n o t f a c i l i t a t e t h e r e t u r n t o h e a l t h w h i c h a s u c c e s s f u l s u r g e r y a l l o w s . The a u t h o r would p o s t u l a t e t h a t perhaps t h e p r e - d i s c h a r g e r e -c o v e r y p a t t e r n s e t s the s t a g e f o r t h e p o s t - h o s p i t a l c o u r s e of r e h a b i l i t a t i o n . I f t h e needs o f p a t i e n t s i n t h i s "hos-p i t a l s t a g e " o f r e c o v e r y were a c c u r a t e l y and s y s t e m a t i c a l l y i d e n t i f i e d and met, t h e c a r d i a c p a t i e n t might e x p e r i e n c e a more s u c c e s s f u l b e g i n n i n g t o e m o t i o n a l r e c o v e r y and r e h a -b i l i t a t i o n as a whole. The d e s c r i p t i o n o f b e h a v i o u r p a t t e r n s (the phases o f r e c o v e r y ) p r o v i d e s a b a s i s f o r d e t e r m i n i n g t h e p a t i e n t ' s r e s p onse t o s u r g e r y and h i s e m o t i o n a l o r i e n t a t i o n toward r e c o v e r y . Any p a t t e r n s e r v e s t o d e s c r i b e a sequence o r an o r g a n i z a t i o n o f c o n t e n t . The S o m a t i c , T r a n s i t i o n and Re-s o l u t i o n phases d e s c r i b e common e m o t i o n a l r e a c t i o n s and a t -t i t u d e s a t p a r t i c u l a r p o i n t s d u r i n g c o n v a l e s c e n c e . Common needs o f p a t i e n t s may be i n f e r r e d from such p a t t e r n s and t h u s , a f o c u s f o r i n t e r v e n t i o n (aimed a t t h e p r o m o t i o n o f e m o t i o n a l r e c o v e r y ) may be o b t a i n e d . 60 I m p l i c a t i o n s f o r N u r s i n g The e x i s t e n c e of phases o f r e c o v e r y from open h e a r t s u r g e r y has i m p o r t a n t i m p l i c a t i o n s f o r n u r s i n g w h i c h have been p r e v i o u s l y a l l u d e d t o . F i r s t , t he phases denote a common r e c o v e r y p a t t e r n w h i c h has n o t f o r m e r l y been the f o c u s o f n u r s i n g assessment and i n t e r v e n t i o n . Second, i f the phases a r e t o some degree a r e p r e s e n t a t i o n of p a t i e n t s ' needs a t v a r i o u s s t a g e s o f r e c o v e r y , t h e n need s a t i s f a c t i o n and the r e s o l u t i o n o f e m o t i o n a l problems ( a n x i e t y , d e p r e s s -i o n , dependency) s h o u l d be t h e c r u x of c a r d i o v a s c u l a r n u r s -i n g p r a c t i c e . P h y s i o l o g i c needs a r e , o f c o u r s e , an e v e r i m p o r t a n t n u r s i n g c o n s i d e r a t i o n ; however, a t t e n t i o n t o p s y c h o s o c i a l needs s h o u l d n ever be o f secondary i m p o r t a n c e , p a r t i c u l a r l y a f t e r t h e p a t i e n t ' s p h y s i c a l c o n d i t i o n has s t a b i l i z e d . N u r s i n g c a r e p l a n n i n g f o r c h r o n i c a l l y o r t e r m i n a l l y i l l p a t i e n t s has r e v o l v e d around the con c e p t o f "phases" f o r a number o f y e a r s . K u b l e r - R o s s (1969) d e s c r i b e d f i v e phases o f adjustment t o t e r m i n a l i l l n e s s w h i c h a r e now used e x t e n s i v e l y by h e a l t h p r o f e s s i o n a l s i n t h e assessment and i n t e r v e n t i o n p r o c e s s e s . Her d i s c u s s i o n o f the b e h a v i o u r s common t o d y i n g p ersons has p r o v i d e d i n s i g h t f o r p h y s i c i a n s and n u r s e s who