UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Family reactions to the crisis of illness Brown, Thelma M. 1979

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1979_A5_7 B76.pdf [ 3.96MB ]
Metadata
JSON: 831-1.0094588.json
JSON-LD: 831-1.0094588-ld.json
RDF/XML (Pretty): 831-1.0094588-rdf.xml
RDF/JSON: 831-1.0094588-rdf.json
Turtle: 831-1.0094588-turtle.txt
N-Triples: 831-1.0094588-rdf-ntriples.txt
Original Record: 831-1.0094588-source.json
Full Text
831-1.0094588-fulltext.txt
Citation
831-1.0094588.ris

Full Text

FAMILY REACTIONS TO THE CRISIS OF ILLNESS  by  Thelma M. Brown B.Sc.N., U n i v e r s i t y o f B r i t i s h Columbia, 1968  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  9  in THE FACULTY OF GRADUATE STUDIES (SCHOOL OF NURSING)  We a c c e p t t h i s  t h e s i s as conforming  to the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA June, 1979 © T h e l m a M. Brown, 19 79  In presenting t h i s thesis in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the Library 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 reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s thesis f o r s c h o l a r l y purposes may be granted by the Head of my Department or by his representatives.  It i s understood that copying or p u b l i c a t i o n  of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission.  Department nf  Nursing  The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5  n a t  .P  J u l y 30,  1979  ABSTRACT  This information illness this  exploratory about  and what  crisis.  incorporating experienced  of  ten  and  criptive  the  The deal  10  areas  of  since  amounts  of  was  the were  during  the  the a  of  helpful  father  with  a  used  father's  were  family  help  crisis  who  of  had  sample wives,  semi-structured  from  one  to  three  hospital.  categories  and  The  des-  used.  roles,  father  changes  that  interactions,  by  families  o p i n i o n were  the  care most  from  varied  expressed  nurses help  had o c c u r r e d  affect  h a d r e t u r n e d home  received of  their  family  discharge  described  offering  time.  during  convenience  A  each  summarized i n t o  families  the  with  i n f o r m a t i o n and reassurance  this  crisis  family  household.  F r i e n d s a n d home  persons  Receiving  on  family  conducted  in  and d i f f e r e n c e s  as  be  elicit  myocardial infarction.  was  living  data  families. seen  first  statistics  structure  to  the  schedule  All in  perceive  back  following  interview  the  to  myocardial infarction patients,  children  weeks  to  focused  into  designed  reactions  families  study  male  interview  family  was  The s t u d y  his  The  study  were to  a  and hospital. great  within  most  some  frequently  families.  were  seen  as  helpful  iii. In summary, the r e s u l t s o f the study i n d i c a t e t h a t f a m i l i e s do experience a v a r i e t y of changes when a f a m i l y member i s i l l .  The q u a n t i t y and q u a l i t y o f change are  r e l a t e d t o the f a m i l y ' s p e r c e p t i o n illness,  o f the nature o f the  the i l l member's enactment o f the s i c k r o l e and  the degree o f d i f f e r e n c e between the f a m i l y ' s p r e - i l l n e s s and p o s t - i l l n e s s s t a t e . illness,  Illness, especially life-threatening  f o s t e r s a review o f i n d i v i d u a l and f a m i l y  goals  which can a l s o produce change. I t i s a l s o presumed t h a t f a m i l y r e a c t i o n s can have an e f f e c t on the course o f i l l n e s s . upon f a m i l y p e r c e p t i o n s  The e f f e c t i s dependent  of the i l l n e s s ,  the amount and k i n d  of c o n t r o l s they can e x e r c i s e , and the p e r s o n a l  needs o f  i n d i v i d u a l f a m i l y members. More r e s e a r c h teristics  i s r e q u i r e d t o i d e n t i f y the charac-  and temporal aspects o f f a m i l y r e a c t i o n s t o  i l l n e s s and f a m i l y e f f e c t s on i l l n e s s . to r e s e a r c h scientific  design theory  Innovative  approaches  and methodology are r e q u i r e d t o ensure development and continued  of the complexity o f f a m i l y systems.  appreciation  iv.  TABLE OF CONTENTS  Page ABSTRACT.  i i  TABLE OF CONTENTS LIST OF TABLES ACKNOWLEDGEMENTS  iv -  vi v i i  I. INTRODUCTION  1  A FAMILY FOCUS  1  ILLNESS AS A FAMILY CRISIS  3  POTENTIAL SIGNIFICANCE OF THE STUDY  4  PROBLEM STATEMENT  5  PURPOSE  6  ASSUMPTIONS  6  LIMITATIONS  6  DEFINITIONS  7  I I . LITERATURE REVIEW  9  FAMILY CRISIS  9  ILLNESS AS A FAMILY CRISIS EFFECT OF ILLNESS ON FAMILY STRUCTURE  13 ...  15  EFFECT OF ILLNESS ON FAMILY FUNCTIONING.  20  EFFECT OF FAMILIES ON ILLNESS  23  SUMMARY OF LITERATURE REVIEW  25  V.  I I I . METHODOLOGY  27  SAMPLE SELECTION  .. 27  DATA COLLECTION  29  DATA ANALYSIS  31  IV. RESULTS  32  DESCRIPTION OF THE SAMPLE  32  FINDINGS  34  Changes i n Roles (Item 1) Changes i n P a t t e r n s o f I n t e r a c t i o n s (Item 2) Changes i n A f f e c t (Item 3) Changes i n Family Contact CItern 4) Family P e r c e p t i o n s o f Help (Item 5). V. ANALYSIS  54  INTERPRETATION OF FINDINGS  55  Family Focus Family Reactions Changes i n Roles Changes i n P a t t e r n s o f I n t e r a c t i o n Changes i n A f f e c t Changes i n S t r u c t u r e Family P e r c e p t i o n s o f Help I l l n e s s as a Family C r i s i s IMPLICATIONS  ;  VI  Nursing P r a c t i c e Nursing Education Nursing Research RECOMMENDATIONS  76  VI. SUMMARY AND CONCLUSIONS..  77  BIBLIOGRAPHY  80  APPENDICES  85  vi.  LIST OF TABLES  Table  Page  1  Ages o f Household Family Members  2  Duration of H o s p i t a l i z a t i o n and Number of Days A f t e r Discharge That Interview Took P l a c e . . .  33  34  3  Areas o f Change D e s c r i b e d by F a m i l i e s .  35  4  Changes i n Roles D e s c r i b e d by F a m i l i e s .  36  5  Changes i n P a t t e r n s o f I n t e r a c t i o n Described by F a m i l i e s  6 7  Changes i n A f f e c t Described by F a m i l i e s ' Changes i n Family Contact w i t h Groups.  40 42 48  8  Amount of Help Received by F a m i l i e s . . . . .  52  9  Person(s) O f f e r i n g the Most Help t o F a m i l i e s . . .  51  vii.  ACKNOWLEDGEMENTS  The author i s g r a t e f u l t o the members o f her committee, M a r i l y n Willman and C r i s s Rogers, f o r t h e i r calm and unvarying guidance i n the development  of this  thesis,  to the head nurses and f a m i l y members who gave so much of themselves, and t o Dan f o r h i s understanding and support.  I. INTRODUCTION  T r a d i t i o n a l l y , the i n d i v i d u a l and h i s symptoms have been the focus of treatment. has  emerged i n h e a l t h  More r e c e n t l y , a f a m i l y  focus  care.  A FAMILY FOCUS  The continues  f a m i l y has  undergone changes through time but  to be an important s o c i a l u n i t .  f o r the s o c i a l i z a t i o n and provides  the o p p o r t u n i t y  It i s responsible  o r i e n t a t i o n of the young. for intimate  social interactions  and  the base of p e r s o n a l  has  i n f l u e n c e on most aspects of human l i f e .  s e c u r i t y f o r a l l i t s members.  F a m i l i e s are viewed as s o c i a l systems which d i s t i n c t from other  the behavior of o t h e r s .  The  i n t e r a c t with and  are  f u n c t i o n s , and  influence  f a m i l y i s d i s t i n g u i s h a b l e from  o t h e r s o c i a l systems such as business o r g a n i z a t i o n s  Carter,  It  systems i n t h a t they are composed of  persons or groups of persons who  goals,  It  c l i m a t e of f e e l i n g s (Anderson  by i t s and  1974). F a m i l i e s are open systems i n t h a t they exchange  m a t e r i a l , energy, and  information  (Watzlawik, Beavin, and  with t h e i r environment  Jackson, 1967, 1.  p.122).  Families,  2. l i k e a l l open systems, have the p r o p e r t y  o f wholeness  (Watzlawik, Beavin, and Jackson, 1967). "Wholeness" c h a r a c t e r i z e s aspects o f system o r g a n i z a t i o n and i n t e r a c t i o n . an i n s e p a r a b l e whole. independent p a r t s .  A f a m i l y system behaves as  I t i s greater  than the sum o f i t s  A change i n one f a m i l y member produces  a change i n each f a m i l y member and the f a m i l y  system.  Another i n t e r a c t i v e component o f the p r o p e r t y  o f wholeness  i s the c i r c u l a r i t y o f r e l a t i o n s h i p s among system elements. A f a m i l y member's response i s a l s o a stimulus lished pattern of i n t e r a c t i o n .  i n an estab-  An example o f the c i r c u l a r -  i t y of a pattern of i n t e r a c t i o n i s : drinks T h i s interdependent r e l a t i o n s h i p of the f a m i l y system i s recognized  as having i m p l i c a t i o n s f o r h e a l t h  care.  The o v e r a l l h e a l t h o f the f a m i l y u n i t and the h e a l t h o f the i n d i v i d u a l a r e interdependent... (Rakel, 1977, p.342). F a m i l i e s a r e very complex o r g a n i z a t i o n s  and the  development o f a f a m i l y focus r e q u i r e s a framework f o r looking at f a m i l i e s .  K a r l Tomm (1977a) o f f e r s a c o g n i t i v e  framework f o r a s s e s s i n g  f a m i l y systems which i s made up o f  three i n t e r r e l a t e d parameters:  family structure, family  f u n c t i o n , and f a m i l y development. The  parameter o f f a m i l y s t r u c t u r e i n c l u d e s  which i d e n t i f y who i s i n c l u d e d i n the f a m i l y . of the connections across s o c i a l network and other  the f a m i l y boundary  factors  The nature (with the  community i n s t i t u t i o n s ) and the  3. family's  location within  the community  socio-economic) f u r t h e r d e f i n e s  the  (geographic  family.  Family f u n c t i o n i s the most dynamic of the parameters because i t i n c l u d e s d e f i n e and family's  redefine  and  three  the f a m i l y behaviors which  f a m i l y r u l e s and  r o l e s to ensure  continuance as an o r g a n i z e d and  the  s t a b l e system.  Stages of f a m i l y development r e l a t e to marriage or the b e g i n n i n g f a m i l y , c h i l d - r e a r i n g , i n d i v i d u a t i o n of members, departure of c h i l d r e n , r e t i r e m e n t spouse ( F i s h e r , 1977). attend  to the tasks  master the  and  death of a  I t i s assumed t h a t " f a m i l i e s must  of one  stage b e f o r e they can  task o f the next"  (Solomon, 1973,  adequately  p.183).  With a framework f o r understanding what f a m i l i e s are and  how  they f u n c t i o n , i t i s p o s s i b l e f o r h e a l t h  care  p r o f e s s i o n a l s to a f f e c t the h e a l t h o f a l l f a m i l y members regardless  of which f a m i l y member i s the c u r r e n t  identified  patient.  ILLNESS AS A FAMILY CRISIS.  Serious  and  prolonged i l l n e s s i n an i n d i v i d u a l has  a d r a s t i c e f f e c t on both the i n d i v i d u a l and  the  family.  I t u s u a l l y p r e c i p i t a t e s a c r i s i s which i s experienced as a p e r i o d of d i s e q u i l i b r i u m and  disorganization  C r i s i s i n i t s s i m p l e s t terms i s d e f i n e d as 'an upset i n a steady s t a t e ' . . . t h e h a b i t u a l problems o l v i n g a c t i v i t i e s are not adequate and do not l e a d r a p i d l y to  (Olsen,  1970).  4. the p r e v i o u s l y achieved balanced s t a t e (Rapoport, 1965, p.24). The v a r i o u s phases of i l l n e s s  (onset, s i c k r o l e ,  convales-  cence) and c h r o n i c i t y or impending death have i n h e r e n t a d a p t i v e tasks which may the person's  precipitate a crisis  depending upon  p e r c e p t i o n of these events and f a c t o r s such  p h y s i c a l and emotional s t a t u s (Murrary and Zentner, The for  f a m i l y ' s response  the course of  t o the c r i s i s  has  as  1975).  implications  illness.  Should the f a m i l y decompensate and f a i l to support... the i l l member...convalescence (may be) prolonged (Rakel, 1977, p.343). The  f a m i l y ' s response  a l s o has i m p l i c a t i o n s f o r i t s own  health. S u c c e s s f u l experience w i t h c r i s i s t e s t s and strengthens a f a m i l y , but d e f e a t i n c r i s i s i s p u n i t i v e on f a m i l y s t r u c t u r e and morale ( H i l l , 1965, p.46).  POTENTIAL SIGNIFICANCE OF THE STUDY  A crisis  i s not n e c e s s a r i l y a bad experience.  can be an o p p o r t u n i t y to l e a r n new  problem-solving  and d e v i s e c r e a t i v e s o l u t i o n s f o r d a i l y l i v i n g . t i o n and l e v e l s of f u n c t i o n i n g may crisis  levels.  c r i s e s may  skills  Satisfac-  e v e n t u a l l y exceed  pre-  F o l l o w i n g an a d a p t i v e experience, f u t u r e  be handled  G l a s s e r , 1970).  It  i n a s u p e r i o r manner (Glasser and  I t i s during a c r i s i s  that individuals  f a m i l i e s are most amenable to help and change  (Aguilera,  and  5. Messick, F a r r e l l ,  1974).  By h e l p i n g f a m i l i e s cope e f f e c -  t i v e l y w i t h p h y s i c a l i l l n e s s o f a f a m i l y member, nurses can promote o p t i m a l r e c o v e r y o f the s i c k i n d i v i d u a l and safeguard the i n t e g r i t y of the f a m i l y (Livsey, 1972). How do nurses help f a m i l i e s cope?  Before we can  begin t o p r e s c r i b e how t o help f a m i l i e s cope, nurses must have a b e t t e r understanding o f how f a m i l i e s f u n c t i o n and what a f a m i l y experiences when a member i s i l l .  It i s  hoped t h a t i n f o r m a t i o n e l i c i t e d i n t h i s study w i l l add t o e x i s t i n g knowledge about how f a m i l i e s experience c r i s i s and how nurses can g i v e e f f e c t i v e care to p a t i e n t s and t h e i r f a m i l i e s as they cope w i t h the c r i s i s o f i l l n e s s .  PROBLEM STATEMENT  The focus o f t h i s study i s t h e f a m i l y ' s experience of  the c r i s i s o f i l l n e s s .  to  elicit  S p e c i f i c a l l y , the study  attempts  i n f o r m a t i o n about f a m i l i e s ' r e a c t i o n s when they  are faced w i t h the c r i s i s o f having a member who i s i l l and about what f a m i l i e s p e r c e i v e t o be h e l p f u l d u r i n g t h i s crisis. For purposes  o f t h i s study f a t h e r s e x p e r i e n c i n g  t h e i r f i r s t myocardial i n f a r c t i o n are used as the example of  i l l n e s s o f a f a m i l y member.  T h i s study focuses s p e c i f -  i c a l l y on the f a m i l y c r i s i s o f having to i n c o r p o r a t e the d i s a b l e d f a t h e r back i n t o the f a m i l y .  6.  PURPOSE  The  purpose o f t h i s study i s t w o - f o l d .  purpose i s to d e s c r i b e  reactions  The f i r s t  t h a t occur i n f a m i l i e s  when f a t h e r s who have experienced t h e i r f i r s t  myocardial  i n f a r c t i o n have been home from h o s p i t a l f o r one t o t h r e e weeks.  The second i s t o d e s c r i b e  families report week  what people and s e r v i c e s  t o be h e l p f u l d u r i n g t h i s one t o three  period.  ASSUMPTIONS  1.  I t i s assumed t h a t i l l n e s s and d i s a b i l i t y o f a f a m i l y member produces d i s e q u i l i b r i u m i n a f a m i l y .  2.  I t i s assumed t h a t v a r i a b l e s such as p r e v i o u s l e a r n i n g e x p e r i e n c e s , i n d i v i d u a l p e r s o n a l i t y f a c t o r s , and s o c i o economic l e v e l s i n f l u e n c e the response o f the f a m i l y system.  LIMITATIONS  1.  This i s not a study u t i l i z i n g an experimental design i n which hypotheses a r e put f o r t h and then t e s t e d u s i n g r i g o r o u s l y c o n t r o l l e d procedures. I t does not focus on r e l a t i o n s h i p s between v a r i a b l e s o r c a u s a l i t y . The focus of the study i s on q u a l i t a t i v e data.  2.  No attempts have been made t o o b t a i n a random sample hence the r e s u l t s a r e not g e n e r a l i z e a b l e beyond the f a m i l i e s o f the study.  3.  The s i z e o f the sample was l i m i t e d by a v a i l a b i l i t y o f e l i g i b l e f a m i l i e s and by l i m i t s o f time.  4.  The e f f e c t s o f extraneous v a r i a b l e s were not c o n t r o l l e d . The purpose o f t h e study was t o c a t e g o r i z e v a r i a b l e s and examine r e l a t i o n s h i p s .  7. 5.  The f a m i l y d e s c r i p t i o n of r e a c t i o n s may be d i s t o r t e d through e f f e c t of time and/or f a m i l y r u l e s regarding d i s c l o s u r e , e l i g i b l e spokespersons, degree o f i n d i v i d u a t i o n of members. The f a m i l y r u l e s t h a t r e p r e s e n t f a m i l y f u n c t i o n i n g (e.g. mother always speaks f o r the family) are l e s s a l i m i t a t i o n t o the study than the d i s t o r t i o n s t h a t do not r e p r e s e n t f a m i l y f u n c t i o n i n g , (e.g. mother i s the spokesperson f o r t h i s one o c c a s i o n ) .  6.  A d i f f e r e n c e of o p i n i o n among f a m i l y members may have been l o s t i n t h e i r consensus of a f a m i l y d e s c r i p t i o n of r e a c t i o n s . More s o p h i s t i c a t e d methods of o b t a i n i n g a f a m i l y ' s p e r c e p t i o n o f change a r e not known t o t h i s investigator.  7.  The s e m i - s t r u c t u r e d some content.  interview  schedule may have r e s t r i c t e d  DEFINITIONS  c r i s i s - a p e r i o d o f d i s o r g a n i z a t i o n and emotional upset t h a t occurs when customary problem-solving a c t i v i t i e s do not produce a steady s t a t e . f a m i l y - a s o c i a l system composed o f mother, f a t h e r , and at l e a s t one c h i l d ( n a t u r a l o r adopted) l i v i n g i n the same household i n the Vancouver area; a f a m i l y can i n c l u d e persons r e l a t e d by blood o r marriage who have l i v e d i n the household three months o r more. f i r s t m y o c a r d i a l i n f a r c t i o n - the f a t h e r ' s f i r s t known and t r e a t e d m y o c a r d i a l i n f a r c t i o n which has been diagnosed during the h o s p i t a l i z a t i o n ending one to three weeks ago. h e l p f u l - people and s e r v i c e s p e r c e i v e d by the f a m i l y t o be .useful i n r e g a i n i n g a steady s t a t e . r e a c t i o n s - v e r b a l statements o f c o g n i t i v e (thoughts), a f f e c t i v e ( f e e l i n g s ) , and b e h a v i o r a l (observeable behaviors) changes t h a t occurred i n and among f a m i l y members d u r i n g the one t o three week p e r i o d f o l l o w i n g f a t h e r ' s r e t u r n home.  8. steady s t a t e - a system's l e v e l of f u n c t i o n i n g c h a r a c t e r i z e d by a dynamic balance between accommodating change and m a i n t a i n i n g s t a t u s quo.  