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

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FAMILY REACTIONS TO THE CRISIS OF ILLNESS by Thelma M. Brown B.Sc.N., University of 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 i n THE FACULTY OF GRADUATE STUDIES (SCHOOL OF NURSING) We accept t h i s thesis as conforming to the required standard 9 THE UNIVERSITY OF BRITISH COLUMBIA June, 1979 ©Thelma M. Brown, 19 79 In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers ity of B r i t i s h Columbia, I agree that the Library shal l make i t f ree ly avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholar ly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publ icat ion of th i s thesis for f inanc ia l gain shal l not be allowed without my written permission. Department nf Nursing The Univers ity of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 n a t.P July 30, 1979 A B S T R A C T T h i s e x p l o r a t o r y s t u d y was d e s i g n e d t o e l i c i t i n f o r m a t i o n a b o u t f a m i l y r e a c t i o n s t o t h e c r i s i s o f i l l n e s s a n d w h a t 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 c r i s i s . The s t u d y f o c u s e d o n t h e 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 b a c k i n t o t h e f a m i l y a f a t h e r who h a d e x p e r i e n c e d h i s 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 s t u d y was c o n d u c t e d w i t h a c o n v e n i e n c e s a m p l e o f t e n m a l e m y o c a r d i a l i n f a r c t i o n p a t i e n t s , t h e i r w i v e s , a n d c h i l d r e n l i v i n g i n t h e h o u s e h o l d . A s e m i - s t r u c t u r e d i n t e r v i e w s c h e d u l e was u s e d w i t h e a c h f a m i l y one t o t h r e e weeks f o l l o w i n g t h e f a t h e r ' s d i s c h a r g e f r o m h o s p i t a l . T h e i n t e r v i e w d a t a w e r e s u m m a r i z e d i n t o c a t e g o r i e s a n d d e s -c r i p t i v e s t a t i s t i c s w e r e u s e d . A l l 10 f a m i l i e s d e s c r i b e d c h a n g e s t h a t h a d o c c u r r e d i n t h e a r e a s 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 a n d s t r u c t u r e s i n c e t h e f a t h e r h a d r e t u r n e d home f r o m h o s p i t a l . T h e a m o u n t s o f h e l p r e c e i v e d b y f a m i l i e s v a r i e d a g r e a t d e a l a n d d i f f e r e n c e s o f o p i n i o n w e r e e x p r e s s e d w i t h i n some f a m i l i e s . F r i e n d s a n d home c a r e n u r s e s w e r e m o s t f r e q u e n t l y s e e n a s p e r s o n s o f f e r i n g t h e m o s t h e l p t o f a m i l i e s . R e c e i v i n g i n f o r m a t i o n a n d r e a s s u r a n c e w e r e s e e n a s h e l p f u l d u r i n g t h i s t i m e . i i i . In summary, the res u l t s of the study indicate that families do experience a variety of changes when a family member i s i l l . The quantity and qual i t y of change are related to the family's perception of the nature of the i l l n e s s , the i l l member's enactment of the sick r o l e and the degree of difference between the family's p r e - i l l n e s s and p o s t - i l l n e s s state. I l l n e s s , e s p e c i a l l y l i f e - t h r e a t e n i n g i l l n e s s , fosters a review of in d i v i d u a l and family goals which can also produce change. It i s also presumed that family reactions can have an e f f e c t on the course of i l l n e s s . The e f f e c t i s dependent upon family perceptions of the i l l n e s s , the amount and kind of controls they can exercise, and the personal needs of ind i v i d u a l family members. More research i s required to i d e n t i f y the charac-t e r i s t i c s and temporal aspects of family reactions to i l l n e s s and family e f f e c t s on i l l n e s s . Innovative approaches to research design and methodology are required to ensure s c i e n t i f i c theory development and continued appreciation of the complexity of family systems. i v . TABLE OF CONTENTS Page ABSTRACT. i i TABLE OF CONTENTS i v LIST OF TABLES - v i ACKNOWLEDGEMENTS 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 II. LITERATURE REVIEW 9 FAMILY CRISIS 9 ILLNESS AS A FAMILY CRISIS 13 EFFECT OF ILLNESS ON FAMILY STRUCTURE ... 