seek t o i n t e r a c t t h e r a p e u t i c a l l y w i t h t e r -m i n a l l y i l l i n d i v i d u a l s . L i k e w i s e , C r a t e (196.5) has d e l i n -e a t e d t h e a d a p t i v e p r o c e s s i n c h r o n i c i l l n e s s , d i s c u s s i n g n u r s i n g f u n c t i o n s i n r e l a t i o n t o p a t i e n t s a t each s t a g e o f a d a p t a t i o n . J a n i s (1965) and o t h e r " l o s s " t h e o r i s t s ( P e r e t z , 197 0; Lindemann, 1965; E n g e l , 1964) have p r o v i d e d s i m i l a r d e s c r i p t i o n s and g u i d e l i n e s f o r t h e r a p e u t i c i n t e r -v e n t i o n . I n each c a s e , the d i s c u s s i o n o f p a t t e r n s has s e r v e d as an o r g a n i z i n g c e n t e r f o r a p p r o a c h i n g problems and w o r k i n g toward need s a t i s f a c t i o n f o r p a t i e n t s . The i n v e s -t i g a t o r b e l i e v e s t h a t t h e i n f o r m a t i o n r e g a r d i n g phases of r e c o v e r y from open h e a r t s u r g e r y may be u s e f u l when d e a l i n g w i t h t h e r e c o v e r y p r o c e s s p r i o r t o the p a t i e n t ' s d i s c h a r g e from h o s p i t a l . From t h e d a t a o b t a i n e d , i t appears t h a t a n t i c i p a t o r y g u i d a n c e i s a major n u r s i n g i n t e r v e n t i o n w h i c h can f a c i l i -t a t e the p a t i e n t ' s l o n g - t e r m e m o t i o n a l adjustment t o open h e a r t s u r g e r y . W i t h a b a s i c knowledge of t h e i n d i v i d u a l ' s r e c o v e r y p a t t e r n , the nurse can a n t i c i p a t e problems and q u e s t i o n s , p r e p a r e t h e p a t i e n t f o r c e r t a i n f e e l i n g s such as d e p r e s s i o n and a n x i e t y , and p r o v i d e him w i t h s u p p o r t as he r e g a i n s independence. Such e g o - s u p p o r t i v e c a r e i s d i s c u s s e d by Abramson (1973) and, a l t h o u g h he r e l a t e s h i s s u g g e s t i o n s s p e c i f i c a l l y t o the t r e a t m e n t o f p s y c h o p a t h o l o g i c a l phenom-ena, he makes c o n c r e t e s u g g e s t i o n s f o r t r e a t m e n t o r i n t e r -v e n t i o n m o d a l i t i e s w h i c h may be a p p l i e d t o any p a t i e n t . A r e c e n t a r t i c l e by H a r t and F r a n t z (1977) n o t e s a need f o r improved d i s c h a r g e p l a n n i n g and p r e - d i s c h a r g e t e a c h i n g programs w i t h open h e a r t s u r g e r y p a t i e n t s . One problem a r e a i d e n t i f i e d by t h e s e r e s e a r c h e r s i s the l a c k o f knowledge r e g a r d i n g the r e a d i n e s s f o r l e a r n i n g e x h i b i t e d by the p a t i e n t . I f one were t o examine t h e r e c o v e r y p a t t e r n o f a p a r t i c u l a r p a t i e n t , perhaps an a p p r o p r i a t e t i m e f o r t e a c h i n g c o u l d be a s s e s s e d a c c o r d i n g t o t h e s t a g e o f r e -62 c o v e r y and t h e b e h a v i o u r s p r e s e n t . To use t h e s u b j e c t s i n t h i s i n v e s t i g a t i o n as an example, r e a d i n e s s f o r l e a r n i n g might c o r r e s p o n d w i t h the T r a n s i t i o n o r R e s o l u t i o n phases, when q u e s t i o n s about d i s c h a r g e b e g i n t o a r i s e . The pa-t i e n t ' s needs f o r i n f o r m a t i o n and s u p p o r t can be more ac-c u r a t e l y a s s e