II.  LITERATURE REVIEW  T h i s review focuses on p u b l i c a t i o n s r e l a t e d t o f a m i l y crisis,  i l l n e s s as a c r i s i s ,  the e f f e c t s o f i l l n e s s on  f a m i l i e s , and the e f f e c t o f f a m i l i e s on i l l n e s s . Although the example o f i l l n e s s i n t h i s study i s the c o n v a l e s c e n t phase o f a p h y s i c a l i l l n e s s , the d e a r t h o f s t u d i e s warrants a review which i n c l u d e s a v a r i e t y o f phases and types o f i l l n e s s .  FAMILY CRISIS  The f a m i l y , l i k e a l l systems, i s s e l f - c o r r e c t i n g and r e s i s t a n t to randomness. to  Jackson used the term "homeostasis"  d e s c r i b e t h i s tendency i n h i s e a r l y w r i t i n g s about f a m i l y  systems  (Jackson, 1957).  The f a m i l y a l s o has a g r e a t capa-  c i t y t o accommodate the many m a t u r a t i o n a l and s i t u a t i o n a l changes o f i t s members and i t s environment.  The term "steady  s t a t e " i s c u r r e n t l y used t o d e s c r i b e a system i n dynamic balance - both changing and m a i n t a i n i n g i t s e l f .  I t does not  imply t h a t a f i x e d m i n i m a l • l e v e l o f s t r e s s must be maintained.  A steady s t a t e d i c t a t e s a l e v e l o f f u n c t i o n i n g  w i t h i n a range o f a c c e p t a b l e l i m i t s which can accommodate the  realms of p l a y , c r e a t i v i t y , and s e l f - r e a l i z a t i o n 9.  10. ( B e r t a l a n f f e y , 1968). F a m i l i e s can experience  c r i s i s when t h e r e i s "an  upset i n a steady s t a t e " (Rapoport, 1965, p.24). who pioneered  much o f the development o f c r i s i s  Caplan, theory,  d e f i n e s c r i s i s as o c c u r r i n g when o b s t a c l e s t o important goals have not been e f f e c t i v e l y r e s o l v e d with problem s o l v i n g methods. anxiety,  customary  There i s a r i s e i n i n n e r  tension,  and d i s o r g a n i z a t i o n o f f u n c t i o n which i s r e f e r r e d  to as " c r i s i s " The  life  ( A g u i l e r a , Messick, and F a r r e l l ,  1974, p . 6 ) .  phases and c h a r a c t e r i s t i c s o f p a r t i c u l a r kinds' o f c r i s e s  i n i n d i v i d u a l s have been s t u d i e d .  Bowlby focused on  separa-  t i o n trauma o f c h i l d r e n e n t e r i n g h o s p i t a l and Lindeman observed g r i e f r e a c t i o n s f o l l o w i n g bereavement  (Rapoport,  1965). C r i s i s theory was a p p l i e d t o f a m i l i e s by H i l l i n h i s s t u d i e s o f war s e p a r a t i o n s war  separation  and war r e u n i o n s .  (1965) With  f a m i l i e s , H i l l d e s c r i b e d f a m i l y c r i s i s and  adjustment as a p e r i o d o f shock f o l l o w e d by d i s o r g a n i z a t i o n , l a c k o f enthusiasm f o r r o l e enactment, and s t r a i n e d r e l a tionships.  Then, through t r i a l and e r r o r or t h o u g h t f u l  planning,  new r o u t i n e s are developed and t h i n g s begin t o  improve.  T h i s process  reunions,  however ( H i l l ,  was not e v i d e n t 1965, p.49).  i n the study of war According  to H i l l  (1965), there are three v a r i a b l e s which determine whether a situation constitutes a c r i s i s  f o r the f a m i l y :  the hard-  ships accompanying the event, the f a m i l y ' s d e f i n i t i o n o f the event  ( t h r e a t e n i n g o r non-threatening  t o s t a t u s and g o a l s ) ,  11. and the f a m i l y ' s r e s o u r c e s p r e v i o u s experience w i t h Parad and Caplan  (role structure,  flexibility,  crisis). (1965) s t u d i e d f a m i l i e s i n c r i s e s  p r e c i p i t a t e d by premature b i r t h , c o n g e n i t a l anomaly, and t u b e r c u l o s i s i n a f a m i l y member. of  life  style  They used the c a t e g o r i e s  ( i n c l u d i n g v a l u e systems, communication network,  and r o l e system), p r o b l e m - s o l v i n g mechanisms, and needresponse p a t t e r n s which r e l a t e t o the needs o f i n d i v i d u a l members, t o o r g a n i z e and analyze t h e i r data. t h a t the f a m i l y ' s l i f e the c r i s i s  for  found  style influences i t s ' perception  i n the impact phase.  problem-solve  They  of  The f a m i l y ' s attempts t o  must be balanced with f a m i l y members' needs  l o v e , support, and independence; freedom and c o n t r o l ;  and r o l e models.  Parad and Caplan support a c u r r e n t r a t h e r  than r e t r o s p e c t i v e approach t o the study o f c r i s e s because " . . . u s e f u l i n f o r m a t i o n about the c r i s i s  (can) be o b t a i n e d  only by i n t e r v i e w i n g the f a m i l y w h i l e i t ( i s ) a c t i v e l y engaged i n i t s coping e f f o r t s " Langsley and Kaplan to  (Parad and Caplan,  1965, p.54).  (1968) a p p l i e d the c r i s i s model  f a m i l i e s i n a study e x p l o r i n g f a m i l y c r i s i s  therapy as  an a l t e r n a t i v e t o p a t i e n t h o s p i t a l i z a t i o n f o r m e n t a l l y i l l patients.  They d e s c r i b e c r i s i s  as a s t r u g g l e t o master a  s i t u a t i o n i n which p r e v i o u s coping mechanisms have been i n e f f e c t i v e and a s t a t e o f imbalance  persists.  They d e t e r -  mined t h a t s t r e s s outcomes are r e l a t e d t o the s t r e s s o r , the i n d i v i d u a l ' s p e r s o n a l i t y f a c t o r s , and the s o c i a l f i e l d i n which he l i v e s .  The s o c i a l f i e l d i n c l u d e s a v a r i e t y o f  12. s o c i a l subsystems which i n f l u e n c e the s t r u g g l e f o r s t r e s s mastery  (Langsley Glasser  and Kaplan, 1968).  and  Glasser  (1970) looked  a t f a m i l i e s exper-  i e n c i n g the s i t u a t i o n a l c r i s e s of p o v e r t y , d i s o r g a n i z a t i o n , i l l n e s s and may  disability.  They found t h a t the  impact of s t r e s s  be accompanied by p s y c h o l o g i c a l s t r e s s or f a m i l y demor-  alization.  For r e l i e f , the f a m i l y may  have to make:  . . . a l t e r a t i o n s i n group s t r u c t u r e s and p r o c e s s e s ... f o r example, s h i f t s i n the f a m i l y power s t r u c t u r e , means o f communication, a f f e c t i o n a l r e l a t i o n s h i p s , tasks assigned members, or ways of s o l v i n g problems and resolving conflicts. Without such modifications, disequilibrium w i l l continue and f a m i l y f u n c t i o n i n g i s l i k e l y to become l e s s e f f e c t i v e and l e s s e f f i c i e n t (Glasser and G l a s s e r , 1970, p.6). The  time frame of f a m i l y c r i s i s  i n the l i t e r a t u r e .  Caplan s a i d c r i s i s i s s e l f - l i m i t i n g w i t h  individuals, lasting Messick, and  from f o u r to s i x weeks  F a r r e l l , 1974).  i f i e d t h a t coping  i s l e s s than c l e a r  (Aguilera,  S i m i l a r l y , Kaplan  (1973) spec-  responses of parents informed of  c h i l d ' s leukemia would be e v i d e n t w i t h i n one  their  t o f o u r weeks.  Other w r i t e r s have s a i d t h a t the d u r a t i o n of the  disorganized  s t a t e i s dependent upon v a r i a b l e s such as f a m i l y  organization  (Hill,  1965)  and  f a m i l y members' a b i l i t y t o communicate  ( S m i l k s t e i n , 1975). There are two  types o f  crises:  Developmental c r i s e s are t r a n s i t i o n p o i n t s , the p e r i o d s t h a t every person experiences i n the process o f b i o p s y c h o s o c i a l growth and development and t h a t are accompanied by  13. changes i n thoughts, f e e l i n g s , and a b i l i t i e s (Murray and Zentner, 1975, p.208). This concept i s not i n c o m p a t i b l e w i t h the m a t u r a t i o n a l changes r e l e v a n t to f a m i l y systems. stages o f development For  F a m i l i e s experience  c h a r a c t e r i z e d by developmental  tasks.  example, the task i n the c h i l d - r e a r i n g stage i s the  s a t i s f a c t o r y development 1977a).  o f mother-father r o l e s  F a m i l i e s are l i k e l y  (Tomm,  t o experience some d i s o r g a n i -  z a t i o n a t each, stage o f development  (Solomon,  19 7 3).  The s i t u a t i o n a l c r i s i s i s an e x t e r n a l event o r s i t u a t i o n , one not necess a r i l y a p a r t of normal l i v i n g , o f t e n sudden, unexpected, and u n f o r t u n a t e ...(Murray and Zentner, 1975, p.209). Caplan i d e n t i f i e d t h i s type of c r i s i s as one " . . . p r e c i p i t a t e d by l i f e  hazard...accompanied  by heightened demands on the  i n d i v i d u a l . . . " ( C a p l a n , 1964, p.35).  In t h e i r l i s t o f  examples of s i t u a t i o n a l c r i s e s , Murray illness  and h o s p i t a l i z a t i o n  and Zentner  list  (Murray and Zentner, 1975, p.210).  ILLNESS AS A FAMILY CRISIS  . . . i l l n e s s i s an event experienced by people t h a t m a n i f e s t s i t s e l f through o b s e r v a b l e and/or f e l t changes i n the body, causing an impairment of c a p a c i t y t o meet minimum p h y s i c a l , p h y s i o l o g i c a l , and p s y c h o s o c i a l requirements f o r a p p r o p r i a t e f u n c t i o n i n g a t the l e v e l d e s i g n a t e d f o r the person's age, sex, and development, o r handicapped s t a t e (Wu, 1973, p.23).  14. An  i n d i v i d u a l ' s b e h a v i o r a l responses to the changes  are d i r e c t l y r e l a t e d to h i s p e r c e p t i o n of h i s i l l n e s s 1973).  (Wu,  I l l n e s s can be viewed by the p a t i e n t as a c h a l l e n g e ,  an enemy, .punishment, weakness, r e l i e f from r e s p o n s i b i l i t i e s , an i n t e r p e r s o n a l s t r a t e g y , i r r e p a r a b l e l o s s or damage, or a v a l u e because i t makes h e a l t h more a p p r e c i a t e d  (Lipowski,  1970). C e r t a i n aspects of i l l n e s s can have d i f f e r e n t meanings as w e l l . The meaning to (each) p a t i e n t of h i s symptoms, l e s i o n , d i a g n o s t i c l a b l e , l o s s of f u n c t i o n , doctor's statements, and so f o r t h , i s determined by m u l t i p l e f a c t o r s , i n t e r n a l and e x t e r n a l (Lipowski, 1970, p.1198) . The  temporal aspects of i l l n e s s  (onset, course, and  w i l l a l s o assume c h a r a c t e r and meaning from p a s t c o g n i t i o n s , and understandings  (Wu,  duration)  experiences,  1973).  I l l n e s s and phases of i l l n e s s have a l s o been viewed i n terms o f a d a p t i v e t a s k s .  Murray and  Zentner  i d e n t i f y the adaptive tasks of convalescence  (1975)  as r e a s s e s s -  ment of l i f e ' s meaning, r e i n t e g r a t i o n of body image, and r e s o l u t i o n of r o l e changes or r e v e r s a l s .  Moos (1977) says  s e r i o u s i l l n e s s or i n j u r y s e t s f o r t h seven adaptive d e a l i n g w i t h p a i n and environment and  i n c a p a c i t a t i o n , d e a l i n g with  treatments,  tasks: hospital  d e v e l o p i n g adequate r e l a t i o n s h i p s  with p r o f e s s i o n a l s t a f f , p r e s e r v i n g emotional  balance,  pre-  serving a s a t i s f a c t o r y self-image, preserving r e l a t i o n s h i p s w i t h f a m i l y and future.  f r i e n d s , and p r e p a r i n g f o r an u n c e r t a i n  Moos notes, "... f a m i l y members and f r i e n d s , as w e l l as p a t i e n t s , a r e a f f e c t e d by the c r i s i s  (of i l l n e s s ) , (and)  encounter many o f the same o r c l o s e l y r e l a t e d tasks..."(Moos, 1977, p.8). perceived  challenge  adaptive  I t would seem t h a t when the  o r t h r e a t o f i l l n e s s exceeds the coping  c a p a b i l i t i e s and resources  o f an i n d i v i d u a l or f a m i l y ,  ill-  ness c o n s t i t u t e s a c r i s i s . The f a m i l y system may become massi v e l y d i s r u p t e d when a member becomes s e r i o u s l y i l l w i t h an o r g a n i c d i s e a s e , and the f a m i l y ' s response t o the i l l n e s s may d r a s t i c a l l y a f f e c t the outcome f o r the s i c k member... (Olsen, 1970, p.237) . L i v s e y says,  "Serious  i l l n e s s i n an i n d i v i d u a l c r e a t e s a  f a m i l y c r i s i s " (Livsey, 1972, p.237).  She s t r e s s e s the  i n t e r r e l a t i o n s h i p o f i l l n e s s and f a m i l y even f u r t h e r ,  "Stress  i n human r e l a t i o n s h i p s i s b e l i e v e d t o p r e c i p i t a t e and/or i n t e n s i f y somatic i l l n e s s "  (Livsey, 1972, p.238).  EFFECT OF ILLNESS ON FAMILY STRUCTURE  "Family s t r u c t u r e " i n c l u d e s f a c t o r s which d e f i n e the f a m i l y through i t s membership and the nature of i t s connect i o n s across  the f a m i l y boundary.  Family membership spec-  i f i e s the composition -of the f a m i l y ; who i s and i s not a member, the alignments and s p l i t s among members.  Family  connections w i t h the environment i n c l u d e the q u a n t i t y and q u a l i t y o f r e l a t i o n s h i p s w i t h other  i n s t i t u t i o n s such as  16. workplace  and s c h o o l , w i t h t h e i r s o c i a l network, and the  f a m i l y ' s socio-economic community  and geographic p o s i t i o n i n the  (Tomm, 1977a).  I l l n e s s can a l t e r f a m i l y household membership i n d i f f e r e n t ways.  The i l l  h o l d t o o b t a i n treatment  person may have t o leave the house(Livsey, 1972).  be lengthy and the d i s t a n c e g r e a t .  The s e p a r a t i o n may  I f a parent i s h o s p i t a l -  i z e d i t may be necessary f o r c h i l d r e n t o l e a v e the household to be cared f o r by f r i e n d s and r e l a t i v e s .  I t may be necessary  to have i n d i v i d u a l s j o i n the f a m i l y t o p r o v i d e a s s i s t a n c e (Parsons and Fox, 1968). Members may r e a l i g n when there i s i l l n e s s i n the family.  F o r example, when a f a t h e r becomes i l l ,  an o l d e r son  may a l i g n w i t h h i s mother as another a d u l t - p a r e n t (Olsen, 1970).  Family members might a l i g n a g a i n s t the i l l  because o f h i s / h e r demands f o r a t t e n t i o n Hill community  member  ( L i v s e y , 1972).  (1965) d e s c r i b e s f a m i l y connections w i t h  institutions: ...the c l o s e d nature o f the f a m i l y i s s e l e c t i v e l y opened f o r t r a n a c t i n g business w i t h o t h e r agencies, i n c l u d i n g k i n and p r o f e s s i o n a l s . . . agencies can be ranked on t h e i r a c c e s s i b i l i t y t o the... f a m i l y : immediate k i n h i g h e s t , f a m i l y f r i e n d s and neighbors next, the f a m i l y phyc i a n , . . . p a s t o r a n d so on... Other agencies e n t e r the f a m i l y w i t h g r e a t e r d i f f i c u l t y and o f t e n through . . . f a m i l y members who a c t as l i a i s o n s f o r the f a m i l y : the s c h o o l , the employer, the h e a l t h c l i n i c , the casework agency, and o t h e r such formal agencies CHI11, 1965, p.33).  I l l n e s s can a l t e r these connections.  F o r example,, connec-  t i o n s w i t h school and workplace might decrease w h i l e conn e c t i o n s w i t h h e a l t h and s o c i a l s e r v i c e agencies might increase. H i l l goes on t o note t h a t f a m i l i e s have changed. Once a s e l f - c o n t a i n e d economic and s o c i a l u n i t b u t t r e s s e d by k i n s h i p supports, the f a m i l y now has i n t e r dependent r e l a t i o n s h i p s w i t h many other a s s o c i a t i o n s i n working out i t s problems ( H i l l , 1965, p.34). Parsons and Fox (1968) say the f a m i l y i s e s p e c i a l l y v u l n e r able t o the e f f e c t s o f i l l n e s s because today's f a m i l i e s a r e i s o l a t e d from k i n r e l a t i o n s h i p s and t h e r e f o r e must become more dependent on s o c i a l i n s t i t u t i o n s . Archbold  say,  MacVicar and  "The number o f persons a v a i l a b l e t o p r o v i d e  a s s i s t a n c e . . . i s an i n d i c a t o r of p o t e n t i a l hardship  imposed  by i l l n e s s "  They  (MacVicar and A r c h b o l d , 1976, p.187).  agree w i t h Parsons t h a t a s s i s t a n c e  from k i n s h i p systems i s  u s u a l l y n e i t h e r s t a b l e nor permanent.  Further  support f o r  the importance o f f a m i l y connections w i t h i n the community i s given by Yokes i n h i s d i s c u s s i o n of p a t i e n t s w i t h myocardial  infarction: Those f a m i l i e s who have c l o s e t i e s w i t h i n the primary f a m i l y , w i t h r e l a t i v e s and w i t h members o f the l o c a l community, seem t o have a cushion o f abs o r b t i o n o f the emotional and sometimes f i n a n c i a l shock exp e r i e n c e d when a f a m i l y member has an acute m y o c a r d i a l i n f a r c t i o n (Yokes, 1973, p.395). I l l n e s s can a l s o d r a i n f a m i l y f i n a n c i a l  reserves.  18. Reduced f i n a n c i a l r e s e r v e and consequent a l t e r e d l i f e  style  add t o the adjustments r e q u i r e d from the f a m i l y with an i l l member (MacVicar  and Archbold,  1976).  In the l i t e r a t u r e , r e a c t i o n s t o the c r i s i s o f i l l ness tend t o be d e s c r i b e d i n terms o f the p a t i e n t o r f a m i l y subsystems.  A common approach has been t o look a t the  r e a c t i o n s o f spouses.  In a study o f p a t i e n t s w i t h  chronic  i l l n e s s and t h e i r spouses, i t was found t h a t 56% o f spouses noted an i n c r e a s e i n t e n s i o n d u r i n g the i l l n e s s o f the o t h e r . The  i n t e r p e r s o n a l t e n s i o n from i l l n e s s i n one member l e d t o  psychophysiologic d i s t r e s s  (symptoms) i n both  ( K l e i n , 196 7).  study l o o k i n g a t r e a c t i o n s o f  spouses, S i l v a  In another  partners  (1977) r e p o r t s t h a t 23 o u t o f 36 p r e s u r g i c a l  spouses scored h i g h e r on the S t a t e A n x i e t y Inventory did  than  the p r e o p e r a t i v e p a t i e n t s themselves. S k e l t o n and Dominian  6 5 wives o f myocardial  (1973) s t u d i e d the r e a c t i o n s o f  i n f a r c t i o n p a t i e n t s d u r i n g the hus-  band's h o s p i t a l stay, then t h r e e , s i x , and twelve months following discharge.  W i t h i n the f i r s t  t h r e e months a f t e r  d i s c h a r g e , 2 5 wives r e p o r t e d f e e l i n g s o f t e n s i o n , a n x i e t y , d e p r e s s i o n , and s l e e p d i s t u r b a n c e .  They were d i s t r e s s e d  because o f t h e i r " l o s s " of a " s t r o n g " husband and f e a r o f recurrence.  They found  t h e i r husbands dependent and i r r i t -  a b l e which c o n t r i b u t e d t o f e e l i n g s o f t e n s i o n and sometimes hostility. In a s i m i l a r more r e c e n t study,  82 wives of myo-  c a r d i a l i n f a r c t i o n p a t i e n t s were i n t e r v i e w e d w h i l e  their  19. husbands were i n h o s p i t a l , and again a t two months and twelve months a f t e r d i s c h a r g e Williamson, 1978).  (Mayou, F o s t e r , and  During the f i r s t few weeks a f t e r  d i s c h a r g e 80% of the wives experienced a n x i e t y , d e p r e s s i o n , f a t i g u e , i r r i t a b i l i t y , poor c o n c e n t r a t i o n , and few weeks the men  insomnia.  "In  the f i r s t  men  had to modify  had  f o r e s e e n . .." (Mayou, Foster:;' and W i l l i a m s o n , 1978,  t h e i r jobs...more o f t e n than the wives  The m a r i t a l subsystem the focus of two  were very dependent... the  studies.  (husband and wife) has been  Kaplan  (1973) assessed  families'  coping behaviors by a s s e s s i n g the coping mechanisms i n parents of leukemic  p. 700).  children.  observed  U n f o r t u n a t e l y , the  article  does not r e v e a l the methodology of the study except t o say i t was  a c l i n i c a l review of 50 f a m i l i e s from the day o f  confirmed d i a g n o s i s u n t i l two months a f t e r the c h i l d d i e d . The m a r i t a l subsystem was patients.  a l s o the focus of a study of burn  P a t i e n t s and t h e i r spouses were asked t o d i s c u s s  t h e i r p o s t - h o s p i t a l experiences i n a group w i t h other p a t i e n t s and t h e i r spouses  burn  (Granite and Goldman, 1975).  T h e i r d i s c u s s i o n s c e n t r e d on concerns  about f a m i l y r e l a t i o n -  s h i p s , work, r e c r e a t i o n and i n t e g r a t i o n i n t o the  larger  community. Some a r t i c l e s appear to have g e n e r a l i z e d i n d i v i d u a l member r e a c t i o n s to f a m i l y r e a c t i o n s .  The r e a c t i o n s are  u s u a l l y i d e n t i f i e d as f e e l i n g s , defence mechanisms or other emotional responses.  For example, Epperson  (1977) found t h a t  f a m i l i e s i n the acute c r i s i s stage, when f i r s t coming to a  20. critical  care  strate  periods  grief,  and  families  and  to  of  high  finally  see  have  possible  reactions  denial,  goes  and d i f f e r e n t  stages  at  same  value.  hostility,  of  She  the  families  demon-  remorse,  on  to  say  members  time.  may  Hence,  that be the  Similarly, Williams  anger, of  member,  anger,  stages  predictive  (1977) l i s t  Rice  injured family  reconciliation.  different little  an  anxiety,  may e l i m i n a t e  experiencing stages  unit  guilt,  intensive  and g r i e f  care  as  unit  patients. It and  not  clear  W i l l i a m s and R i c e  affective Perhaps or  is  or  more  emotional  emotional  that  EFFECT  studies  (1977) h a v e , responses  correctly, responses  the  they in  have  in  to  by E p p e r s o n  fact,  acute  individual family  OF I L L N E S S  identified  illness  identified  (1977) family  situations.  common  affective  members.  ON F A M I L Y F U N C T I O N I N G  Family f u n c t i o n i n g i s concerned w i t h the d e t a i l s o f how i n d i v i d u a l s a c t u a l l y behave i n r e l a t i o n t o one another i n the process o f f u l f i l l i n g the needs and goals of the f a m i l y . and i t s members... f u n c t i o n i n g r e f e r s to r o u t i n e a c t i v i t i e s o f d a i l y l i v i n g i n v o l v e d i n s u r v i v a l . . . and i n the procurement and use o f goods and s e r v i c e s ... ( f u n c t i o n i n g a l s o ) r e f e r s to the emotional, communicative, problems o l v i n g , and c o n t r o l behaviors of f a m i l y members (Tomm, 1977a, p . 3 ) . Almost a l l aspects o f f a m i l y f u n c t i o n i n g can be viewed as formal  and i n f o r m a l r o l e  allocations.  A r o l e can be d e f i n e d as the p a t t e r n o f wants and g o a l s , beliefs, feelings, attitudes, values and a c t i o n s which members o f a community expect should c h a r a c t e r i z e the typi c a l occupant o f a p o s i t i o n (Robischon and S c o t t , 1962, p.52) . Informal r o l e s r e f e r t o p r e s c r i b e d p a t t e r n s o f behavior i d i o s y n c r a t i c t o p a r t i c u l a r i n d i v i d u a l s i n c e r t a i n settings.  Formal r o l e s are those broadly  i n the community.  Examples i n c l u d e the r o l e s o f mother,  policeman, student,(Tomm, 1977c). by age and sex a r e u n i q u e l y system  agreed upon w i t h -  Roles commonly determined  d e f i n e d w i t h i n each f a m i l y  (Anderson and C a r t e r ,  1974).  By mutual consent,  f a m i l y members can be breadwinners, n u r t u r e r s ,  disciplin-  a r i a n s , and clowns. Roles e x i s t i n p a i r e d p o s i t i o n s . not adopt a " v i c t i m " r o l e unless r e c i p r o c a l r o l e o f "persecutor"  An i n d i v i d u a l can  another member adopts the (Robischon and S c o t t ,  1969).  A l t e r a t i o n o f one r o l e r e q u i r e s a l t e r a t i o n o f the other. Although mutually agreed upon a t some l e v e l o f awareness, i t i s p o s s i b l e f o r a r o l e t o e x i s t , such as scapegoat, which i s f u n c t i o n a l f o r the f a m i l y but d i s f u n c t i o n a l f o r the i n d i v i d u a l ( B e l l and V o g e l , 1968). Nye  and Gecas i d e n t i f y e i g h t p a r e n t a l r o l e s i n t h e i r  review o f f a m i l y l i t e r a t u r e : care, c h i l d s o c i a l i z a t i o n , and  kinship  p r o v i d e r , housekeeper, c h i l d  sexual, r e c r e a t i o n a l , therapeutic,  (Nye and Gecas, 1976, p.13).  Role change i s l i s t e d as a very common f a m i l y  22. occurrence f o l l o w i n g i l l n e s s o f a f a m i l y member.  Anthony  (1970) s t u d i e d f a m i l i e s i n which one o f the parents was mentally  or p h y s i c a l l y i l l . There i s no doubt t h a t i l l n e s s b r i n g s about a d i s e q u i l i b r i u m w i t h i n the f a m i l y and a change i n complementarity o f r o l e s (Anthony, 1970, p.60).  Anthony  (.1970) p o i n t e d  initially  out t h a t the f a m i l y must a c c l i m a t i z e  t o i l l n e s s and then t o the "wellness"  o f the  patient. Shellhase  and S h e l l h a s e  (1972) s t a t e t h a t the neces-  sary r e o r g a n i z a t i o n o f f a m i l y o b j e c t i v e s f o l l o w i n g p h y s i c a l d i s a b i l i t y o f a member o f t e n r e s u l t s i n changes o f r o l e s . They go on to say: Established patterns of d e c i s i o n making a c t i v i t i e s a r e no longer workable i f they had depended upon the able-bodied presence and p a r t i c i p a t i o n o f the nowd i s a b l e d member. In a d d i t i o n to the e a r l i e r purpose o f the f a m i l y ...the f a m i l y i s now r e q u i r e d to d e v i s e and implement an accommodar t i o n f o the r e a l i t y o f the d i s a b i l i t y w i t h i n the f a m i l y group (Shellhase and S h e l l h a s e , 1972, p. 549) . Besides r o l e changes, another n o t i c e a b l e area o f change f o l l o w i n g i l l n e s s of a f a m i l y member may be i n a family's patterns  of interaction.  t e r n s o f i n t e r a c t i o n to organize reasonably s t a b l e system. acceptable  F a m i l i e s e s t a b l i s h pat-  family functioning into a  These p a t t e r n s  and not acceptable  regarding  i d e n t i f y what i s  how, when, and t o  whom t o r e l a t e i n a wide v a r i e t y o f content areas  (Watzlawik,  23. Beavin, and Jackson, 1967).  Jackson  (1964) coined  the term  " f a m i l y r u l e s " to i d e n t i f y these governings o f f a m i l y Repetitive patterns  life.  o f i n t e r a c t i o n among f a m i l y members  d e f i n e f a m i l y r u l e s which, i n t u r n , govern p a t t e r n s o f interaction. Haley  (.19 62)  s a i d the focus o f a f a m i l y study  should  be on the t o t a l f a m i l y and the i n t e r a c t i o n s between f a m i l y members r a t h e r than the i n t e r a c t i o n s between f a m i l y members and  the i n t e r v i e w e r  or t e s t e r .  But r a r e l y i s r e f e r e n c e  made  to i n t e r a c t i o n a l changes as a response t o i l l n e s s o f a f a m i l y member. in  Shellhase  response t o traumatic  and S h e l l h a s e  (1972) r e p o r t  i n j u r y o f a f a m i l y member,  that,  "...the  f u l l range o f a c t i v i t i e s and t r a n s a c t i o n s which c o n t r i b u t e to the maintenance o f the f a m i l y as a group undergoes extens i v e change"  (Shellhase and S h e l l h a s e ,  1972, p.549).  EFFECT OF FAMILIES ON ILLNESS  F a m i l i e s have an e f f e c t on the course of i l l n e s s and  rehabilitation.  Power (19 76)  observedchronically  i l l  p a t i e n t s and t h e i r f a m i l i e s and determined t h a t the f e e l i n g s and a t t i t u d e s o f the p a t i e n t ' s f a m i l y a r e a v i t a l f a c t o r i n the adjustment to i l l n e s s .  T h i s was s t r o n g l y  supported i n a two year study of p a t i e n t s , t h e i r f a m i l i e s , and r e h a b i l i t a t i o n problems  (Peck, 19 74).  Problems i n  r e h a b i l i t a t i o n were most f r e q u e n t l y a s i g n o f uncooperative f a m i l y s t r a t e g i e s such as undermining the experts o r  24. c o n t r o l l i n g the p a t i e n t ' s The  initiative.  v a r i a b l e of time probably has  importance of f a m i l y to p a t i e n t progress.  an e f f e c t on The  low  signi-  f i c a n c e i n the r e l a t i o n s h i p between f a m i l y s o l i d a r i t y r e h a b i l i t a t i o n i n Litman"s to the e a r l y , c r i t i c a l it  (19 66)  stage of the o r t h o p e d i c  e f f e c t on e a r l y t r a i n i n g o f the p a t i e n t .  therapy may  due  i n j u r y when little  C l o s e r to the  p e r i o d of t r a i n i n g i t was  end  found t h a t  the f a m i l y d i d p l a y an i n f l u e n t i a l r o l e In the convalescence.  and  study i s most l i k e l y  i s f e a s i b l e t h a t f a m i l y s o l i d a r i t y would have  of the fifteen-month  the  patient's  Litman concluded t h a t , " I t appeared  that  be enhanced i f performance i s conceived  i n terms  of r e - e n t r y i n t o an e s t a b l i s h e d f a m i l y c o n s t e l l a t i o n r a t h e r than an i n d i v i d u a l or p e r s o n a l matter" Using a questionnaire., t h a t the f a m i l y resources and  (Litman, 1966,  Levinson  (1976) determined  of r e l i g i o u s b e l i e f ,  income were more s i g n i f i c a n t than m a r i t a l  i n reducing  s t r e s s and  i n c r e a s i n g coping  c r i s i s r e l a t e d to having a mentally m e t h o d o l o g i c a l shortcoming was  p.216).  education, satisfaction  a b i l i t y i n the  retarded  child.  A  this project's retrospective  approach to the study of the coping  process.  Family f a c t o r s p r e d i c t i n g home placement of  severely  d i s a b l e d p o l i o p a t i e n t s were the kinds arid degree o f r o l e changes which the d i s a b i l i t y imposed. ences e x i s t e d i n pre and  Where l a r g e  p o s t - i l l n e s s f a m i l y r o l e s , the  p a t i e n t s were more l i k e l y to remain i n h o s p i t a l and  Goldston, 1960).  differ-  (Deutsch  25. The  f a m i l y a l s o has an e f f e c t on i l l n e s s  suscep-  tibility. The f a m i l y c o n t r i b u t e s not o n l y to g e n e t i c p r e d i s p o s i t i o n but a l s o t o the a c t u a l e t i o l o g y o f s p e c i f i c d i s e a s e s through the t r a n s m i s s i o n of s o c i a l v a l u e s , the s o c i a l i z a t i o n process of the c h i l d , and the f a m i l y p a t t e r n o f d a i l y l i v i n g and behavior (Murray and Zentner, 19 75, p.229).  SUMMARY OF LITERATURE REVIEW  Family systems attempt but can experience c r i s i s .  to m a i n t a i n a steady  Caplan's  state  definition of c r i s i s  as an experience o f a f f e c t i v e change and d i s o r g a n i z a t i o n o f f u n c t i o n appears and F a r r e l l ,  t o be w i d e l y accepted  (Aguilera,  Messick,  1974, p . 6 ) .  However, the study of f a m i l i e s i n c r i s i s i s comp l i c a t e d by two f a c t o r s .  The focus o f the early' develop-  ment o f c r i s i s theory was the i n d i v i d u a l .  Attempts t o  d i r e c t l y apply c r i s i s theory t o f a m i l y systems i g n o r e s the complexity o f a system comprised Secondly,  o f many i n d i v i d u a l s .  i n v e s t i g a t o r s and w r i t e r s have used numerous  approaches and p o i n t s o f view i n t h e i r attempts stand the f a m i l y . and temporal determine  Consequently  t o under-  the phases, c h a r a c t e r i s t i c s ,  aspects o f c r i s i s i n f a m i l i e s a r e d i f f i c u l t t o  from the r e a d i n g s .  The  l i t e r a t u r e supports the view t h a t i l l n e s s can  constitute a c r i s i s  i n a family.  The f a m i l y ' s response t o  26. the c r i s i s has an e f f e c t on the course o f i l l n e s s and i m p l i c a t i o n s f o r the f a m i l y ' s  integrity.  The l i t e r a t u r e most f r e q u e n t l y d e s c r i b e s  family  r e a c t i o n s i n terms o f an i n d i v i d u a l or f a m i l y subsystem. T h i s i s e s p e c i a l l y t r u e i n the s t u d i e s d e s c r i b i n g a f f e c t i v e or emotional responses. been d e s c r i b e d  Other responses to i l l n e s s have  as changes i n f a m i l y s t r u c t u r e , r o l e s , and  o c c a s i o n a l l y as changes i n p a t t e r n s  of i n t e r a c t i o n .  Using e x i s t i n g knowledge of f a m i l y dynamics and crisis,  t h i s study then, i s designed to f u r t h e r  explore  the f a m i l y ' s responses to i l l n e s s of a family, member.  III.  The  f i r s t purpose o f t h i s study was t o d e s c r i b e  r e a c t i o n s t h a t occur experienced  METHODOLOGY  i n f a m i l i e s when f a t h e r s who have  t h e i r f i r s t myocardial  i n f a r c t i o n have been  home from h o s p i t a l f o r one t o three weeks.  The second  purpose was t o d e s c r i b e what people and s e r v i c e s these f a m i l i e s r e p o r t to be h e l p f u l during t h i s one t o three week p e r i o d .  T h i s i n f o r m a t i o n c o u l d be added to e x i s t i n g  knowledge about how f a m i l i e s experience  c r i s i s and how  nurses can g i v e e f f e c t i v e care t o p a t i e n t s and t h e i r f a m i l i e s as they cope w i t h the c r i s i s of i l l n e s s .  The  purposes o f t h i s study and the l a c k o f s i g n i f i c a n t  research  i n the area d i r e c t e d t h e i n v e s t i g a t o r to an e x p l o r a t o r y d e s c r i p t i v e r e s e a r c h design chapter  (Brink and Wood, 1978).  This  d e s c r i b e s the v a r i o u s aspects of the methodology  used t o c a r r y out t h i s study.  Discussed  i n the f o l l o w i n g  pages a r e sample s e l e c t i o n , data c o l l e c t i o n , and data analysis.  SAMPLE SELECTION  The  c o n v e n i e n c e s a m p l e was s e l e c t e d  of coronary p a t i e n t s  f r o m a: p o p u l a t i o n  C n o n - s u r g i c a l ) i n two l a r g e u r b a n 27.  28. general h o s p i t a l s . to  In both s e t t i n g s the p a t i e n t s spend one  seven days i n a coronary acute care area b e f o r e being  t r a n s f e r r e d to the p o s t acute coronary care u n i t s where they remain u n t i l d i s c h a r g e . acute u n i t s  The head nurses on both p o s t  (8 and 18 beds r e s p e c t i v e l y ) r e p o r t e d t h a t t h e i r  bed occupancy was almost always 100%. For purposes  o f homogeneity o f developmental  stage,  the 10 f a m i l i e s i n the sample had a t l e a s t one c h i l d  living  at  home.  Other c r i t e r i a of e l i g i b i l i t y  were:  - the f a t h e r had r e c e n t l y experienced h i s f i r s t known m y o c a r d i a l i n f a r c t i o n - the f a m i l y l i v e d i n the lower mainland, and was a c c e s s i b l e f o r a home v i s i t - parents and c h i l d r e n nineteen years o r o l d e r would be able t o read and respond to the l e t t e r s o f consent Each week t h i s i n v e s t i g a t o r spoke w i t h the head nurses o f both u n i t s t o g e t a l i s t o f e l i g i b l e p a t i e n t s about t o be d i s c h a r g e d from h o s p i t a l .  The i n v e s t i g a t o r  v i s i t e d each e l i g i b l e p a t i e n t i n the h o s p i t a l . of  The content  the l e t t e r o f consent was d i s c u s s e d and consent was  sought  t o p a r t i c i p a t e i n the study and to approach o t h e r  f a m i l y members were sought  (See Appendix A ) .  Telephone v e r b a l consents  from other f a m i l y members and an appointment  made f o r a home v i s i t .  W r i t t e n consents were o b t a i n e d on  the o c c a s i o n o f the home v i s i t b e f o r e the i n t e r v i e w began (See Appendix B ) . One p a t i e n t r e f u s e d t o p a r t i c i p a t e i n the study. He was very anxious  in. h o s p i t a l and about d i s c h a r g e i n  29. particular.  He asked to have two weeks t o "take i t easy"  and then he would c o n s i d e r i t .  (When c o n t a c t e d by the  i n v e s t i g a t o r , a l l f a m i l y members agreed t o p a r t i c i p a t e . ) The method of sample s e l e c t i o n d i d not p r o v i d e a random sample hence the r e s u l t s of the study are not g e n e r a l i z e a b l e beyond the f a m i l i e s of the study. I t i s assumed t h a t v a r i a b l e s such as p r e v i o u s learning experiences, i n d i v i d u a l p e r s o n a l i t y f a c t o r s , socioeconomic  and  l e v e l s i n f l u e n c e the response of the f a m i l y  system to i l l n e s s .  The e f f e c t s of these extraneous  vari-  a b l e s were not c o n t r o l l e d except f o r the v a r i a b l e of p r e v i o u s l e a r n i n g experience.  T h i s study s p e c i f i e s  that  the p a t i e n t w i l l have experienced h i s f i r s t known m y o c a r d i a l infarction.  Since the focus of t h i s study was  on  qualita-  t i v e data r a t h e r than p r o v i n g or d i s p r o v i n g a h y p o t h e s i s , t h i s l i m i t a t i o n was  not a major concern.  DATA COLLECTION  The method chosen  f o r c o l l e c t i o n of the data was  a  s e m i - s t r u c t u r e d i n t e r v i e w to a v o i d r e s t r i c t i o n o f responses but to ensure t h a t comparable data were c o l l e c t e d Wood, 1978).  