s s e d and d i s c h a r g e p l a n n i n g and r e f e r r a l can be i c a r r i e d o u t more e f f i c i e n t l y w i t h t h e knowledge of the pa-t i e n t ' s s t a g e of r e c o v e r y . Over the l a s t decade, the n u r s i n g p r o f e s s i o n has made g r e a t s t r i d e s i n the improvement o f c a r d i o v a s c u l a r n u r s i n g c a r e . P r e o p e r a t i v e t e a c h i n g programs have been im-plemented and p a t i e n t s have gone t o s u r g e r y much b e t t e r p r e -p a r e d f o r the e x p e r i e n c e t h a n p r e v i o u s l y . P o s t - h o s p i t a l r e -h a b i l i t a t i o n programs have a l s o been d e v e l o p e d i n many areas t o p r o v i d e f o r t h e t e a c h i n g and f o l l o w - u p of c a r d i a c pa-t i e n t s . P r e - d i s c h a r g e t e a c h i n g about m e d i c a t i o n s , d i e t and a c t i v i t y i s a l s o c a r r i e d out t h o r o u g h l y i n most h o s p i t a l s where open h e a r t s u r g e r y i s performed. However, the r e -s e a r c h o f H a r t and F r a n t z (1977) n o t e s t h a t t h i r t y - f o u r p e r c e n t o f U n i t e d S t a t e s h o s p i t a l s w i t h f a c i l i t i e s f o r open h e a r t s u r g e r y do not have o r g a n i z e d p o s t o p e r a t i v e t e a c h i n g programs. I f t h e s e s t a t i s t i c s can be c o n s i d e r e d r e p r e s e n t a -t i v e o f N o r t h American t r e n d s , t h e n they i n d i c a t e t h a t t h e emphasis on p r e - d i s c h a r g e t e a c h i n g s h o u l d be examined and, i f n e c e s s a r y , improved; perhaps the e x a m i n a t i o n of t h e r e -c o v e r y p a t t e r n can a t t e s t t o t h i s n e c e s s i t y , s i n c e the sub-j e c t s s t u d i e d here e x h i b i t e d needs f o r i n f o r m a t i o n i n t h e h o s p i t a l r e c o v e r y p e r i o d . 63 Recommendations f o r C a r d i o v a s c u l a r N u r s i n g P r a c t i c e On the b a s i s o f t h e f i n d i n g s d i s c u s s e d , and w i t h c o n s i d e r a t i o n o f t h e i r i m p l i c a t i o n s f o r n u r s i n g , the f o l l o w -i n g recommendations a re put f o r t h by t h e i n v e s t i g a t o r : When p r o v i d i n g c a r e f o r the p a t i e n t who has undergone open h e a r t s u r g e r y , t h e nurse s h o u l d remain a l e r t f o r p a t i e n t b e h a v i o u r s w h i c h i n d i c a t e l e v e l o f o r i e n t a t i o n , emo-t i o n a l s t a t u s , degree o f dependency and r e a d i n e s s t o a s s i m i l a t e new i n f o r m a t i o n . U s i n g t h i s i n f o r m a t i o n , the n u r s e s h o u l d . . . 1. A s s e s s t h e p a t i e n t ' s phase o f r e c o v e r y from open h e a r t s u r g e r y (Somatic, T r a n s i t i o n o r R e s o l u t i o n ) . 2. A c c e p t t h e p a t i e n t ' s b e h a v i o u r i n each phase o f r e c o v e r y , a l l o w i n g f o r s e l f - e x p r e s s i o n , dependency, e g o c e n t r i c i t y and a s o m a t i c f o c u s where a p p r o p r i a t e . 3. Recognize i n d i v i d u a l d i f f e r e n c e s i n needs m a n i f e s t e d d u r i n g t h e r e c o v e r y p e r i o d . 4. A s s i s t t h e p a t i e n t toward independence, r e -c o g n i z i n g h i s i n d i v i d u a l needs and concerns as he p r o g r e s s e s . 