A combination of open-ended and  q u e s t i o n s and s c a l e items was (1973). schedule.  (Brink and  closed-ended  used as a d v i s e d by  Kerlinger  F i v e content areas were covered by the i n t e r v i e w Four content areas were r e l a t e d to f a m i l y r e a c -  t i o n s i n the realms of a f f e c t , i n t e r a c t i o n , r o l e s  and  30. structure.  The f i f t h content area was r e l a t e d t o what  people and s e r v i c e s the f a m i l y p e r c e i v e d t o be h e l p f u l . The i n t e r v i e w schedule was examined by t h e s i s comm i t t e e members and r e v i s e d . experts  I t was submitted t o two  (a member o f the n u r s i n g f a c u l t y and a nurse  c l i n i c i a n i n a community mental h e a l t h centre) f o r review. Adjustments  were made t o e l i m i n a t e a m b i g u i t i e s and inade-  quate wording.  The r e v i s e d i n t e r v i e w schedule was p r e t e s t e d  with two e l i g i b l e f a m i l i e s and minor f i n a l adjustments were made.  The i n t e r v i e w schedule i n i t s f i n a l form i s presented  i n Appendix C. One  t o three weeks a f t e r the f a t h e r had been d i s -  charged from h o s p i t a l , each f a m i l y was i n t e r v i e w e d once i n t h e i r home.  T h i s p r o v i d e d them w i t h a f a m i l i a r and com-  fortable setting.  I t a l s o p r o v i d e d o p p o r t u n i t i e s f o r the  i n v e s t i g a t o r to observe i n t e r a c t i o n s , non v e r b a l cues, and environmental f a c t o r s which v a l i d a t e d f a m i l y responses. i n v e s t i g a t o r used the i n t e r v i e w schedule w i t h each  The  family.  The i n t e r v i e w s were tape recorded and the content o f the tape r e c o r d i n g s was compared to notes w r i t t e n d u r i n g the i n t e r v i e w t o ensure t h a t the w r i t t e n data were complete and accurate.  A d d i t i o n a l notes o f o b s e r v a t i o n s were made  immediately a f t e r each i n t e r v i e w . Members o f the t h e s i s committee monitored random s e c t i o n s o f tape r e c o r d i n g s w i t h the i n t e r v i e w schedules to ensure v a l i d i t y o f the i n v e s t i g a t o r ' s judgements. O b j e c t i v i t y o f the p a r t i c i p a n t i n v e s t i g a t o r was f o s t e r e d  31. by the t h e s i s committee's m o n i t o r i n g o f tape r e c o r d i n g s and i n t e r v i e w schedules, the use o f a standard i n t e r v i e w schedule, and the i n v e s t i g a t o r ' s  self-scrutiny.  The i n t e r v i e w s ranged from 30 t o 6 0 minutes the average being approximately 50 minutes. spent w i t h each f a m i l y was about 75 minutes.  with  The t o t a l  time  A l l interviews  took p l a c e i n the f a m i l y home, 8 i n the evening and 2 i n the afternoon.  Only one f a m i l y member, an 11 year o l d , r e p o r t e d  f e e l i n g s e l f c o n s c i o u s with the tape r e c o r d e r once the i n t e r v i e w had ended.  DATA ANALYSIS  D e s c r i p t i v e a n a l y s i s was planned f o r the data s i n c e the purposes o f the study were to d e s c r i b e r e a c t i o n s and people and s e r v i c e s p e r c e i v e d t o be h e l p f u l .  The i n f o r m a t i o n  from the study would be added to e x i s t i n g knowledge.  Des-  c r i p t i v e a n a l y s i s was a l s o a p p r o p r i a t e s i n c e , without a random sample, the c o n c l u s i o n s o f the study r e f e r o n l y t o the study sample (Brink and Wood, 19 78). The abundant data from the s e m i - s t r u c t u r e d i n t e r views were summarized i n t o c a t e g o r i e s and d e s c r i p t i v e s t a t i s t i c s such as frequency d i s t r i b u t i o n s were used. approach  i s d e f i n e d by H o l s t i as content a n a l y s i s . Content a n a l y s i s i s any technique f o r making i n f e r e n c e s by o b j e c t i v 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 y i n g s p e c i f i e d c h a r a c t e r i s t i c s of messages C H o l s t i , 1969, p.14).  This  IV.  The reactions  first  purpose of  that occur  experienced t h e i r  services This  the  first  s t u d y was  families report  chapter w i l l  f i n d i n g s of  the  this  myocardial  families  to describe t o be  describe  in  age  from  children  or  full  to  58  from 2 to All  of  describe have  have been  The  second  what p e o p l e  sample and  and  this  report  period.  the  study.  included 40  weeks.  h e l p f u l during  the  shown i n T a b l e 1,  and  to  infarction  to three  DESCRIPTION OF  As  s t u d y was  i n f a m i l i e s when f a t h e r s who  home f r o m h o s p i t a l f o r one purpose of  RESULTS  the  w i v e s worked f u l l  the  SAMPLE  sample c o n s i s t e d  f a m i l y members.  years,  of  Fathers  m o t h e r s f r o m 34  to  10  ranged  55,  and  23. fathers  s a l a r y a t the  worked p a r t - t i m e  41  THE  (up  i n the  time o f the to three  time.  sample were on interview.  Two  d a y s a week), and  partial wives three  33. TABLE 1 Ages o f Household Family Members  Age i n Years Family  Father  Mother  Children  1  40  39  11, 17  2  40  34  2, 8  3  43  42  8, 12, 17, 21  4  46  44  15, 19, 21  5  44  41  6, 7, 9, 1 5  6  44  42  15  7  50  48  9  8  58  55  23  9  52  49  17, 23  10  43  39  8  a  cl  L i v e s i n household but was not a v a i l a b l e f o r i n t e r v i e w .  The number o f days f a t h e r s spent i n h o s p i t a l ranged from 8 t o 15.  The l e n g t h o f time between date o f d i s c h a r g e  and the f a m i l y i n t e r v i e w ranged from 8 t o 19 days 2) .  (See Table  34. TABLE 2 D u r a t i o n o f H o s p i t a l i z a t i o n and Number o f Days A f t e r Discharge That Interview Took P l a c e  Number o f Days Subject  Acute Care  Post Acute Care  After  Discharge  1  3  10  2  1  12  3  6  9  10  4  3  11  19  5  4  6  1  7  2  6  8  4  11  8  9  7  7  12  10  1  12  8  11 8  14  8  9  11  11  E i g h t f a t h e r s were being v i s i t e d by home care nurses twice a week a t the time o f the i n t e r v i e w .  One f a t h e r was  a t t e n d i n g a physiotherapy program.  FINDINGS  The  l i t e r a t u r e review suggested  that families  exper-  i e n c i n g i l l n e s s o f a f a m i l y member would m a n i f e s t r e a c t i o n s or changes i n f a m i l y r o l e s , p a t t e r n s o f i n t e r a c t i o n ,  affect,  35. and s t r u c t u r e .  Items 1 through  4 of the i n t e r v i e w schedule  were designed to gather these data. viewed  The 10 f a m i l i e s  inter-  d e s c r i b e d changes i n a l l 4 areas, as shown i n Table 3.  TABLE 3 Areas of Change Described by F a m i l i e s  Changes Family  Role  Interactions  Affect  Structure  1  X  X  X  X  2  X  X  X  X  3  X  X  X  X  4  X  X  X  X  5  X  X  X  X  6  X  X  X  X  7  X  X  X  X  8  X  X  X  X  9  X  X  X  X  10  X  X  X  X  Includes changes i n S o c i a l Contact and Family Membership but excludes reduced c o n t a c t w i t h f a t h e r ' s co-workers.  More d e t a i l s r e g a r d i n g these areas of change are d e s c r i b e d i n subsequent  s e c t i o n s of t h i s  chaper.  3  36. Changes i n Roles  (Item 1).  Table 4 shows the changes i n r o l e s i n descending order o f frequency.  Of the 10 f a m i l i e s , one r e p o r t e d  changes i n 4 r o l e s , 5 r e p o r t e d changes i n 3, one r e p o r t e d changes i n 2, and 3 r e p o r t e d changes i n one r o l e .  TABLE 4 Changes i n Roles D e s c r i b e d by F a m i l i e s  Family Roles Household chores(la)  X  2  3  4  X  X  X  5  X  F i n a n c i a l (If) management X Looking a f t e r f e e l i n g s (le) X  6  X  7  X  8  X  X  9  X  10  X  X  X  X  X  Disciplining c h i l d r e n (lb) X  X  Decision making (Id)  X  X  X  I n i t i a t i n g (lc) social activities  The r o l e s i n c l u d e d were those i d e n t i f i e d by Nye (1976) except f o r the sexual r o l e which was not e x p l o r e d by the i n v e s t i g a t o r All  nor mentioned by f a m i l y members.  10 f a m i l i e s experienced changes i n household  chores.  The changes were minimal  i n some f a m i l i e s :  Dad d i d n ' t do anything (before the h e a r t a t t a c k ) anyway. The o n l y change i s Mom d i d some gardening one day and the boys u s u a l l y do i t . One  mother s a i d : I'm doing l e s s because I'm spending time w i t h him, but i t Chousework) i s s t i l l my r e s p o n s i b i l i t y .  N e v e r t h e l e s s , a l l 10 f a m i l i e s r e p o r t e d t h a t wives and  chil-  dren were doing more work to reduce  around  the house.  f a t h e r ' s workload  However, 4 f a t h e r s assumed new  household  respon-  sibilities : (Father's) doing more around the house because he's home and i t ' s e a s i e r because he has l o t s of time. Dad i s h e l p i n g more w i t h d i s h e s and cooking because he's bored. One  f a t h e r assumed r e p o n s i b i l i t y f o r waking h i s w i f e  daughter  " . . . t o get her to s c h o o l on time.  sleeps i n . "  And  Usually  Mom  c h i l d r e n r e p o r t e d of t h e i r f a t h e r ,  "He  makes us snacks now  for after school."  F i v e f a m i l i e s r e p o r t e d changes i n the management of the f a m i l y .  financial  In a l l 5, the wives had i n c r e a s e d  t h e i r p a r t i c i p a t i o n from no involvement  to "... doing more l e g  work" and to "...going t o s t a r t paying the b i l l s and the  doing  banking." Four f a m i l i e s r e p o r t e d changes i n who  people's h u r t f e e l i n g s and concerns. had  and  l e s s time to p r o v i d e r e l i e f  One  looks a f t e r  mother s a i d  she  f o r her c h i l d r e n because  38. she had to be nurse-companion t o her husband.  In the other  3 f a m i l i e s , the c h i l d r e n r e p o r t e d going t o Dad l e s s  than  they used t o . The changes r e p o r t e d by 3 f a m i l i e s i n regards t o d i s c i p l i n i n g the c h i l d r e n were v a r i e d .  One mother r e p o r t e d :  I'm doing 100% now to ease the s t r e s s f o r Dad. One f a t h e r r e p o r t e d having i n c r e a s e d involvement w i t h the children: I can't put up w i t h the screaming and y e l l i n g . I'm f o r e v e r p u t t i n g the c h i l d r e n i n t h e i r rooms. And  the youngest  (15 years) o f 3 boys i n a f a m i l y r e p o r t e d :  Dad y e l l s l e s s now. I'm doing some y e l l i n g now - keeping (older b r o t h e r s ) i n l i n e . Only 2 f a m i l i e s r e p o r t e d a change i n d e c i s i o n making roles.  In one f a m i l y , the boys d e s c r i b e d the u s u a l f a m i l y  pattern: U s u a l l y we l e t Dad do the worrying and l e t Mom go h y s t e r i c a l . However, i n a r e c e n t episode when the youngest  c h i l d was  b e l i e v e d t o be l o s t , the o l d e s t boy "took over" and mother calmed the f a t h e r .  In the second f a m i l y , the w i f e got a  d r i v e r ' s l e a r n e r permit without d i s c u s s i n g i t w i t h her husband and t h i s was a change.  F a m i l i e s who hadn't exper-  ienced having t o make a major d e c i s i o n as y e t d i d not a n t i c i p a t e a change i n the d e c i s i o n making i n the f a m i l y . None o f the f a m i l i e s r e p o r t e d a change i n the r o l e of i n i t i a t i n g s o c i a l a c t i v i t i e s i n the f a m i l y .  39. Another r o l e t h a t emerged i n the i n t e r v i e w s was which 7 wives i d e n t i f i e d .  They r e p o r t e d a c t i v i t i e s and  one con-  cerns r e l a t e d to t h e i r p e r c e i v e d h e a l t h care worker responsibilities.  Some t y p i c a l comments made were: I t takes me a long time to shop because the d i e t has changed f o r everyone and I know I have t o get i t r i g h t . I'm nagging more...Don't do Leave t h a t alone.  this.  I'm t r y i n g to keep the k i d s q u i e t , stop them from a c t i n g up while he's home - but i t ' s hard. I f he's having aches or pains or problems, I s i n k r i g h t down. At f i r s t I babied him too much. Now I'm a f r a i d h e ' l l get i n t o the h a b i t o f l y i n g around. I t ' s hard t o know what to do. L a s t week I s l e p t l i g h t l y i n case he needed something. I f e e l more r e s p o n s i b i l e f o r making him f e e l O.K.  Changes i n P a t t e r n s of I n t e r a c t i o n s (Item 2) Table 5 shows t h a t of the 10 f a m i l i e s , 9 r e p o r t e d changes i n the amount of. t a l k i n g they were doing, and a l l 10 r e p o r t e d changes i n the kinds of t h i n g s they t a l k e d about. Data y i e l d e d from item 2c of the i n t e r v i e w schedule were redundant and omitted from the a n a l y s i s .  40. TABLE 5 Changes i n Patterns o f I n t e r a c t i o n Described by F a m i l i e s  Family Patterns of Interaction  1  2  3  4  5  6  7  8  9  10  + -  +  -  +  +  .  V  -  Amount of T a l k i n g (2a)  +  Topics (2b) X X X X X X X X X X Note. V i n d i c a t e s d i f f e r i n g responses from f a m i l y members In 8 f a m i l i e s d i s c u s s i o n of s t r e s s f u l t o p i c s was reduced.  Children required  quickly.  There was l e s s arguing  and parents and c h i l d r e n .  l e s s d i r e c t i o n and were obedient between s i b l i n g s ,  parents,  In 2 of these f a m i l i e s parents  avoided t a l k i n g about f i n a n c i a l matters and i n one f a m i l y , f i n a n c i a l matters were the one " s e r i o u s " t o p i c they d i d discuss.  Very f r e q u e n t l y ,  i t was the' wife who was e d i t i n g  s u b j e c t matter i n the f a m i l y : Don't bug f a t h e r w i t h t h a t r i g h t now o r he'11..get upset. Only one f a t h e r r e p o r t e d w i t h h o l d i n g  information  to control  stress l e v e l s of h i s wife. I don't t e l l her i f I'm not f e e l i n g well. I t r y t o hide i t . Six f a m i l i e s reported about h e a l t h - r e l a t e d t o p i c s :  t h a t they were t a l k i n g more d i e t , weight, e x e r c i s e .  Only  41. 4 f a m i l i e s r e p o r t e d t h a t the f a t h e r ' s heart a t t a c k per se had  been d i s c u s s e d i n the f a m i l y but t h i s q u e s t i o n was not  asked o f a l l f a m i l i e s . In one f a m i l y there was more j o k i n g and l o v i n g looks exchanged between the parents  than had been the case  before  the h e a r t a t t a c k , and one f a t h e r s a i d he was t a l k i n g about school w i t h h i s c h i l d r e n more than he had b e f o r e . In terms of the amount o f t a l k i n g being done, 5 f a m i l i e s r e p o r t e d they were t a l k i n g more than they had before the f a t h e r had had h i s heart a t t a c k and 3 f a m i l i e s r e p o r t e d t a l k i n g l e s s than they used t o .  In one f a m i l y 3  members s a i d the f a m i l y was t a l k i n g the same amount and one member s a i d the f a m i l y was t a l k i n g  less.  While d i s c u s s i n g changes i n p a t t e r n s o f i n t e r a c t i o n , 4 f a m i l i e s commented on new p e r s p e c t i v e s the h e a r t had brought about i n the f a m i l y : ...more aware t h a t l i f e i s r e a l l y short. Don't waste p r e c i o u s time arguing about s i l l y t h i n g s . I've done l o t s o f t h i n k i n g t h a t I've never done b e f o r e . . . t h i n g s are b e t t e r now, more l i k e they used t o be (more l o v i n g , time together). (Husband) I used to be s t r o n g , s t e a d f a s t , a rock. I feel closer and more i n t i m a t e towards (my w i f e ) . I'm much more conscious o f how much I need her. (Wife) I t ' s been the same f o r me. I a p p r e c i a t e him a l o t more...He's more important t o me than I thought. The f a m i l y i s n ' t q u i t e as permanent as I thought.  attack  42. Perhaps we were drawn c l o s e r t o g e t h e r when Dad had t h i s h e a r t a t t a c k . Makes you f o r g e t the l i t t l e t h i n g s and we t r y t o get around i t r a t h e r than get on each o t h e r ' s nerves. We don't take anyone f o r granted anymore.  Changes i n A f f e c t  (Item 3)  Table 6 shows the changes i n a f f e c t i n descending order o f frequency. 5 areas of a f f e c t ,  S i x f a m i l i e s r e p o r t e d changes i n a l l 3 f a m i l i e s r e p o r t e d changes i n 4- areas,  and one f a m i l y i n one area of a f f e c t . "impatience",  "hopefulness", " f e a r f u l n e s s " , 9 f a m i l i e s  r e p o r t e d changes. "nervousness",  With the a f f e c t s o f  With the a f f e c t s o f "happiness" and  8 f a m i l i e s r e p o r t e d changes.  TABLE 6 Changes i n A f f e c t D e s c r i b e d by F a m i l i e s  Family Affect  1  2  (3b) -  V  V  V  V  Hopefulness (3c)  +  V  V  V  +  +  Fearfulness (3e)  +  +  +  V  +  + V  Impatience  Happiness  4  (3a) V  Nervousness (3d) Note.  3  V  +  +  5  6  7  8  9  V  .  10  V  v  V  +  +  v  V  V  +  -  V  V  V  +  V  V  +  V I n d i c a t e s d i f f e r i n g responses  V  from f a m i l y members.  43. In 7 o f the 9 f a m i l i e s e x p e r i e n c i n g changes i n "impatience,"  f a m i l y members r e p o r t e d t r y i n g t o be n i c e r ,  more r e l a x e d and t o l e r a n t Of one another.  As one c h i l d -  s i b l i n g put i t : Our f a m i l y i s more subdued, l e s s reactive, less boisterous. In one f a m i l y the 4 c h i l d r e n r e p o r t e d t h a t t h i s more p a t i e n t behavior occurs, impatience  "...only when Dad's around."  with d i e t and a c t i v i t y r e s t r i c t i o n s was r e p o r t e d  by 4 o f the 7 f a t h e r s . impatience  Increased  In the 2 f a m i l i e s where l e s s  was r e p o r t e d o v e r a l l , some f a m i l y members  i n c r e a s e d impatience  w i t h the c h i l d r e n .  reported  In one o f these  f a m i l i e s , the f a t h e r thought he was " b i t c h i e r " but the mother thought he was the same. son r e p o r t e d i n c r e a s e d impatience t i o n o f d i e t and a c t i v i t y  In one f a m i l y , the o l d e s t with h i s f a t h e r ' s i n f r a c -  limits.  Of the 9 f a m i l i e s r e p o r t i n g changes i n ^ h o p e f u l n e s s i " 5 f a m i l i e s s a i d they were f e e l i n g more h o p e f u l . remaining  In the  4 f a m i l i e s , there were d i f f e r e n c e s expressed.  Fathers expressed  hopefulness  w h i l e mothers and c h i l d r e n  were l e s s h o p e f u l . (Father) I'm more h o p e f u l . I feel s t r o n g e r every day. (Mother) I'm s t i l l i n s e c u r e , e s p e c i a l l y i f he's not f e e l i n g w e l l . (Father) At the end, I ' l l be back to normal. (Mother, C h i l d r e n ) We're s t i l l nervous about i t .  (Father) When I was i n h o s p i t a l I thought, "What w i l l happen next time?" But now I'm j u s t t h i n k i n g about g e t t i n g b e t t e r . (Mother) I t happened. Things can't be the same. (Son) Expect the unexpected but don't dwell on i t . (Father) Make the best of i t . The worst i s behind us. (Mother) I t might happen again. I guess t h a t f e e l i n g w i l l wear o f f . Family members i n 9 f a m i l i e s s a i d the f a m i l y was more f e a r f u l than i t had been b e f o r e the h e a r t a t t a c k . father  One  said: No one can t e l l you when i t ' s going to happen a g a i n . . . i f i t ' s going to happen.  In 4 f a m i l i e s where mothers expressed  increased fearfulness,  d i f f e r i n g views were presented by other f a m i l y members. One  son expressed  the view o f f a t h e r and two  Think of i t as a one won't happen again.  of the  shot d e a l .  children  It  But the t h i r d son i n the f a m i l y s a i d : Sometimes you f o r g e t he had one (heart a t t a c k ) . E v e r y t h i n g ' s f i n e and dandy. Then I remember, something c o u l d happen. In response  to h i s wife saying she was  more f e a r f u l , a hus-  band responded: I wouldn't say I'm more a f r a i d . A l l I can say i s I'm more aware of what's going on around me. E a r l i e r i n the i n t e r v i e w , t h i s same f a t h e r had activity: The p h y s i c a l s t r e n g t h might be there but I'm a f r a i d to use i t .  s a i d about  Another f a t h e r s a i d : I disagree. There's no change (in f e a r f u l n e s s ) . Another f a t h e r s a i d : I know they're (wife and son) more f e a r f u l but I couldri't say f o r myself. I'd have t o t h i n k on i t .  :  Of the 8 f a m i l i e s r e p o r t i n g a change i n happiness 2 f a m i l i e s r e p o r t e d being l e s s happy and 2 were- more so. In 4 f a m i l i e s there were v a r y i n g responses from f a m i l y members. Wives and c h i l d r e n r e p o r t e d more happiness because, "He's here with us,"and p o s i t i v e changes i n f a m i l y r e l a t i o n s h i p s and h e a l t h h a b i t s had taken p l a c e . w i f e expressed  In these  her ambivalence about  f a m i l i e s one  happiness:  I t ' s hard t o g e n e r a l i z e u n t i l the d o c t o r says he's O.K. Two f a t h e r s . s a i d there hadn't been any change i n f a m i l y happ i n e s s and one f a t h e r s a i d the f a m i l y was l e s s happy because of the r e s t r i c t i o n s on everyone.  In t h i s l a s t f a m i l y , the  2 c h i l d r e n s a i d there was no change i n happiness. Three f a m i l i e s r e p o r t e d an i n c r e a s e i n nervousness and  5 f a m i l i e s r e p o r t e d v a r y i n g responses.  In these 5  f a m i l i e s , the mothers r e p o r t e d i n c r e a s e d nervousness due t o having  t o manage the c h i l d r e n ' s problems alone,  reduced  f i n a n c e s , f a t h e r ' s h e a l t h , and..other new r e s p o n s i b i l i t i e s . As one woman s a i d : There's more pressure and s t r a i n to do t h i n g s . And there are deadlines.  In these  5 f a m i l i e s , 2 f a t h e r s and t h e i r c h i l d r e n r e p o r t e d  no change i n nervousness, 2 f a t h e r s r e p o r t e d l e s s nervousness, and one son s a i d , "There's l e s s t e n s i o n because i t goes away a l o t f a s t e r now." Of 43 responses i n regards  t o changes i n a f f e c t , 24  were v a r i e d responses where f a m i l y members s t a t e d d i f f e r e n t o p i n i o n s on more, l e s s , o r no change. There were other expressions to adjustment t o the i l l n e s s .  of a f f e c t i n r e l a t i o n  One f a t h e r c l e a r l y  expressed  a sense o f l o s s : You have t o g i v e up e v e r y t h i n g (food, c i g a r e t t e s , a c t i v i t y ) a l l a t once. I've had t o g i v e up a helluva l o t ' And  another f a t h e r expressed  anger towards h i m s e l f :  I'm r e a l l y mad. I should have done i t (stop smoking, d i e t ) e a r l i e r . Only one m a r i t a l p a i r s a i d the husband's i n c r e a s e d dependence on the wife was "...something new f o r both o f us ...not  frustrating,  just  inconvenient."  Some c h i l d r e n were demonstrating marked changes i n behavior.  In one f a m i l y , the 15 year o l d son d i d not come  home f o r the evening  interview.  H i s parents  d e l i b e r a t e l y a v o i d i n g the d i s c u s s i o n .  thought he was  They d e s c r i b e d him as  ...changed completely. He used to run around a l o t (before the h e a r t attack). Something's b o t h e r i n g him. He's much q u i e t e r , s e t t l e d down. The s c h o o l c o u n s e l l o r c a l l e d but (the son) won't c o n f i d e i n him. In another f a m i l y where the f a t h e r and daughter r e p o r t e d l y never got along, the daughter f e l t unable t o argue with her  f a t h e r about keeping a p a r t time job t h a t was very to her.  U n c h a r a c t e r i s t i c a l l y , she complied  job without  argument.  important  and gave up her  In another f a m i l y , the daughter  planned t o stop seeing her b o y f r i e n d because her f a t h e r had disapproved  o f him.  She had been d a t i n g the boy f o r  s e v e r a l months and her f a t h e r had not mentioned i t s i n c e coming home from h o s p i t a l .  The daughter thought she should  do i t " . . . t o make Dad happy." Statements o f shock and d i s b e l i e f were expressed by 4 f a t h e r s d u r i n g i n t e r v i e w s t h a t took p l a c e on the e i g h t h , t e n t h , e l e v e n t h , and f o u r t e e n t h days post  discharge:  Why me? I had only one on the risk scale - heredity. The b i g g e s t t h i n g was the shock. I never g e t s i c k . I never miss work. Nothing c o u l d happen t o me! I have a mental b l o c k . I'm only 44 years o l d . I shouldn't be here. I've never been s i c k . I still can't b e l i e v e i t . . . I ' v e always been so h e a l t h y . Of these  4 f a t h e r s , 2 had experienced  f i r s t week home from h o s p i t a l .  difficulties  One f a t h e r r e p o r t e d :  I had a s o r t o f f l u f o r f o u r days: nausea and vomiting, headache, shakes, and c r y i n g j a g s . I still have an eye inflammation-and a headache. One  i n the  son r e p o r t e d and a l l members agreed: In the f i r s t few days Dad was p i c k y , edgy, almost e x p l o s i v e . Now he's a l o t quieter.  48. Changes i n Family Contact  (Item 4),  The parameter of f a m i l y s t r u c t u r e has The  aspects.  f i r s t i s f a m i l y c o n t a c t with o u t s i d e groups and the  i s f a m i l y membership. one  two  Table 7 shows t h a t of the 10  second  families,  f a m i l y experienced changes i n the amount of c o n t a c t they  had w i t h 6 groups, w i t h 2^groups. cending order of  5 f a m i l i e s w i t h 4 groups,  and ;4 f a m i l i e s  Table 7 shows the changes i n c o n t a c t i n desfrequency.  TABLE 7 Changes i n Family Contact w i t h Groups  Family Groups  1  12  3  4  5  6  7  +  +  -  +  -  +  + +  +  +  +  +  +  +  . - . +  Family Members (outside household) ( 4 a i i ) +  +  NA  NA  +  .  .  Neighbors  -  .  +  +  .  .  .  .  .  .  .  .  .  .  Friends  (4ai)  Community Agency People ( 4 a v i i )  Clergy  (4aiii) +  (4avi)  .  People from school (4av) People from work (excl. father) (4aiv) Note.  .  NA  NA  .  NA  .  .  -  +  NA  .  8  10  +  +  .  -  9  +  + .  + +  .  .  .  .  NA  NA i n d i c a t e s not a p p l i c a b l e . F a m i l i e s d i d not have extended f a m i l y i n Canada or f a m i l y members, other than f a t h e r s , who worked.  49. By group, 10 f a m i l i e s experienced changes w i t h f r i e n d s , 8 w i t h community agency people, 6 o f 8 f a m i l i e s w i t h extended  f a m i l y members experienced changes, 5 exper-  i e n c e d changes w i t h neighbors, 2 w i t h c l e r g y , one w i t h people from s c h o o l , and 2 o f 5 f a m i l i e s w i t h working members other than f a t h e r s experienced changes. All  10 f a m i l i e s experienced changes i n the amount o f  c o n t a c t they had with f r i e n d s . seen more.  In 7 cases, f r i e n d s had been  In 2 o f the 3 f a m i l i e s where f r i e n d s had been  seen l e s s , the f a m i l i e s remarked t h a t f r i e n d s seem t o be " h e s i t a t i n g - a f r a i d t o t i r e him ( f a t h e r ! I guess." E i g h t f a m i l i e s had c o n t a c t w i t h home care nurses. Of these 8, 2 had c o n t a c t w i t h a d i e t i c i a n , c o n t a c t with a p h y s i o t h e r a p i s t as w e l l . been seen by 2 o f these  and one had  Bank managers had  families.  Two f a m i l i e s ' d i d not have other r e l a t i v e s i n Canada. Of the 8 remaining, extended  6 f a m i l i e s had i n c r e a s e d c o n t a c t w i t h  f a m i l y members and one f a m i l y s a i d the h e a r t a t t a c k  had brought  the whole f a m i l y " c l o s e r . "  H a l f o f the f a m i l i e s r e p o r t e d no change i n the amount of c o n t a c t they had w i t h neighbors. way."  "We never saw them any-  "I doubt t h a t they even know Dad had a h e a r t a t t a c k . "  Of the 5 f a m i l i e s r e p o r t i n g a change i n c o n t a c t , 2 s a i d  they  d i d n ' t know the neighbors but the neighbors had asked how the f a t h e r was f e e l i n g . Similarly,  5 f a m i l i e s r e p o r t i n g no change i n the  amount o f c o n t a c t with c l e r g y remarked t h a t they d i d n ' t have  50. any c o n t a c t anyway.  Two  families reported less contact  because of i n a b i l i t y to get to church s e r v i c e s . continued to a t t e n d church as b e f o r e .  Two  One  wife  f a m i l i e s reported  no change and made no f u r t h e r comment. Only one  s c h o o l c o u n s e l l o r c o n t a c t e d the parents  about t h e i r son's behavior and p o s s i b l e adjustment  to the  father's i l l n e s s .  The most f r e q u e n t comment made by th_e  f a m i l y i n response  to the q u e s t i o n was,  they  "No  change.  I doubt  (teachers, c o u n s e l l o r s ) even know (about the h e a r t  attack)." Of the 5 f a m i l i e s where someone o t h e r than the f a t h e r was  employed, one member r e p o r t e d having l e s s c o n t a c t w i t h  people from work and t h i s was the s h i f t she worked.  r e l a t e d to her having changed  Another member took a leave of absence  from work to be home w i t h her husband. In r e l a t i o n t o the amount f a m i l i e s were going out of the home, (Item 4b), 6 f a m i l i e s r e p o r t e d they were going out less.  In 3 f a m i l i e s , t h i s was  due  to f a t h e r ' s l i m i t e d  p h y s i c a l a c t i v i t y and mother's i n a b i l i t y to. d r i v e the f a m i l y car.  With 4 f a m i l i e s , mothers and c h i l d r e n r e p o r t e d " s t i c k i n g  c l o s e r to home."  In one  f a m i l y , f a t h e r s and some c h i l d r e n  were going out l e s s while mothers and some c h i l d r e n were going out the same amount.  In one  out l e s s and t h e i r c h i l d was b e f o r e the h e a r t a t t a c k .  f a m i l y parents were going  going out the same amount as  T h i s q u e s t i o n prompted 4 f a m i l i e s  to say they planned t o spend much more time together once f a t h e r was  well.  51. Only one membership  f a m i l y experienced a change i n f a m i l y  (Item 4c).  The  two  c h i l d r e n had  spent a  few  days w i t h r e l a t i v e s " . . . t o g i v e the k i d s a break."  Family P e r c e p t i o n s  of Help  (Item 5)  Table 8 shows the f a m i l i e s ' r e p o r t s of the amount of help they r e c e i v e d s i n c e the f a t h e r was  discharged  from  hospital. Table 9 shows which person(s) f a m i l i e s p e r c e i v e d o f f e r i n g the most help to the f a m i l y s i n c e f a t h e r had discharged  as  been  from h o s p i t a l . TABLE 9  Person(s) O f f e r i n g the Most Help to  Families  Family Person(s)  1  Friends  X.  (5ai)  Relatives  (5aii)  2  X NA  NA  X  Nurses  (5aiv)  X  X  (5av)  •  X  X  6  7  8  9  10  X  ..  X  X  •  X  •  •  X  X  • •  •  •  X  .  x  NA i n d i c a t e s not a p p l i c a b l e . were not i n Canada. a  5  (5avi)  Others ( 5 a v i i ) Note.  X •  (5aiii)  Community  4  •  Clergy  Doctors  3  F a m i l i e s 1-6, Dietician.  9, 10 had  b  .  Extended f a m i l y members  home care nurses twice a week.  TABLE 8 Amount o f Help Received by F a m i l i e s  Family  No Help  Very L i t t l e Help  1  •••  2  •••  X  3  « * •  •••  • • •  (4)  X  X  5  •••  ••*  (6)  •• •  Quite A B i t o f Help  X  • • •  3  •••  X  (9)  . . •  ...  10  •••  A Great Deal o f Help  ••• ••*  •••  ••• •••  • • •  •••  X •••  X  •••  • • •  X  X  X  • . •  •••  . . .  7  a  Some Help  •••  • • •  X  ... ...  ••• X X  F a m i l i e s i n parentheses i n d i c a t e d i f f e r i n g responses from family members.  53. Of most help to f a m i l i e s d u r i n g t h i s p e r i o d 5b,  5c,  5d)  was  i n f o r m a t i o n and  r e a s s u r e f a m i l y members. mation was  been h e l p f u l  Of  Seven f a m i l i e s s a i d g e t t i n g  i f the  these 7,  c o n f l i c t i n g and  calming e f f e c t was  cheerful,  l i s t e d by  was  the been l e s s  5 f a m i l i e s as being h e l p f u l .  r e p o r t e d by  been o f f e r e d  3 f a m i l i e s as h e l p f u l .  i d e n t i f i e d by  Specific services  i t was  helpful  and  was  Financial  2 f a m i l i e s as being h e l p f u l .  such as t r a n s p o r t a t i o n ,  meals were mentioned by  babysitting,  f a m i l y ' s independence. Help's been o f f e r e d never accepted.  but  We d i d n ' t need i t . self-sufficient.  We're p r e t t y  We don't ask f o r h e l p . independent.  and  3 families.  Four f a m i l i e s made statements i n d i c a t i n g and the  to  support mothers.  knowing that help had  a v a i l a b l e was  from  a good l i s t e n e r , a  s p e c i f i c a l l y i d e n t i f i e d that  Just  s a i d i t would have  g e n e r a l p r a c t i t i o n e r had  have someone to r e a s s u r e and  providing  infor-  more understandable.  Being r e a s s u r i n g ,  families  3 families  i n f o r m a t i o n they r e c e i v e d  nurses, c a r d i o l o g i s t , and  assistance  and  the most h e l p f u l or would have been the most  helpful service.  Two  someone to l i s t e n  (Items  I've  We're  valuing  V. ANALYSIS  All in  10 f a m i l i e s d e s c r i b e d changes t h a t had o c c u r r e d  the areas o f f a m i l y r o l e s , i n t e r a c t i o n s , a f f e c t and s t r u c -  ture s i n c e the f a t h e r had r e t u r n e d home from h o s p i t a l .  In  terms o f the help they p e r c e i v e d r e c e i v i n g d u r i n g t h i s time, one  f a m i l y r e p o r t e d "no h e l p , " 2 f a m i l i e s r e p o r t e d  "very  l i t t l e help," one r e p o r t e d "some h e l p , " and 3 r e p o r t e d "a great deal of help."  A d i f f e r e n c e o f o p i n i o n among f a m i l y  members o c c u r r e d i n 3 f a m i l i e s r e p o r t i n g "no help - very little and  help," " q u i t e a b i t o f help - a g r e a t d e a l o f h e l p , "  "some help - a g r e a t d e a l o f h e l p . "  F r i e n d s and home  care nurses were most f r e q u e n t l y seen as the persons o f f e r i n g the most h e l p t o the f a m i l i e s . reassurance  R e c e i v i n g i n f o r m a t i o n and  were seen as h e l p f u l d u r i n g t h i s time.  T h i s chapter c o n t a i n s the d i s c u s s i o n o f these f i n d i n g s and t h e i r r e l a t i o n s h i p t o the conceptual and e x i s t i n g knowledge.  The chapter concludes  t i o n s and recommendations f o r n u r s i n g p r a c t i c e , and  research.  framework  with i m p l i c a education,  55. INTERPRETATION OF FINDINGS  T h i s study was  of an e x p l o r a t o r y  nature u s i n g  convenience sample of 10 myocardial i n f a r c t i o n and  their families.  patients  Hence, the f i n d i n g s are not  able beyond the f a m i l i e s i n the sample.  generalize-  Considering  these  l i m i t a t i o n s , d i s c u s s i o n of the p o s s i b l e meanings of f i n d i n g s w i l l be organized  as a f a m i l y  the  under the headings f a m i l y  family reactions, family perceptions  a  of h e l p , and  focus,  illness  crisis.  Family Focus Many authors i n n u r s i n g and medicine suggest t h a t a f a m i l y e v a l u a t i o n should  be an i n t e g r a l p a r t of any  patient  assessment  L i v s e y , 1972;  Archbold,  1976;  (Olsen,  Eichel,  f a m i l y focus  1970;  1978).  The  MacVicar and  f i n d i n g s of t h i s study support a  i n h e a l t h care.  F a m i l i e s had  indeed experienced  changes i n response to the f a t h e r ' s h e a r t a t t a c k .  The  f a m i l i e s were a l s o very a c t i v e l y i n v o l v e d i n f a t h e r ' s convalescence.  The  (19 78)  concur.  advice  and  f i n d i n g s of Mayou, F o s t e r , They advise  and  Williamson  t h a t the whole f a m i l y be  given  help throughout the convalescence of the myocar-  d i a l infarction patient. I t i s to be expected t h a t most f a m i l i e s focus on ill  member, expending time and  But  i t seems c l e a r t h a t other  support d u r i n g  energy i n t h a t  direction.  f a m i l y members may  t h i s d i f f i c u l t time as w e l l .  the  need e x t r a  In t h i s  study,  mothers appear t o be very f a t h e r and the pressures wives  s t r e s s e d w i t h concerns about the o f added r e s p o n s i b i l i t i e s .  (38%) i n the study conducted by S k e l t o n  and Dominian  (1973) had a l s o found the p e r i o d a f t e r d i s c h a r g e ful.  Consider the son who was r e p o r t e d l y  Many  very s t r e s s -  demonstrating  marked behavior changes and d i d not p a r t i c i p a t e i n the interview.  What o f the daughter unable t o vent her f e e l i n g s  of anger towards her f a t h e r and her f e e l i n g s o f l o s s about the p a r t time job?  In the near o r d i s t a n t f u t u r e , these  members' r e a c t i o n s may i n f l u e n c e t h e i r h e a l t h , the c u r r e n t p a t i e n t ' s h e a l t h , and the h e a l t h o f the f a m i l y A concern o f t e n accompanying a p r o p o s a l  system. f o r a whole  f a m i l y system study i s , "Family members won't be able t o express themselves with everyone present." engage i n a f a m i l y i n t e r v i e w  Willingness to  i s i n d i c a t e d by the f a c t  that  o n l y one p a t i e n t d e c l i n e d when approached by the i n v e s tigator.  