5. A s s e s s f a c t o r s w h i c h may impede " r e s o l u t i o n " and endeavour t o a l l e v i a t e t h e s e . 6. Teach the p a t i e n t r e g a r d i n g a s p e c t s o f h i s r e c o v e r y as he demonstrates an i n t e r e s t and m o t i v a t i o n t o l e a r n . 7. P r o v i d e p s y c h o l o g i c a l as w e l l as p h y s i c a l c a r e , w i t h t h e g o a l o f o p t i m a l e m o t i o n a l and p h y s i o l o g i c r e c o v e r y from open h e a r t s u r g e r y . S u g g e s t i o n s f o r F u r t h e r Research I f a common r e c o v e r y p a t t e r n i s a key t o the s o l u -t i o n o f i n a d e q u a t e e m o t i o n a l r e c o v e r y from open h e a r t s u r -g e r y , t h e n i t i s a p p r o p r i a t e t h a t t h i s p a t t e r n be examined t o a g r e a t e r e x t e n t w i t h a random sample o f p a t i e n t s from a v a r i e t y of i n s t i t u t i o n s . I f t h e p a t t e r n (or phases) were well-documented, i t might n e x t be f e a s i b l e t o examine p a t i e n t s ' needs a t v a r i o u s s t a g e s o f r e c o v e r y w i t h t h e spe-c i f i c purpose of i d e n t i f y i n g " t e a c h a b l e moments". S i n c e p r e o p e r a t i v e t e a c h i n g has been demonstrated t o reduce t h e i n c i d e n c e o f p o s t o p e r a t i v e c o m p l i c a t i o n s , perhaps p o s t o p e r -a t i v e t e a c h i n g s t r a t e g i e s ( f o c u s i n g on needs p e r c e i v e d by the p a t i e n t ) would a l l e v i a t e adverse e m o t i o n a l outcomes (both s h o r t - and l o n g - t e r m ) . T h i s h y p o t h e s i s b e a r s i n v e s -t i g a t i o n . A n o t h e r approach t o f u r t h e r i n v e s t i g a t i o n o f t h e problem would be t o measure the e f f e c t s o f r o u t i n e p l a n n e d c o u n s e l l i n g w i t h open h e a r t s u r g e r y p a t i e n t s i n the p o s t -o p e r a t i v e p e r i o d . Would such c o u n s e l l i n g f a c i l i t a t e l o n g -term e m o t i o n a l r e c o v e r y by p r o v i d i n g - t h e p a t i e n t w i t h a s u p p o r t i v e l i s t e n e r and a s s i s t a n c e w i t h p r o b l e m - s o l v i n g ? The q u e s t i o n i s an i n t e r e s t i n g one - a p o s i t i v e c o r r e l a t i o n between c o u n s e l l i n g and s u c c e s s f u l e m o t i o n a l outcomes c o u l d s i g n a l an expanded r o l e f o r t h e c a r d i o v a s c u l a r n u r s e . To summarize t h e s e c o n c e r n s , t h e f o l l o w i n g q u e s t -i o n s f o r f u r t h e r c o n s i d e r a t i o n a r e enumerated: 1. To what e x t e n t a r e "phases" of r e c o v e r y p r e s e n t i n t h e p o p u l a t i o n of p a t i e n t s u n d e r g o i n g open h e a r t s u r g e r y i n N o r t h America? 2. What a r e t h e s p e c i f i c p s y c h o l o g i c a l needs o f p a t i e n t s a t v a r i o u s s t a g e s o f r e c o v e r y from open h e a r t s u r g e r y ? 3. At what stage of recover y do p a t i e n t s e x h i b i t c e r t a i n l e a r n i n g needs? 4. What are the e f f e c t s o f s e l e c t e d , planned n u r s i n g i n t e r v e n t i o n s on the p a t i e n t ' s emotional s t a t u s f o l l o w i n g open h e a r t surgery? 