F a m i l i e s w i l l i n g t o p a r t i c i p a t e i n such a study  probably have the a b i l i t y t o express t h e i r thoughts and f e e l i n g s t o some extent. opportunity family.  They may a l s o be seeking  because they p e r c e i v e  These m o t i v a t i o n s  i n interviewing  study.  i t may be h e l p f u l t o the  t o p a r t i c i p a t e are s i m i l a r to  those f o r i n d i v i d u a l s consenting i n d i v i d u a l focused  this  t o p a r t i c i p a t e i n an  Further,  the l i m i t a t i o n s i n h e r e n t  f a m i l i e s are not d i s s i m i l a r to those o f  i n t e r v i e w i n g i n d i v i d u a l respondents.  In both, the s u b j e c t i v e  data are f a l l i b l e but continue t o be important sources o f  57. i n f o r m a t i o n . . The most t e l l i n g argument f o r the f a m i l y members' a b i l i t y t o express themselves i n a f a m i l y i n t e r view i s the r i c h n e s s o f the data i n the p r e v i o u s  chapter.  Although w i l l i n g t o p a r t i c i p a t e i n a f a m i l y i n t e r view, some f a m i l i e s needed a c a t a l y s t t o be a b l e t o t a l k together as a f a m i l y .  Four f a m i l i e s had d i s c u s s e d the  h e a r t a t t a c k and subsequent events o n l y when v i s i t o r s had asked about i t .  I t was through  such v i s i t s t h a t many f a m i l y  members gained t h i s i n f o r m a t i o n .  Yokes (1973) suggests  that  i n t e r p e r s o n a l r e l a t i o n s h i p s may s u f f e r i f f a m i l y members do not t a l k w i t h the p a t i e n t about the h e a r t a t t a c k .  The data  c o l l e c t i o n i n t e r v i e w was a l s o h e l p f u l t o some f a m i l i e s . Only one w i f e had expressed  s u r p r i s e t h a t the e n t i r e  view would take p l a c e w i t h a l l f a m i l y members.  inter-  She s a i d she  wouldn't be a b l e t o d i s c u s s her annoyance w i t h her husband f o r "maybe g e t t i n g too used t o doing n o t h i n g . "  She admitted  being unable  t o express annoyance towards him even when he  wasn't i l l .  Her d i f f i c u l t y was manifested  o v e r p r o t e c t i v e n e s s and withdrawal  i n her a l t e r n a t i n g  from her husband.  a l s o nervous about asking him how he was f e e l i n g .  She was During  the i n t e r v i e w the husband spoke o f h i s f a t i g u e , h i s f e a r f u l n e s s , and d e t e r m i n a t i o n t o comply w i t h the d o c t o r ' s orders t o "take i t easy."  Both w i f e and daughter asked him  q u e s t i o n s and a l l three t a l k e d about the degrees o f overp r o t e c t i v e n e s s demonstrated i n the past two weeks. s a i d l a t e r o f the i n t e r v i e w , " I t was good. i t once we got i n t o i t . "  I really  The w i f e enjoyed  Given the o p p o r t u n i t y , f a m i l y  58. members can p a r t i c i p a t e i n a f a m i l y d i s c u s s i o n , e x p r e s s i n g themselves and c l a r i f y i n g  perceptions.  C h i l d r e n were a c t i v e and v a l u a b l e p a r t i c i p a n t s . Parents  seemed t o welcome the o p p o r t u n i t y t o hear t h e i r  c h i l d r e n d i s c u s s t h e i r o b s e r v a t i o n s and r e a c t i o n s .  In  response t o the opening q u e s t i o n , "What changes have you n o t i c e d i n the f a m i l y i n the past two weeks?," i t was a 6 year o l d who s a i d , Mom c r i e s a l o t .  "Dad can't smoke and e a t much anymore.  And we don't have much money."  To t h i n k  of c h i l d r e n as unaware and unable to r e p o r t Is a gross underestimation  of t h e i r c a p a b i l i t i e s .  The a t t e n t i v e n e s s  and p a r t i c i p a t i o n o f a l l f a m i l y members i n d i c a t e the potent i a l need f o r f a m i l i e s t o have o p p o r t u n i t i e s t o d i s c u s s t h e i r changed s i t u a t i o n  together.  Ther>e were many o p p o r t u n i t i e s t o v a l i d a t e i n t e r v i e w content with d i r e c t o b s e r v a t i o n s .  A f a t h e r who had r e p o r t e d  f e e l i n g impatient with h i s c h i l d r e n l i f t e d and c a r r i e d h i s 2 year o l d daughter t o her room because she had changed her p o s i t i o n i n the s i t t i n g arrangement.  Another f a m i l y w i t h  3 sons had r e p o r t e d t h a t a l l f a m i l y members were h e l p i n g around the house.  The house was immaculate, the d i e t  cookies  served had been baked by the 15 year o l d , and the o l d e s t son t a l k e d from the k i t c h e n while making lunch f o r h i s evening job. Family members do not always agree.  Disagreement  can range from h e a l t h y i n d i v i d u a t i o n o f members to pathological conflict  ( S a t i r , 1967).  Differences of opinion are  o f t e n based on d i f f e r e n t p e r c e p t i o n s .  These p e r c e p t i o n s  are i n f l u e n c e d by a v a i l a b l e i n f o r m a t i o n , i n d i v i d u a l needs, and p r e v i o u s e x p e r i e n c e s .  This was the s i t u a t i o n when  f a m i l y members were asked  t o i d e n t i f y changes i n p a t t e r n s  of i n t e r a c t i o n and a f f e c t and asked t o score the amount o f help they had r e c e i v e d . o p i n i o n was normalized interview.  During  The occurrence o f d i f f e r e n c e s o f i n the opening  comments o f the  the i n t e r v i e w , d i f f e r e n c e s o f o p i n i o n  were e x p l o r e d and i n d i v i d u a l s were asked views.  to c l a r i f y  their  Family members e i t h e r agreed o r d i s a g r e e d w i t h views  presented and the i n v e s t i g a t o r continued the i n t e r v i e w . O p p o r t u n i t i e s t o g a i n new p e r s p e c t i v e s were u t i l i z e d but each member's view was accepted.  Family  Reactions Changes i n Roles.  change as a response defined i n t h i s  A l l 10 f a m i l i e s experienced  role  t o i l l n e s s o f a f a m i l y member as  study.  The major impetus f o r the adjustment i n r o l e s was the f a m i l y ' s attempts t o l i m i t p h y s i c a l a c t i v i t y and c o n t r o l l e v e l s o f s t r e s s f o r the f a t h e r s . r o l e changes f o r household  T h i s was expressed  i n the  chores, f i n a n c i a l management,  l o o k i n g a f t e r f e e l i n g s , d i s c i p l i n i n g c h i l d r e n , and d e c i s i o n making.  A l l f a m i l y members p e r c e i v e d these l i m i t a t i o n s as  necessary  f o r keeping  f a t h e r w e l l and a l l members were  i n v o l v e d t o some extent. Another m o t i v a t i n g f a c t o r c o u l d be the wives'  60. r e a l i z a t i o n o f t h e i r dependence on a husband who might not always be t h e r e .  One woman who was becoming more i n v o l v e d  i n the f a m i l y ' s f i n a n c i a l management  said:  When I was s i n g l e I was r e a l l y independent... took care o f b i l l s , insurance, a l l that s t u f f . Ever s i n c e we've been m a r r i e d I've l e f t a l l t h a t t o him. E v e r y t h i n g , e v e r y t h i n g i n my l i f e , d e c i s i o n s , I've j u s t l e t him take care o f e v e r y t h i n g i n my l i f e . I realize I have t o stand on my own two f e e t . I t ' s r e a l l y hard...a b i g change. I have no c o n f i d e n c e l e f t . Another woman who hadn't worked f o r 22 years  said:  I wish I was working now...for the money and the independence. T h i s attempt  t o reduce dependence on the husband prompted  t h i s woman t o g e t her d r i v e r ' s l e a r n e r permit. I'm l e a r n i n g t o d r i v e and t h a t ' s . a b i g step f o r me...We had t a l k e d about i t b e f o r e b u t nothing was f i r m . . . I kept p u t t i n g i t o f f u n t i l now. The f a t h e r ' s s i c k r o l e i n i t s e l f  n e c e s s i t a t e d the  development o f a corresponding h e a l t h - c a r e worker r o l e i n families. sibility  Most wives and many c h i l d r e n shared t h i s  respon-  f o r monitoring the d i e t , o b s e r v i n g f a t h e r ' s con-  d i t i o n , reminding him t o do and not do t h i n g s , c r e a t i n g a t h e r a p e u t i c environment. None o f the f a m i l i e s r e p o r t e d a change i n the r o l e of  initiating  social activities.  In f a c t , most f a m i l i e s  were e x p e r i e n c i n g a marked decrease and the resumption  i n social  activities  o f same was seen as something f o r the  future.  One  man  s a i d he c o u l d n ' t answer the  because he d i d n ' t in  the  family.  done i n the lar  know how  He  was  future.  s o c i a l a c t i v i t i e s were i n i t i a t e d  unable to a n t i c i p a t e  His  do  how  i t would  l a c k of awareness of t h i s  s a i d she  together as a f a m i l y ,  i n i t i a t e s the  a c t i v i t i e s and  be  particu-  p a t t e r n of i n t e r a c t i o n i s c o n t r a s t e d w i t h h i s son  f e l t they d i d very l i t t l e who  question  and  who  h i s wife  would continue  to  so. Although some couples spoke of f e e l i n g c l o s e r to  another, none of the activity. of p o s s i b l e  The  not  q u e s t i o n had  sexual  been p u r p o s e l y omitted because  p a r e n t a l d i s c o m f o r t with c h i l d r e n p r e s e n t .  also possible was  f a m i l i e s mentioned l i m i t a t i o n s on  that,  one  like social activities,  It i s  sexual a c t i v i t y  a p r i o r i t y f o r these couples d u r i n g the  time of  this  study. The  v a r i a n c e i n the number and  degree of r o l e changes  among f a m i l i e s i s most l i k e l y r e l a t e d t o the v a r i a n c e between pre  and  post i l l n e s s r o l e s i n each f a m i l y .  only one. r o l e change was one  ities.  He  father's  involvement and  r o l e was few  appeared somewhat p a s s i v e and  to h i s w i f e who  was  hence i l l n e s s of the imal changes  (Wu,  role  1973).  p r e - i l l n e s s r o l e was  responsibil-  i n t h i s f a m i l y may  In another f a m i l y ,  l a r g e l y that of being an  contrast  interview.  s i m i l a r to those of a s i c k  father  In  characterized  compliant i n  very dominant d u r i n g the  These c h a r a c t e r i s t i c s are  families  r e p o r t e d - household chores.  of these 3 f a m i l i e s , the  by r e l a t i v e l y l i t t l e  In 3  role  produce minthe  father's  ample wage  62. earner and having the ness had  " f i n a l word" i n major d e c i s i o n s .  a f f e c t e d n e i t h e r of these r o l e s thus f a r and  Illthe  f a m i l y d i d not a n t i c i p a t e changes. The  t h i r d f a m i l y r e p o r t i n g o n l y one  r o l e change  p o i n t s out the i n f l u e n c e of/ the f a m i l y ' s r e a d i n e s s a b i l i t y to r e a l i s t i c a l l y acknowledge the f a t h e r ' s - i t s nature, extent,  prognosis,  consequence.  The  and disability father  frequently said: I've had a h e a r t a t t a c k but there's no d r a s t i c change i n our l i v e s . T h i s f a m i l y ' s r e p o r t contained g e s t i n g t h e i r own tory.  The  perceptions  s e v e r a l c o n t r a d i c t i o n s sugwere confused and  f a t h e r denied being more f e a r f u l but  t a k i n g n i t r o g l y c e r i n e on s e v e r a l occasions He  drove the c a r a f t e r being  to do so.  He  s a i d he was  t o l d i t was  reported  f o r chest  pain.  not s a f e f o r  him  on h o l i d a y time not  he would have been home anyway.  contradic-  s i c k time so  Maintaining p r e - i l l n e s s  f u n c t i o n s as much as p o s s i b l e seemed important i n t h i s f a m i l y and  the i l l n e s s - i m p o s e d  changes were minimized i n  t h e i r r e p o r t more than i n f a c t . Changes i n P a t t e r n s patterns  of I n t e r a c t i o n .  of i n t e r a c t i o n o c c u r r e d  major f a c t o r again  Alterations in  i n a l l 10 f a m i l i e s .  The  appeared to be the f a m i l y ' s attempts to  c o n t r o l the l e v e l s o f s t r e s s experienced by the f a t h e r . one  mother s a i d : I know s t r e s s can b r i n g on a heart attack. I b i t e my tongue and t h i n k , "Is i t r e a l l y worth i t ? "  As  A son  said: We're more aware o f when we're doing something wrong. This i s going to k i l l my Dad.  Before the f a t h e r r e t u r n e d younger c h i l d r e n had to be c o o p e r a t i v e , there was  home from h o s p i t a l , mothers of  already  impressed upon them the need  obedient, and q u i e t .  With o l d e r c h i l d r e n  a l s o a c o n s c i o u s e f f o r t to be h e l p f u l and  argumentative.  less  I t would seem t h a t a l l f a m i l y members assume  some r e s p o n s i b i l i t y f o r f a t h e r ' s h e a l t h d u r i n g  this  period  of time. Members were a l s o i n v o l v e d i n the regime.  They monitored f a t h e r ' s d i e t and  convalescent exercise.  These  seemed to be t a n g i b l e t h i n g s over which members c o u l d  exert  some c o n t r o l to keep f a t h e r w e l l . The  l i f e - t h r e a t e n i n g . , nature o f the i l l n e s s i n t h i s  study a l s o prompted a r e - e v a l u a t i o n of f a m i l y values goals.  The q u a l i t y of r e l a t i o n s h i p s and  gether were two  and  having time t o -  values which a l s o i n f l u e n c e d p a t t e r n s  i n t e r a c t i o n i n the d i r e c t i o n of reducing  conflict.  was  a r e a l i z a t i o n f o r most f a m i l i e s t h a t t h e i r time  was  not  of  There together  unlimited. Changes i n A f f e c t .  by a l l 10 f a m i l i e s . f a m i l i e s reported The  one  A f f e c t changes were experienced  Of the 5 a f f e c t areas explored,  9  changes i n 4 or 5 o f them.  family that reported  having only one  affect  change o r i g i n a l l y s a i d they hadn't experienced any a f f e c t change.  The  f a t h e r l a t e r s a i d he was  g e t t i n g more  impatient  to go out,  go bowling, go to work.  Several f a c t o r s  may  have i n f l u e n c e d t h i s l a c k o f r e a c t i o n to the f a t h e r ' s ness.  The  f a t h e r ' s involvement i n the f a m i l y was  even b e f o r e s h i f t s and family.  the heart a t t a c k . the w i f e  had  Both parents worked d i f f e r e n t  the sense o f d i s b e l i e f t h a t  a heart a t t a c k .  He  and  hadn't had h e a l t h problems.  who  has  had  His w i f e  i s an obese smoker  a s e r i e s o f i l l n e s s e s i n the past 10 years.  f a m i l y adaptive  more t h i n g . "  may  have f o s t e r e d  "His h e a r t a t t a c k  A l l o f these f a c t o r s :  previous  experiences may  n o n - r e a c t i v e n e s s to f a t h e r ' s heart The  is just  one  s i m i l a r i t i e s between  f a t h e r ' s s i c k r o l e and w e l l r o l e , d i s b e l i e f and d e n i a l , and  Her  s k i l l s which manifested themselves as marked  n o n - r e a c t i v e n e s s to i l l n e s s .  possible  have i n f l u e n c e d  their  attack.  f a m i l i e s ' attempts to c o n t r o l l e v e l s o f s t r e s s  to prevent f a t h e r ' s relapse, and another c o n t r i b u t e d  impatient"  the  i s l e a n , a non-smoker,  i l l n e s s e s , which i n c l u d e d a m y o c a r d i t i s ,  of one  limited  seemed to be the main f o r c e i n the  Another f a c t o r was  f a t h e r had  ill-  w i t h one  impatience and in their l i f e  to t h e i r sense of being  another.  But  t h e i r self-image.  f o r f a t h e r s who  "less  f a t h e r s experienced  a sense o f l o s s r e g a r d i n g s t y l e and  more d i f f i c u l t  t h e i r renewed a p p r e c i a t i o n  the imposed changes T h i s was  even  were f e e l i n g q u i t e w e l l .  They looked w e l l , f e l t q u i t e w e l l , but were l i m i t e d i n what they c o u l d  do.  A l l f a m i l y members, i n c l u d i n g the youngest c h i l d r e n , seemed to be  s h a r i n g a r e s p o n s i b i l i t y f o r making f a t h e r  65. b e t t e r and p r e v e n t i n g him from dying.  The extremes of  a f f e c t were no longer a c c e p t a b l e i n the f a m i l y - no a r g u i n g , "mustn't l e t my  t e a r f u l n e s s h u r t him,"  s c h o o l and y e l l  'Hi, Dad!," no t e a s i n g .  tolerated l i t t l e  "can't run i n from Family members  d e v i a t i o n from the v a l u e d "good" b e h a v i o r s .  U n f o r t u n a t e l y , these e x p e c t a t i o n s are d i f f i c u l t f o r c h i l dren to meet a l l of the time.  T h e i r normal  developmental  needs continue to e x i s t at. a time when a parent's needs seem greater' and p a r e n t a l r e s o u r c e s are l e s s  available.  Compliance w i t h the c o n v a l e s c e n t regime was h i g h l y v a l u e d i n the f a m i l i e s . about new  Compliance was. remarked upon.  from.the regime was I t was  his  family.  Deviation  a source o f s t r a i n i n f a m i l i e s .  father's l i f e  important  t h a t had been t h r e a t e n e d  and  f o r him to see a f u t u r e f o r h i m s e l f and  Hence, f a t h e r s expressed more optimism  hopefulness than d i d mothers. Williamson  pleasure  h e a l t h h a b i t s which would prevent r e c u r r e n c e of  a heart attack.  i t was  They expressed  also  and  Mayou, F o s t e r , and  (1978) a l s o found wives to be more d i s t r e s s e d  than husbands i n t h e i r study of wives o f myocardial t i o n .patients.  infarc-  Fathers a l s o seemed t o have more d i f f i c u l t y  s a y i n g they were a f r a i d of having another h e a r t a t t a c k . Mothers experienced the p r e s s u r e s of an i n c r e a s e d workload.  They were having to a t t e n d to a l l o t h e r s ' needs  and assumed added r e s p o n s i b i l i t y when t h e i r own system was for  diminished.  support  They were a l s o e x p e r i e n c i n g concerns  t h e i r husbands' l i v e s .  S k e l t o n and Dominian  C19 7 3)  suggest wives r e c e i v e a l t e r n a t i v e r e l i a b l e sources t o help them express t h e i r f e e l i n g s .  The more dependent the w i f e  had been, probably the more f r i g h t e n i n g the p r o s p e c t o f being l e f t to d e a l w i t h matters  alone.  T h i s one t o 3 week p e r i o d f o l l o w i n g h o s p i t a l charge  seems t o be a time o f a f f e c t i v e ambivalence  contradiction.  dis-  and  Family members can be happy and f e a r f u l ,  h o p e f u l and a f r a i d , happy and i m p a t i e n t . l i f e has been threatened.  A f a m i l y member's  He i s home r e c u p e r a t i n g .  Con-  v a l e s c e n c e i s c h a r a c t e r i z e d by l i m i t a t i o n s t o p r e v i o u s  life-  style.  