5. What are the e f f e c t s of s e l e c t e d , planned n u r s i n g i n t e r v e n t i o n s on the long-term r e h a b i l i t a t i o n of the c a r d i a c s u r g i c a l p a t i e n t ? Whatever the r e s e a r c h approach to f o l l o w , the door i s open t o f u r t h e r i n v e s t i g a t i o n of emotional r e c o v e r y from open heart surgery. I t i s a n t i c i p a t e d t h a t the knowledge of p a t i e n t s and t h e i r r e c o v e r y p a t t e r n s w i l l a s s i s t the members of the n u r s i n g p r o f e s s i o n with the esta b l i s h m e n t o f i n t e r v e n t i o n s which promote recover y and prevent poor psy-c h o l o g i c a l outcomes. I t i s i n t e r e s t i n g to note t h a t phases of recov e r y e x i s t , but i t i s most important to use t h i s knowledge to f a c i l i t a t e o p t i m a l r e c o v e r y o f the p a t i e n t ex-p e r i e n c i n g c a r d i a c surgery. ) BIBLIOGRAPHY A. Books A b d e l l a h , Faye G. and L e v i n e , Eugene. 1965. B e t t e r p a t i e n t  c a r e t h r o u g h n u r s i n g r e s e a r c h . New York: M a c m i l l a n P u b l i s h i n g Company, I n c . A g u i l e r a , Donna C. e t a l . 1970. C r i s i s i n t e r v e n t i o n :  t h e o r y and methodology. S t . L o u i s : C. V. Mosby Company. A s p i n a l l , Mary J o . 1973. N u r s i n g t h e open h e a r t s u r g e r y  p a t i e n t . New York: M c G r a w - H i l l . B a t e s , B a r b a r a . 1974. A g u i d e t o p h y s i c a l e x a m i n a t i o n , ch. 16. T o r o n t o : J.B. L i p p i n c o t t Company. B e c k e r , Howard S. 197 0. Problems of i n f e r e n c e and p r o o f i n p a r t i c i p a n t o b s e r v a t i o n . Q u a l i t a t i v e methodology. E d i t e d by W i l l i a m J . F i l s t e a d . C h i c a g o : Markham P u b l i s h i n g Company. B l a c h e r , R i c h a r d S. 1970. R e a c t i o n t o c h r o n i c i l l n e s s . L o s s and g r i e f : p s y c h o l o g i c a l management i n m e d i c a l  p r a c t i c e . E d i t e d by B e r n a r d Schoenberg. New York: Columbia U n i v e r s i t y P r e s s . C a r l s o n , C a r o l y n E. 1970. B e h a v i o r a l c o n c e p t s and n u r s i n g  i n t e r v e n t i o n , ch. 3. P h i l a d e l p h i a : J.B. L i p p i n c o t t Company. D e u t s c h e r , I r w i n . 1970. L o o k i n g backward: case s t u d i e s on the p r o g r e s s o f methodology i n s o c i o l o g i c a l r e s e a r c h . Q u a l i t a t i v e methodology. E d i t e d by W i l l i a m J . F i l s t e a d . C h i c a g o : Markham P u b l i s h i n g Company. E n g e l , George L. 1964. P s y c h o l o g i c a l development i n h e a l t h  and d i s e a s e . P h i l a d e l p h i a : W.B. Saunders Company. Evans, F r a n c e s M.C. 1971. P s y c h o s o c i a l n u r s i n g . New York: M a c m i l l a n Company. G l a s e r , Barney a n d ^ S t r a u s s , Anselm. 19 67. The d i s c o v e r y of  grounded t h e o r y : s t r a t e g i e s f o r q u a l i t a t i v e r e s e a r c h . 