It i s  He might have a h e a r t a t t a c k without warning.  a time o f e x p l o r i n g l i m i t s .  How f a r can I walk?  can I do?  Am I e x p e c t i n g too much?  Can I get angry?  are the l i m i t s ?  What i s O.K.?  One daughter  How much Where  reported:  I saw Dad r e a c h up t o c u t a l i l a c . He d i d n ' t say anything but I know, i t h u r t him. A father discovered l i m i t s . I thought I'd l o a d the dishwasher to help out. And i t r e a l l y t i r e d me. I mean, I c o u l d n ' t b e l i e v e i t , you know? And  one mother who i s s t i l l  unsure s a i d :  They ( f a t h e r and son) k i d each other and I'm a f r a i d they're g e t t i n g too rambunctious. I t ' s not l i k e (my son) would h i t h i s f a t h e r i n the chest o r anything. But now I don't bug (father) 'cause I f i g u r e he should know. Changes i n S t r u c t u r e .  Five families  experienced  changes i n the amount o f c o n t a c t they had w i t h more than 50% o f the groups mentioned.  67. A l l f a m i l i e s experienced changes i n the amount o f c o n t a c t they were having w i t h f r i e n d s .  Most f a m i l i e s  (80%)  had i n c r e a s e d c o n t a c t with;community h e a l t h c a r e p r a c t i t i o n e r s w h i l e 75% of the e l i g i b l e f a m i l i e s had i n c r e a s e d c o n t a c t w i t h t h e i r extended f a m i l y . T h i s study i n d i c a t e s t h a t f a m i l i e s are somewhat i s o l a t e d from t h e i r neighbors.  Even i n f o r m a t i o n was  not  r e a d i l y shared w i t h neighbors.  Few  study  families in this  had r e g u l a r c o n t a c t w i t h r e l i g i o u s i n s t i t u t i o n s The c h i l d r e n ' s s c h o o l was  either.  another r e l a t i v e l y c l o s e d  system  w i t h which f a m i l i e s had l i t t l e c o n t a c t . These data suggest t h a t f r i e n d s , f a m i l y , and community h e a l t h agencies have much more access to the than do neighbors, c l e r g y and people from s c h o o l . expected t h a t the openness of the f a m i l y system groups w i l l a l s o d e f i n e the f a m i l y ' s support  families I t can be  to c e r t a i n  system.  Since the f a m i l i e s are going out of the  household  l e s s than they used t o , the i n c r e a s e d c o n t a c t s are o c c u r r i n g i n the f a m i l y home.  Although s e v e r a l f a m i l i e s mentioned  t h a t the i n c r e a s e d number of v i s i t s from f r i e n d s c o u l d be tiring,  they were p l e a s e d t h a t people v i s i t e d .  I t provided  d i v e r s i o n f o r the r e l a t i v e l y home-bound f a m i l y and was  seen  as a demonstration of c a r i n g . F a m i l y households  appear t o cope w i t h i l l n e s s o f a  f a m i l y member without a l t e r i n g f a m i l y membership.  For some  f a m i l i e s having help by a l t e r i n g membership would d i m i n i s h t h e i r independence.  Other f a m i l i e s c o u l d n ' t c a l l on  friends  68. or f a m i l y f o r help because they were p e r c e i v e d as being too busy with t h e i r own  l i v e s and  concerns.  Family P e r c e p t i o n s of Help Most f a m i l i e s l e a s t some help. f a m i l i e s who  (6) r e p o r t e d they had r e c e i v e d a t  There was  no apparent  had made statements  pendence and those who  c o r r e l a t i o n between  asserting t h e i r inde-  had r e c e i v e d v e r y l i t t l e or no  help. Three f a m i l i e s had members who  differed  o p i n i o n s of the amount of help r e c e i v e d .  The  in their  differences  o f o p i n i o n r e l a t e d to d i f f e r e n c e s i n circumstances i n d i v i d u a l need.  One  f a t h e r found the home care nurses  very h e l p f u l but other f a m i l y members had not met One  and  them.  w i f e found the nurses very h e l p f u l i n p r o v i d i n g her  with information.  I t was  i n f o r m a t i o n the husband had  r e c e i v e d i n h o s p i t a l so he p e r c e i v e d the nurses as helpful.  One  less  f a t h e r p e r c e i v e d the o f f e r of help as h e l p f u l  while other f a m i l y members d i d not. Most f a m i l i e s i n d i c a t e d f r i e n d s and nurses were the most h e l p f u l and t h i s concurs with s e r v i c e s i d e n t i f i e d being most h e l p f u l :  reassurance and  information.  as  This also  c o r r e l a t e s w i t h the i n c r e a s e d c o n t a c t f a m i l i e s r e p o r t e d having w i t h f r i e n d s and community agencies Although c o n t a c t w i t h r e l a t i v e s had  (home care n u r s e s ) .  i n c r e a s e d f o r 6 of the  8 f a m i l i e s w i t h r e l a t i v e s i n Canada, o n l y 2 f a m i l i e s perc e i v e d f a m i l y as being very h e l p f u l .  Perhaps extended f a m i l y  69. members were too anxious themselves about the i l l to be of much support to the household  I l l n e s s as a Family The defined  member  family.  Crisis  findings c l e a r l y indicate that i l l n e s s  i n t h i s study a f f e c t s the f a m i l y .  as  A l l families  experienced some change i n t h e i r r o l e s , i n t e r a c t i o n s , a f f e c t , and  structure.  Inasmuch as these changes are a  p e r i o d of d i s e q u i l i b r i u m and  d i s o r g a n i z a t i o n of  function,  the changes i n d i c a t e t h a t i l l n e s s i s a c r i s i s . Caplan  (19 64)  a l s o d e f i n e d c r i s i s as an a f f e c t i v e  change, a p e r i o d of i n c r e a s i n g t e n s i o n and changes d i d occur i n 10 f a m i l i e s .  anxiety.  But w i t h i n the  t i o n s of t h i s study i t seems d o u b t f u l  limita-  t h a t a " f a m i l y mood"  or a f f e c t can be measured i f i t e x i s t s a t a l l . of the a f f e c t changes r e p o r t e d  Affect  From 40-100%  by each of the 10 f a m i l i e s  i n c l u d e d d i f f e r i n g responses from i n d i v i d u a l f a m i l y members. Their perceptions and  t h e i r own  responses.  of other  personal  The  f a m i l y members and  the  needs governed t h e i r own  events,  affective  m u l t i p l i c i t y of v a r i a b l e s a f f e c t i n g each  f a m i l y member makes i t u n l i k e l y t h a t the f a m i l y , t h a t i s all  f a m i l y members, c o u l d r e p o r t the  same a f f e c t a t  the  same time. Without a measureable e n t i t y of f a m i l y a f f e c t , i s there  such a phenomenon as f a m i l y c r i s i s ?  i s required.  More  research  T h i s study i n d i c a t e s t h a t c r i s i s theory  developed f o r i n d i v i d u a l s may  not d i r e c t l y apply  to  as  family  70. systems.  L i t e r a t u r e d e s c r i b i n g f a m i l y emotional responses  to s i t u a t i o n s must be read c r i t i c a l l y . d e f i n i t i o n f o r a f a m i l y c r i s i s may corded by Rapoport  To date, the  best  be the s i m p l e s t as r e -  (1965, p.24): ,  C r i s i s i n i t s s i m p l e s t terms i s d e f i n e d as 'an upset i n a steady s t a t e ' . . . Findings  are i n c o n c l u s i v e and more r e s e a r c h  i s required  i d e n t i f y the c h a r a c t e r i s t i c s and phases of f a m i l y Several  crisis.  f a m i l i e s suggested t h a t each week a f t e r the  returned  home was  s e t t l e d and  Two  father  becoming e a s i e r - people becoming more  relaxed.  Routines had  were known, r o l e s were enacted, and tested.  to  been e s t a b l i s h e d , some l i m i t s had  resources been  f a m i l i e s a n t i c i p a t e d s l i p p i n g back i n t o pre-  i l l n e s s patterns  soon.  T h i s i m p l i e s t h a t f a m i l i e s experience  the most d i s e q u i l i b r i u m and  d i s o r g a n i z a t i o n c l o s e s t to  the  time of the imposed change - f a t h e r r e t u r n i n g home. Negotiating one ill.  new  f a m i l y r u l e s and  of the f a m i l y ' s adaptive The  r o l e s appears to  tasks when a member becomes  sooner these n e g o t i a t i o n s are completed to  r e l a t i v e s a t i s f a c t i o n of a l l members, the r e t u r n s to some l e v e l of system s t a b i l i t y . r e q u i r e a s s i s t a n c e i d e n t i f y i n g and changes.  A s s i s t a n c e may  sooner the Families  family may  be i n the form of f a c i l i t a t i n g  necessary r e c a l i b r a t i o n s are, i n f a c t , the  The  a  These  opportunities  f o r f a m i l i e s to enhance t h e i r i n t e r a c t i o n s , l e a r n new perspectives.  the  c a l i b r a t i n g necessary  change i n f a m i l y c o g n i t i o n , a f f e c t , or behavior.  gain new  be  converse i s a l s o t r u e .  skills>  Dysfunctional with increased  f a m i l i e s may respond to the demands o f i l l n e s r i g i d i t y and i n f l e x i b i l i t y .  r o l e s are perpetuated, i n n o v a t i o n s ated, high.  O l d r u l e s and  and r i s k are not t o l e r -  and the c o s t t o f a m i l y and f a m i l y member h e a l t h i s For the f a m i l i e s i n t h i s study, i t c o u l d be assumed  t h a t the f a t h e r ' s t r a n s i t i o n t o "wellness" perceived  (as d e f i n e d and  by the family) w i l l n e c e s s i t a t e n e g o t i a t i o n and  r e c a l i b r a t i o n o f f a m i l y r u l e s and r o l e s again.  F o r some  f a m i l i e s t h i s might c o n s t i t u t e a c r i s i s and one can specul a t e about i t s e f f e c t on the compliance behaviors characteristic  i n t h i s study.  progressive  S i m i l a r l y , how would the f a m i l y ' s  non-compliant behavior  ( c h i l d r e n begin t o argue  w i f e asks f o r support) a f f e c t f a t h e r ' s t r a n s i t i o n t o "wellness?"  IMPLICATIONS  Although the.design  o f the study i s such t h a t the  f i n d i n g s can o n l y be considered  t e n t a t i v e , they s t r o n g l y  suggest t h a t the f a m i l y i s an i n t e g r a l p a r t o f the p a t i e n t ' i l l n e s s and as such, w i l l a f f e c t and be a f f e c t e d by the illness.  T h i s study holds some i m p l i c a t i o n s f o r n u r s i n g  p r a c t i c e , education,  and r e s e a r c h .  Nursing P r a c t i c e In a l l h e a l t h care s e t t i n g s the nurse should comp l e t e a f a m i l y assessment r e g a r d l e s s  o f which f a m i l y member  i s the c u r r e n t i d e n t i f i e d p a t i e n t .  The assessment should  i n c l u d e the b a s e l i n e data o f p r e - i l l n e s s f a m i l y s t r u c t u r e , developmental  stage, and l e v e l s o f f u n c t i o n i n g .  members should be asked  Family  f o r t h e i r p e r c e p t i o n s o f the i l l n e s s  and t h e i r c u r r e n t s i t u a t i o n .  A f t e r determining f a m i l y  r e a c t i o n s t o the c u r r e n t s i t u a t i o n , the nurse  should compare  t h i s data to the f a m i l y ' s p r e - i l l n e s s s t a t e and i t s ' t i o n s i n o t h e r s i t u a t i o n s o f change.  reac-  The d i f f e r e n c e s i n  these f a m i l y s i t u a t i o n s a r e most v a l u a b l e data.  The g r e a t e r  the d i f f e r e n c e or change between the c u r r e n t s i t u a t i o n and p r e - i l l n e s s s t a t e , the more help the f a m i l y may need t o cope w i t h the adaptive tasks c o n f r o n t i n g i t .  I t i s also  important  to assess the f a m i l y ' s p e r c e p t i o n o f the q u a n t i t y and q u a l i t y of i t s '  support system and r e s o u r c e s . Nurses should meet with f a m i l y members r e g u l a r l y  throughout  the course o f i l l n e s s .  Understandable  information  and e x p l a n a t i o n should be p r o v i d e d t o the f a m i l y as i t s ' need and r e a d i n e s s t o l e a r n d i c t a t e s .  Family members should  be encouraged t o v e r b a l i z e t h e i r thoughts  and f e e l i n g s  and the nurse should be a v a i l a b l e to l i s t e n .  The f a m i l y  members need t o hear acknowledgement o f t h e i r  difficult  tasks and support of t h e i r e f f o r t s .  The nurse  i t a t e i n t e r a c t i o n among f a m i l y members t o f u l l y t h e i r knowledge and support o f one another.  should  facil-  utilize  The nurse,  p a t i e n t , and f a m i l y members should i d e n t i f y problems and goals together. necessary.  Outside r e s o u r c e s should be p r o v i d e d as  The f a m i l y i s i t s '  own s p e c i a l i s t and best  73. resource i n times of change.  The nurse,  as f a c i l i t a t o r ,  can maximize change f o r the improved h e a l t h o f a l l f a m i l y members.  Nursing Education All  l e v e l s o f n u r s i n g education should i n c l u d e the  a p p r o p r i a t e l e v e l s o f knowledge and s k i l l s r e l a t e d t o a f a m i l y focus i n h e a l t h care and the b e h a v i o r a l aspects o f illness.  T h i s would i n c l u d e a p r o g r e s s i v e a p p l i c a t i o n o f  an expanded base o f knowledge from the n a t u r a l and s o c i a l s c i e n c e s and humanities.  Included would be content  related  to the concepts o f f a m i l y dynamics, a d a p t a t i o n , r o l e theory, i n t e r p e r s o n a l and communication theory, change theory, developmental  theory.  Nursing students would r e q u i r e super-  v i s e d o p p o r t u n i t i e s t o i n t e r a c t w i t h and assess f a m i l i e s i n v a r i o u s developmental  stages and s i t u a t i o n s .  They would a l s o  r e q u i r e o p p o r t u n i t i e s t o c o n s i d e r t h e i r own f a m i l y e x p e r i ences and coping p r o c e s s e s . Community and h o s p i t a l n u r s i n g s e r v i c e s c o n j o i n t l y w i t h n u r s i n g education should prepare and make a v a i l a b l e t o nurses  i n p r a c t i c e , a s e r i e s o f workshops designed t o help  them develop and apply a f a m i l y focus i n t h e i r c a r e .  Nursing  Research T h i s study r a i s e s many q u e s t i o n s and l e a v e s many  unanswered.  How do f a m i l y responses observed  i n this  study  compare t o t h e i r responses when the p a t i e n t f i r s t came home?  What was i t l i k e f o r the f a m i l y when f a t h e r was f i r s t hos^ pitalized? conscious,  What w i l l happen t o these c o - o p e r a t i v e ,  health-  compliant f a m i l i e s when f a t h e r s t a r t s t o smoke,  the teenagers begin t o argue?  W i l l i t happen?  When?  How  would data from t h i s study compare t o t h a t from a sample o f f a m i l i e s i n which the p a t i e n t was a c h i l d w i t h leukemia, a mother w i t h a h i g h - r i s k pregnancy, a grandparent w i t h a broken h i p , an a d u l t with m u l t i p l e s c l e r o s i s ? the same f o r f a m i l i e s ?  How i s i t d i f f e r e n t ?  account f o r the d i f f e r e n c e s ? t e l l us about f a m i l y theory, behavior and i l l n e s s ? responses? The  How i s i t How can we  What more can these  f a m i l y therapy, c r i s i s  What c o n s t i t u t e  theory,  good and bad f a m i l y  How do they a f f e c t the course o f i l l n e s s ? amount and the r i c h n e s s o f the data i n t h i s  study i n d i c a t e t h a t f a m i l y system s t u d i e s should all  studies  f a m i l y members.  include  Given t h a t a f a m i l y system i s g r e a t e r  than the sum o f i t s independent elements i t i s not approp r i a t e t o present  a f a m i l y "score" which i s the mean o f  f a m i l y member " s c o r e s . "  There i s a g r e a t need f o r the  development o f r e l i a b l e and v a l i d f a m i l y study t o o l s and approaches t o a n a l y s i s . most a p p r o p r i a t e "scores"  U n t i l then, i t i s probably  still  t o have f a m i l y members "average" t h e i r own  through seeking  consensus o r continue to r e p o r t  the d i f f e r e n c e s among members. most r e p r e s e n t a t i v e  This l a t t e r approach i s  o f f a m i l y f u n c t i o n i n g and r e t a i n s  p o t e n t i a l l y useful information. o f a study, i t may be a p p r o p r i a t e  Depending upon the purpose f o r a f a m i l y system study  75. to i n c l u d e both the f a m i l y system and members as  i n d i v i d u a l family  respondents.  In f a m i l y system s t u d i e s where f a m i l y members are only interviewed s e c r e t s may  i n d i v i d u a l l y , i t i s true that i n d i v i d u a l  be r e v e a l e d ,  a v a i l a b l e to other  that i s , information  f a m i l y members.  the data have l i m i t e d meaning and jeopardized  because the  e f f e c t s of the  As  t h a t i s not  secret  information,  the f a m i l y focus may  be  i n v e s t i g a t o r c o u l d not explore  " s e c r e t " on the f a m i l y nor  f a m i l y on the i n d i v i d u a l and  his secret.  the  the e f f e c t of At best,  the  the  i n v e s t i g a t o r would have to hypothesize the e f f e c t s i n terms of f a m i l y o r g a n i z a t i o n , The a f f e c t , and other  i n t e r a c t i o n , values  parameters of r o l e s , p a t t e r n s s t r u c t u r e were u s e f u l and  s t u d i e s o f s i m i l a r design.  The  and  goals.  of i n t e r a c t i o n ,  c o u l d be used i n developmental stage  of the f a m i l y , the nature of the i l l n e s s , the s e t t i n g , and the t i m i n g of the c a t e g o r i e s and The was  useful.  study would presumably y i e l d s p e c i a l  d i f f e r e n t data w i t h i n these parameters.  semi-structured  approach o f the data c o l l e c t i o n  With s p e c i f i c open and  closed-ended  the f a m i l i e s were able to r e p o r t concrete  questions,  changes and  concrete  changes r e l a t e d to f e e l i n g s and i n t e r a c t i o n s .  Allowing  f a m i l i e s to r e l a t e anecdotes a l s o y i e l d e d  data r e l a t e d to the i n t e r v i e w open and  schedule.  closed-ended questions  l o o k i n g at themselves, was comparable  data.  The  less  valuable  flexibility  helped o r i e n t f a m i l i e s to  not r e s t r i c t i v e , and  yielded  of  76. RECOMMENDATIONS  On the b a s i s o f the f i n d i n g s and i m p l i c a t i o n s o f t h i s study, i t i s recommended  that:  1. F a c i l i t a t i n g the e f f e c t i v e coping o f p a t i e n t s and t h e i r f a m i l i e s be a unique and i n t e g r a l focus o f n u r s i n g care i n a l l s e t t i n g s . 2. A l l l e v e l s o f n u r s i n g the a p p r o p r i a t e  education  include  knowledge and s k i l l s  r e q u i r e d f o r nurses t o p r a c t i c e with a family  focus.  3. Research be conducted w i t h  various  stages o f numerous i l l n e s s e s i n different settings to identify concepts r e l e v a n t t o r e l a t i o n s h i p s between f a m i l y r e a c t i o n s and i l l n e s s . 