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A P P E N D I X 74 APPENDIX A INTERVIEW GUIDELINES FOR THE PREOPERATIVE PERIOD A) I n t r o d u c t i o n to the p a t i e n t ; e x p l a n a t i o n o f the study B) Consent form: p a t i e n t ' s signature., date INTERVIEW C) General assessment df the p a t i e n t : (1) (2) knowledge of d i s e a s e p e r c e p t i o n of reason f o r proposed surgery (3) medical h i s t o r y (4) f a m i l y / s o c i a l h i s t o r y (5) l e v e l of f u n c t i o n i n g / c a r d i a c s t a t u s (6) l i m i t a t i o n s of f u n c t i o n (7) l e v e l of a n x i e t y (8) a d d i t i o n a l p e r t i n e n t i n f o r m a t i o n (1) appearance (2) a f f e c t (3) nonverbal behaviour; f a c i a l e x p r e s s i o n s , a c t i v i t y dur-i n g i n t e r v i e w (4) v e r b a l behaviour: focus of c o n v e r s a t i o n , tone of v o i c e OBSERVATION D) Problems, p o t e n t i a l problems o r concerns i d e n t i f i e d on the b a s i s o f assessment data 76 APPENDIX B INTERVIEW GUIDELINES FOR THE POSTOPERATIVE PERIOD A) General assessment: (1) l e v e l of consciousness (2) o r i e n t a t i o n to time/person/ p l a c e (3) presence of thought d i s t u r b -ances or h a l l u c i n a t i o n s B) Opening q u e s t i o n : How are you doing? How are t h i n g s going f o r you? C) General l e a d - i n : Is there anything you would l i k e to t a l k about to-day? Is there anything you would l i k e to t e l l me about? P i c k up on v e r b a l and nonverbal cues here D) Concurrent o b s e r v a t i o n s : (1) appearance (2) a f f e c t (3) nonverbal behaviour (4) v e r b a l behaviour: focus of c o n v e r s a t i o n c h a r a c t e r i s t i c s o f speech E) A d d i t i o n a l d a t a : (1) (2) (3) (4) pump time q u a l i t y / d u r a t i o n of s l e e p e l e c t r o l y t e s b l o o d gases v i t a l s i g n s ECG a n a l g e s i c s / h y p n o t i c s number of days p o s t o p e r a t i v e s e t t i n g stage of medical regime -c u r r e n t orders p h y s i o l o g i c a l parameters -F) Interview schedule: f i r s t week p o s t o p e r a t i v e - every o t h e r day, to i n c l u d e time i n PAR and ICU 77 INTERVIEW GUIDELINES FOR THE POSTOPERATIVE PERIOD-continued second week p o s t o p e r a t i v e - e v e r y two days d u r a t i o n of i n t e r v i e w s * - f i v e m i n u t e s t o f o r t y - f i v e m i n u t e s , depending upon t h e p a t i e n t ' s con-d i t i o n and need ( f i v e - t e n minutes o n l y i n PAR and ICU) 78 APPENDIX C DATA COLLECTION TOOL DEMOGRAPHIC DATA DATE: NAME OF PATIENT (INITIALS) : ROOM NUMBER: DIAGNOSIS: PROPOSED SURGERY: PROPOSED DATE OF SURGERY: N CARDIOLOGIST/SURGEON: PATIENT'S AGE: MARITAL STATUS: RELIGION: EDUCATION/OCCUPATION :_ INTERVIEW DATA (1) KNOWLEDGE OF DISEASE - d i a g n o s i s - prognosis (2) PERCEPTION OF REASON FOR PROPOSED SURGERY -(3) MEDICAL HISTORY - onset of c a r d i a c d i s e a s e - c u r r e n t symptoms - p r e v i o u s h o s p i t a l i z a t i o n f o r t h i s problem - pa s t i l l n e s s e s , c o m plaints, s u r g e r i e s (other than c a r d i a c ) - c o n d i t i o n s e x i s t i n g c o n c u r r e n t l y w i t h c a r d i a c d i s e a s e 79 DATA COLLECTION TOOL - continued (4) FAMILY/SOCIAL HISTORY - s i g n i f i c a n t o t h e r s - o c c u p a t i o n - sources of enjoyment (hobbies, etc.) or i n t e r e s t - s i g n i f i c a n t l i f e e x p eriences (5) LEVEL OF FUNCTIONING/CARDIAC STATUS/LIMITATIONS OF FUNCTION - p a t i e n t ' s p e r c e p t i o n of l i m i t a t i o n s , i f any - data from c h a r t r e : f u n c t i o n a l c a p a c i t y (6) LEVEL OF ANXIETY (7) ADDITIONAL PERTINENT INFORMATION (8) OBSERVATIONS - appearance - a f f e c t - nonverbal behaviour - v e r b a l behaviour (9) PROBLEMS, POTENTIAL PROBLEMS OR CONCERNS IDENTIFIED DATA COLLECTION TOOL - continued POSTOPERATIVE DATA DATE : NUMBER OF DAYS POSTOPERATIVE: SETTING: STAGE OF MEDICAL REGIME: 1) LEVEL OF CONSCIOUSNESS -2) ORIENTATION TO TIME/PERSON/PLACE -3) PRESENCE OF THOUGHT DISTURBANCES, HALLUCINATIONS 4) APPEARANCE, AFFECT -LEVEL OF ANXIETY 5) VERBAL BEHAVIOUR * focus of c o n v e r s a t i o n * c h a r a c t e r i s t i c s of speech * patterns; of communication 6) NONVERBAL BEHAVIOUR * appearance * a c t i v i t y d u r i n g i n t e r v i e w DATA COLLECTION TOOL - continued 7) PHYSIOLOGICAL PARAMETERS - pump time q u a l i t y / d u r a t i o n of s l e e p e l e c t r o l y t e s blood gases v i t a l signs ECG a n a l g e s i c s / h y p n o t i c s other 8) . GENERAL COMMENTS 9) PROBLEMS, POTENTIAL PROBLEMS OR CONCERNS IDENTIFIED LENGTH OF INTERVIEW: APPENDIX D DATA ANALYSIS WORKSHEET IP . DAY PT. I N I T I A L : <_>' En CO O r i e n t a t i o n A n x i e t y A f f e c t C o n v e r s a t i o n Communication -V e r b a l , N o n v e r b a l P h y s i o l o g i c a l L • 4 7 9 11 13 15 83 APPENDIX E AN OVERVIEW OF THE RECOVERY PATTERN Phase Common V e r b a l B e h a v i o u r s Common N o n v e r b a l B e h a v i o u r s Somatic c o m p l a i n t s o f p a i n and d i s c o m f o r t s t a t e m e n t s i n d i c a t -i n g w e l l - b e i n g s t a t e m e n t s i n d i c a t -i n g f a t i g u e m o n o s y l l a b i c r e -sponses s t a t e m e n t s i n d i c a t -i n g o p t i m i s m f a i n t speech w i n c i n g o r o t h e r ex-p r e s s i o n s o f d i s -c o m f o r t nods, g e s t u r e s eye c o n t a c t T r a n s i t i o n s t a t e m e n t s i n d i c a t -i n g d e c r e a s e d d i s -c o m f o r t i n c r e a s e d grooming b e h a v i o u r s c o m p l a i n t s o f p a i n c o m p l a i n t s o f f a t i g u e and/or poor s l e e p i n g p a t t e r n s s t a t e m e n t s about s p e c i f i c r o u t i n e s o r a c t i v i t y l e v e l i n t e r m i t t e n t o r t o t a l eye c o n t a c t d i s p l a y o f i n c i s i o n s o r o t h e r s i t e s o f trauma i n c r e a s e d use o f g e s t u r e s w i t h speech q u e r i e s about o t h e r p a t i e n t s d i s p l a y o f g r e e t i n g c a r d s o r f l o w e r s 84 AN OVERVIEW OF THE RECOVERY PATTERN - c o n t i n u e d Common Common Phase V e r b a l B e h a v i o u r s N o n v e r b a l B e h a v i o u r s mention o f f a m i l y o r f r i e n d s s t a t e m e n t s i n d i c a t -i n g s a t i s f a c t i o n w i t h s u r g i c a l o u t -come q u e r i e s r e g a r d i n g s u r g i c a l outcome and p r o g n o s i s w ondering about da t e o f d i s c h a r g e l o w e r i n g o f mood o r d e p r e s s i o n mention o f i r r i -t a b i l i t y u n e x p l a i n e d p a i n o r o t h e r d i s t u r b a n c e i n c r e a s e d s p o n t a -n e i t y i n c o n v e r s a -t i o n R e s o l u t i o n a n t i c i p a t i o n o f i n c r e a s e d s m i l i n g d i s c h a r g e i n c r e a s e d eye c o n t a c t q u e r i e s r e g a r d i n g m e d i c a t i o n s , v i s i t s t o p h y s i c i a n , ac-t i v i t y i n c r e a s e d c o n c e r n f o r appearance and p l a n s f o l l o w i n g grooming d i s c h a r g e d i s c u s s i o n of t o p i c s u n r e l a t e d t o s u r g e r y o r h o s p i t a l i z a t i o n 

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