4. L o n g i t u d i n a l  s t u d i e s be conducted  to e f f e c t i v e l y i d e n t i f y r e l a t i o n s h i p s of time, f a m i l y r e a c t i o n s , and i l l n e s s .  VI. SUMMARY AND CONCLUSIONS  This exploratory  study was designed t o e l i c i t  infor-  mation about f a m i l y r e a c t i o n s to the c r i s i s o f i l l n e s s and what f a m i l i e s p e r c e i v e The  study focused  t o be h e l p f u l during  this  crisis.  on the f a m i l y c r i s i s o f i n c o r p o r a t i n g back  i n t o the f a m i l y a f a t h e r who had experienced h i s f i r s t myocardial  infarction.. The  study was conducted w i t h a convenience sample o f  ten m y o c a r d i a l i n f a r c t i o n male p a t i e n t s , t h e i r wives, and c h i l d r e n l i v i n g i n the household. A semi-structured  i n t e r v i e w schedule was used w i t h  each f a m i l y one t o three weeks f o l l o w i n g the f a t h e r ' s charge from h o s p i t a l .  The i n t e r v i e w s  dis-  took p l a c e i n the  f a m i l y ' s home and averaged 50 minutes i n l e n g t h .  The i n t e r -  view covered f o u r content areas r e l a t e d t o f a m i l y  reactions  in The  the realms o f a f f e c t , i n t e r a c t i o n , r o l e s and s t r u c t u r e . f i f t h content area r e l a t e d t o what people and s e r v i c e s  the f a m i l y p e r c e i v e d  t o be h e l p f u l .  summarized i n t o c a t e g o r i e s  The i n t e r v i e w data were  and d e s c r i p t i v e s t a t i s t i c s were  used. All  10 f a m i l i e s d e s c r i b e d  changes t h a t had occurred  i n the areas o f f a m i l y r o l e s , i n t e r a c t i o n s , a f f e c t and s t r u c t u r e s i n c e the f a t h e r had returned  home from h o s p i t a l .  78. In terms o f the help they p e r c e i v e d r e c e i v i n g d u r i n g time, one f a m i l y r e p o r t e d "very l i t t l e  in  "no h e l p , " 2 f a m i l i e s r e p o r t e d  h e l p , " one r e p o r t e d  "a great d e a l o f h e l p . " 3 families.  this  "some h e l p , " and 3 r e p o r t e d  A difference of opinion  occurred  F r i e n d s and home care nurses were most  f r e q u e n t l y seen as the persons o f f e r i n g the most h e l p t o families.  R e c e i v i n g i n f o r m a t i o n and reassurance  were seen  as h e l p f u l d u r i n g t h i s time. Although the sample was s m a l l and not randomized, i t i s p o s s i b l e t o draw some c o n c l u s i o n s based on the data collected.  When a f a m i l y member i s i l l , f a m i l i e s may exper-  ience changes i n t h e i r r o l e s , p a t t e r n s o f i n t e r a c t i o n , a f f e c t , and s t r u c t u r e .  The q u a l i t y and q u a n t i t y o f changes  are r e l a t e d t o s e v e r a l f a c t o r s . is  Of c o n s i d e r a b l e  the f a m i l y ' s p e r c e p t i o n o f the nature  o f the i l l n e s s - i t s  c h a r a c t e r , extent, e f f e c t , and p r o g n o s i s . and  importance  These  perceptions  the enactment o f the s i c k r o l e by the p a t i e n t produce  changes which may c o n t r a s t markedly o r m i n i m a l l y with the family's p r e - i l l n e s s state. threatening i l l n e s s ,  Illness, especially  life-  f o s t e r s a review o f i n d i v i d u a l and  f a m i l y values and g o a l s .  This review can a l s o produce  changes i n f a m i l y r o l e s , p a t t e r n s o f i n t e r a c t i o n ,  affect  and s t r u c t u r e . It  i s presumed t h a t f a m i l y r e a c t i o n s can have an  e f f e c t on the p a t i e n t ' s course  of i l l n e s s .  The e f f e c t i s  dependent upon the f a m i l y ' s p e r c e p t i o n o f the i l l n e s s and t h e i r p e r c e p t i o n o f the amount and k i n d o f c o n t r o l s they  79. can e x e r c i s e .  A l s o r e l a t e d are the p e r s o n a l needs of  i n d i v i d u a l f a m i l y members. Family d i s c u s s i o n s of t h e i r changed s i t u a t i o n serve many purposes.  New  I n d i v i d u a l s ' needs may c l a r i f i e d , and a l t e r e d .  i n f o r m a t i o n can be  emerge.  can  shared.  P e r c e p t i o n s can be  Members can p o s i t i v e l y  each o t h e r ' s e f f o r t s and n e g a t i v e l y r e i n f o r c e  shared,  reinforce  deviance.  S o l u t i o n s to problems can be e x p l o r e d and agreed Family p e r c e p t i o n s of the amount of help  upon. they  r e c e i v e and the people they f i n d h e l p f u l are i n f l u e n c e d by the needs and p e r c e p t i o n s of i n d i v i d u a l f a m i l y members. Most f a m i l i e s i n t h i s study coped w i t h i l l n e s s of a f a m i l y member without a l t e r i n g membership of t h e i r  household.  F a m i l i e s f i n d c l e a r i n f o r m a t i o n and reassurance  from  o t h e r h e l p f u l when they are coping w i t h i l l n e s s of a f a m i l y member. More r e s e a r c h i s r e q u i r e d to i d e n t i f y the t e r i s t i c s and temporal  charac-  aspects o f f a m i l y r e a c t i o n s to  i l l n e s s and f a m i l y e f f e c t s on i l l n e s s .  For these purposes  i n n o v a t i v e approaches to r e s e a r c h design and methodology are r e q u i r e d to ensure s c i e n t i f i c theory development and continued a p p r e c i a t i o n of the complexity o f f a m i l y systems.  BIBLIOGRAPHY  A g u i l e r a , D.; Messick, J . ; and F a r r e l l , M. C r i s i s I n t e r v e n t i o n . 2ed. S t . L o u i s : C.V. Mosby, 1974. Anderson, R., and C a r t e r , I. Human Behavior i n the S o c i a l Environment, A S o c i a l Systems Approach. Chicago: A l d i n e , 1974. Anthony, E. "Impact o f Mental and P h y s i c a l I l l n e s s on Family L i f e . " Am. J . P s y c h i a t r y 127 (August 1970):138-146. B e l l , N.,and Vogel, E., ed. A Modern I n t r o d u c t i o n t o the Family. New York: MacMillan, 19 68. B e r t a l a n f f e y , L. "General Systems Theory - A C r i t i c a l Review," i n Modern Systerns Research f o r the B e h a v i o r a l S c i e n t i s t . 11-30. E d i t e d by W. Buckley. Chicago: A l d i n e , 1968. B r i n k , P., and Wood, M. B a s i c Steps i n P l a n n i n g Nursing Research. North S c i t u a t e , Mass.: Duxbury P r e s s , 1978. Caplan, G. P r i n c i p l e s o f P r e v e n t i v e P s y c h i a t r y . New York: B a s i c Books, 19 64. Deutsch, C , and Goldston, J . "Family F a c t o r s i n Home Adjustment o f the S e v e r e l y D i s a b l e d . " Marriage and Family L i v i n g 22 (November 1960):312-316. E i c h e l , E l l e n . "Assessment with a Family Focus." J o u r n a l of P s y c h i a t r i c Nursing 16 (June 197 8)^:11-14. Epperson, M. " F a m i l i e s i n Sudden C r i s e s : Process and I n t e r v e n t i o n i n a C r i t i c a l Care Center." S o c i a l Work i n H e a l t h Care 2 (Spring 1977):265-273. F e r r e i r a , A. "Family Myth and Homeostasis," i n A Modern I n t r o d u c t i o n t o the Family. 541-548. E d i t e d by N. B e l l and E. V o g e l . New York: MacMillan, 1968. F i s h e r , L. "On the C l a s s i f i c a t i o n o f F a m i l i e s . " A r c h i v e s o f General P s y c h i a t r y 34 ( A p r i l 1977):423-433.  80.  81. Freedman, A.; Kaplan, H.; and Sadock, B. Modern Synopsis o f Comprehensive Textbook o f P s y c h i a t r y . 2ed. B a l t i m o r e : W i l l i a m s and W i l k i n s , 1976. G l a s s e r , P., and G l a s s e r , L. F a m i l i e s i n C r i s i s . Harper and Row, 19 70.  New  York:  G r a n i t e , U., and Goldmon, S. " R e h a b i l i t a t i o n Therapy f o r Burn P a t i e n t s and Spouses." S o c i a l Casework 56 (December 1975):593-598. Haley, J . "Family o f the S c h i z o p h r e n i c - A Model System." J . o f Nervous and Mental D i s o r d e r s 129 (1962): 357-374. Hill,  R. " S o c i a l S t r e s s e s on the Family," i n C r i s i s I n t e r v e n t i o n . S e l e c t e d Readings. 32-52. E d i t e d by H.J. Parad. New York: Family S e r v i c e s A s s o c i a t i o n o f America, 1965.  Holsti,  0. Content A n a l y s i s For the S o c i a l S c i e n c e s and Humanities. Don M i l l s , O n t a r i o : Addison-Wesley, 1969.  Jackson, D. "Family Rules. M a r i t a l Quid Pro Quo." A r c h i v e s of General P s y c h i a t r y 12 (June 1965):589-599. Jackson, D. "The Question o f Family Homeostasis." Q u a r t e r l y Supplement 31 (1957) :79-90.  Psychiatric  Jackson, D. "The Study o f the F a m i l y . " Family Process 41 (March 1964):l-20. Kaplan, D.; G r o b s t e i n , R.; Smith, A.; and Fischman, S. "Family M e d i a t i o n o f S t r e s s . " S o c i a l Work (July 1973):5-14. K e r l i n g e r , F. Foundations o f B e h a v i o r a l Research. 2ed. Toronto: H o l t , Rinehart, and Winston, 1973. K l e i n , D., and Bogdonoff, M. "Impact o f I l l n e s s on the Spouse." J . C h r o n i c Disease 20 (1967):241-248. Langsley, D., and Kaplan, D. The Treatment of F a m i l i e s i n C r i s i s . New York: Grune and S t r a t t o n , 19 68. Levinson, R. "Family C r i s i s and A d a p t a t i o n . Coping with a M e n t a l l y Retarded C h i l d . " D i s s e r t a t i o n , U n i v e r s i t y of Wisconsin, 1976. L i p o w s k i , Z.J. " P h y s i c a l I l l n e s s , the I n d i v i d u a l , and the Coping P r o c e s s . " I n t e r n a t i o n a l J o u r n a l o f P s y c h i a t r y i n Medicine 1 (1970):91-101.  82. Litman,  T. "The Family and P h y s i c a l R e h a b i l i t a t i o n . " J . C h r o n i c Disease 19 (1966):211-217.  L i v s e y , C. " P h y s i c a l I l l n e s s and Family Dynamics." Advanced Psychosomatic Medicine 8 (19.72) : 237-251. MacVicar, M., and A r c h b o l d , P. "A Framework f o r Family Assessment i n Chronic I l l n e s s . " N u r s i n g Forum 15 (1976):180-194. Mayou, R.; F o s t e r , A.; and W i l l i a m s o n , B. "The P s y c h o l o g i c a l and S o c i a l E f f e c t s of M y o c a r d i a l I n f a r c t i o n on Wives." B r i t i s h M e d i c a l J o u r n a l 1 (March 1978):699-701. Moos, Rudolf. Coping w i t h P h y s i c a l I l l n e s s . Plenum M e d i c a l Book, 1977.  New  York:  Murray, R., and Zentner, J . Nursing Concepts f o r H e a l t h Promotion. Englewood C l i f f s , N.J.: P r e n t i c e - H a l l , 1975. Nye,  F. Role S t r u c t u r e and A n a l y s i s of the Family. B e v e r l y H i l l s : Sage P u b l i c a t i o n s , 1976.  Olsen, E. "The Impact of Serious I l l n e s s on the Family System." Postgraduate Medicine 47 (February 1970): 169-174. Oppenheimer, J . "Use of C r i s i s I n t e r v e n t i o n i n Casework w i t h the Cancer P a t i e n t and His Family." S o c i a l Work 12 ( A p r i l 1967):44-52. Parad,  H.J.,and Caplan, G. "A Framework f o r Studying Families in C r i s i s , " i n C r i s i s Interventions. S e l e c t e d Readings. 53-72. E d i t e d by Parad. New York: Family S e r v i c e s A s s o c i a t i o n o f America, 1965.  Parsons, T., and Fox, R. " I l l n e s s , Therapy, and the Modern Urban Family," i n A Modern I n t r o d u c t i o n t o the Family. 377-390. E d i t e d by N. B e l l and E. Vogel. New York: MacMillan, 1968. Peck, B. " P h y s i c a l Medicine and Family Dynamics: The D i a l e c t i c s of R e h a b i l i t a t i o n . " Family Process 13 (December 1974):469-479. Power, P. "The U t i l i z a t i o n of the Family i n the R e h a b i l i t a t i o n o f the C h r o n i c a l l y 111 P a t i e n t . " J . A l l i e d H e a l t h 5 (Spring 1976):42-50.  83. Quint, J . "The Case f o r T h e o r i e s Generated from E m p i r i c a l Data. "'• Nursing Research -16 (Spring 1967) : 109-114 . Rakel, R. P r i n c i p l e s o f Family Medicine. Toronto: W.B. Saunders, 1977. Rapoport, L. "The S t a t e o f C r i s i s : Some T h e o r e t i c a l Considerations," i n C r i s i s Intervention: Selected Readings. 22-31. E d i t e d by H.J. Parad. New York: Family S e r v i c e s A s s o c i a t i o n o f America, 1965. Robischon, P., and S c o t t , D. "Role Theory and I t s A p p l i c a t i o n i n Family Nursing." Nursing Outlook (July 1969): 52-57. S a t i r , V. C o n j o i n t Family Therapy. Palo A l t o : Science and Behavior Books, 196 7. S h e l l h a s e , L., and S h e l l h a s e , F. "Role o f the Family i n R e h a b i l i t a t i o n . " S o c i a l Casework 53 (November 1972):544-550. S i l v a , Mary. "Spouses Need Nurses Too." The Canadian Nurse 73 (December 1977):39-41. S k e l t o n , M., and Dominian, J . " P s y c h o l o g i c a l S t r e s s i n Wives o f P a t i e n t s w i t h M y o c a r d i a l I n f a r c t i o n . " B r i t i s h M e d i c a l J o u r n a l 2 ( A p r i l 1973):101-103. S m i l k s t e i n , G. "The Family i n Trouble - How t o T e l l . " J . o f Family P r a c t i c e 2 (1975):19-24. Solomon, M. "A Developmental Conceptual Premise f o r Family Therapy." Family Process 12 (1973):179-188. Tomm, K. "A Family Assessment Model." Notes from c l a s s , "The Family i n Health and I l l n e s s , " February 19 77a, U n i v e r s i t y o f Calgary. Tomm, K. " C i r c u l a r P a t t e r n Diagramming." Notes from c l a s s , "The Family i n Health and I l l n e s s , 1977b, U n i v e r s i t y of C a l g a r y . Tomm, K. "Expressive Family F u n c t i o n i n g Guide." 19 77c, U n i v e r s i t y o f C a l g a r y .  February  Watzlawik P.; Beavin, J . ; and Jackson, D. Pragmatics o f Human Communication. New York: W.W. Norton, 1967. W i l l i a m s , C , and R i c e , D. "The I.C.U. - S o c i a l Work I n t e r v e n t i o n w i t h F a m i l i e s o f the C r i t i c a l l y 111 P a t i e n t . " S o c i a l Work i n H e a l t h Care 2 (Summer 1977):391-398. f  84. Wu,  Ruth. Behavior and I l l n e s s . P r e n t i c e - H a l l , 1973.  Englewood G l i f f s ,  N.J.:  Yokes, J . "Family R e h a b i l i t a t i o n : an A d u l t w i t h M y o c a r d i a l I n f a r c t i o n , " i n Family H e a l t h Care. 390-404. E d i t e d by D. Hymovich. New York: McGraw-Hill, 19 73.  87.  APPENDIX C Interview  Schedule  Introduction: 1. E x p l a i n the purpose of the study. 2. Obtain consents to p a r t i c i p a t e i n the study consents to r e c o r d . Engagement: 1. Speak to each member b r i e f l y i n s o c i a l  and  conversation.  Opening Comments: Your f a m i l y has experienced a l o t o f changes d u r i n g the past few weeks. A r e c e n t change i s having Mr. home from h o s p i t a l . What I'd l i k e to do i s spend the next one to one and one-half hours hearing from a l l of you about the changes you've n o t i c e d i n the f a m i l y d u r i n g the past weeks s i n c e Mr. came home. What i s d i f f e r e n t i n the f a m i l y now as compared to how t h i n g s were b e f o r e Mr. went i n t o the h o s p i t a l . Each o f you might have d i f f e r e n t i d e a s on what the changes have been and t h a t i s to be expected. I'd l i k e to hear everyone's i d e a s . Body of the Interview: 1. When f a m i l i e s experience major changes, they u s u a l l y need time to r e o r g a n i z e the jobs and a c t i v i t i e s t h a t keep a f a m i l y running smoothly. What changes have you n o t i c e d i n the s h a r i n g of jobs and r e s p o n s i b i l i t i e s i n the f a m i l y ? If necessary,.clarify: la) What changes have you n o t i c e d i n the area, of household chores? lb) of d i s c i p l i n i n g the c h i l d r e n ? lc) of i n i t i a t i n g s o c i a l a c t i v i t i e s ? Id) of making important d e c i s i o n s ? le) o f l o o k i n g a f t e r peoples' needs f o r a f f e c t i o n , t h e i r h u r t f e e l i n g s , concerns, etc.? If) of l o o k i n g a f t e r the f i n a n c i a l needs of the f a m i l y ? Are there any other changes i n the s h a r i n g of jobs and r e s p o n s i b i l i t i e s t h a t you would l i k e to add?  88. A l l f a m i l i e s have p a t t e r n s o f who t a l k s t o whom about what. These p a t t e r n s change p e r i o d i c a l l y depending on what i s happening i n the f a m i l y . What changes have you n o t i c e d d u r i n g t h e past weeks i n how you t a l k t o one another i n the f a m i l y ? I f necessary, c l a r i f y : 2a) Has t h e r e been a change i n the amount o f t a l k i n g t h a t goes on? In what way? 2b) i n the kinds o f t h i n g s you t a l k about? In what way has i t changed? 2c) i n who t a l k s t o whom? In what way? Are there any other changes i n p a t t e r n s o f t a l k i n g you'd l i k e t o add? F a m i l i e s u s u a l l y experience a change o f mood o r f e e l i n g tone when they f i n d themselves i n new situations. Have you n o t i c e d changes i n t h e f a m i l y ' s mood d u r i n g the p a s t weeks? I f necessary, c l a r i f y : 3a) Would you say the f a m i l y i s more happy, l e s s happy, no change? 3b) ...more impatient, l e s s i m p a t i e n t , no change? 3c) ...more h o p e f u l , l e s s h o p e f u l , no change? 3d) ...more nervous, l e s s nervous, no change? 3e) ...more a f r a i d , l e s s a f r a i d , no change? Are t h e r e any other mood o r f e e l i n g changes you'd l i k e t o add? When e x p e r i e n c i n g major changes, f a m i l i e s sometimes n o t i c e changes i n t h e i r own membership and the amount of c o n t a c t they have w i t h o t h e r s . 4a)  In the p a s t weeks, have you had more o r l e s s c o n t a c t with people other than f a m i l y members? i ) . . . s e e n more o r l e s s o f f r i e n d s ? i i ) . . . o f f a m i l y members o u t s i d e o f t h i s household? i i i ) . . . o f neighbours? i v ) . . . o f people from work? v) ...of people from school? v i ) . . . o f clergy? v i i ) . . . o f community agency people?  4b)  How much are you going out o f the home? i ) more ii.) the same i i i ) less  89. 4c) Has the membership o f the f a m i l y changed d u r i n g the p a s t weeks? 5. What amount o f help have you r e c e i v e d d u r i n g the past weeks from people or agencies o u t s i d e of the household? 1 no help  2 very little help  3 some help  4 a fair amount o f help  5 a great deal of help  ( A l l but #1) 5a) Who has been most h e l p f u l t o your f a m i l y i n the past weeks? i) friends v) doctors ii) relatives v i ) community i i i ) clergy v i i ) others i v ) nurses 5b) In what ways were they h e l p f u l ? 5c) What e l s e would you have found d u r i n g t h i s time?  agencies  helpful  (Received no help) 5d) What would have been h e l p f u l t o your f a m i l y d u r i n g these p a s t weeks? Termination: 1. Express a p p r e c i a t i o n . 2. Give them r e c o g n i t i o n f o r t h e i r  efforts.  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0094588/manifest

Comment

Related Items