15 EFFECT OF ILLNESS ON FAMILY FUNCTIONING. 20 EFFECT OF FAMILIES ON ILLNESS 2 3 SUMMARY OF LITERATURE REVIEW 25 V . III. METHODOLOGY 27 SAMPLE SELECTION .. 27 DATA COLLECTION 29 DATA ANALYSIS 31 IV. RESULTS 32 DESCRIPTION OF THE SAMPLE 32 FINDINGS 34 Changes in Roles (Item 1) Changes i n Patterns of Interactions (Item 2) Changes i n A f f e c t (Item 3) Changes i n Family Contact CItern 4) Family Perceptions of Help (Item 5). V. ANALYSIS 54 INTERPRETATION OF FINDINGS 55 Family Focus Family Reactions Changes i n Roles Changes i n Patterns of Interaction Changes i n A f f e c t Changes i n Structure Family Perceptions of Help I l l n e s s as a Family C r i s i s IMPLICATIONS ; VI Nursing Practice Nursing Education Nursing Research RECOMMENDATIONS 76 VI. SUMMARY AND CONCLUSIONS.. 77 BIBLIOGRAPHY 80 APPENDICES 85 v i . LIST OF TABLES Table Page 1 Ages of Household Family Members 33 2 Duration of Hospitalization and Number of Days After Discharge That Interview Took Place... 34 3 Areas of Change Described by Families. 35 4 Changes i n Roles Described by Families. 36 5 Changes i n Patterns of Interaction Described by Families 40 6 Changes i n Af f e c t Described by Families 42 7 ' Changes i n Family Contact with Groups. 4 8 8 Amount of Help Received by Families..... 52 9 Person(s) Offering the Most Help to Families... 51 v i i . ACKNOWLEDGEMENTS The author i s gratef u l to the members of her committee, Marilyn Willman and Criss Rogers, for t h e i r calm and unvarying guidance i n the development of thi s thesis, to the head nurses and family members who gave so much of themselves, and to Dan for his understanding and support. I. INTRODUCTION Tr a d i t i o n a l l y , the i n d i v i d u a l and his symptoms have been the focus of treatment. More recently, a family focus has emerged i n health care. A FAMILY FOCUS The family has undergone changes through time but continues to be an important s o c i a l unit. It i s responsible for the s o c i a l i z a t i o n and orientation of the young. I t provides the opportunity for intimate s o c i a l interactions and the base of personal security for a l l i t s members. I t has influence on most aspects of human l i f e . Families are viewed as s o c i a l systems which are d i s t i n c t from other systems i n that they are composed of persons or groups of persons who i n t e r a c t with and influence the behavior of others. The family i s distinguishable from other s o c i a l systems such as business organizations by i t s goals, functions, and climate of feelings (Anderson and Carter, 1974). Families are open systems i n that they exchange material, energy, and information with t h e i r environment (Watzlawik, Beavin, and Jackson, 1967, p.122). Families, 1. 2. l i k e a l l open systems, have the property of wholeness (Watzlawik, Beavin, and Jackson, 1967). organization and inte r a c t i o n . A family system behaves as an inseparable whole. It i s greater than the sum of i t s independent parts. A change i n one family member produces a change i n each family member and the family system. Another i n t e r a c t i v e component of the property of wholeness i s the c i r c u l a r i t y of relationships among system elements. A family member's response i s also a stimulus i n an estab-l i s h e d pattern of in t e r a c t i o n . An example of the c i r c u l a r -i t y of a pattern of in t e r a c t i o n i s : This interdependent rel a t i o n s h i p of the family system i s recognized as having implications for health care. Families are very complex organizations and the development of a family focus requires a framework for looking at families. Karl Tomm (1977a) o f f e r s a cognitive framework for assessing family systems which i s made up of three i n t e r r e l a t e d parameters: family structure, family function, and family development. The parameter of family structure includes factors which i d e n t i f y who i s included i n the family. The nature of the connections across the family boundary (with the s o c i a l network and other community i n s t i t u t i o n s ) and the "Wholeness" characterizes aspects of system drinks The o v e r a l l health of the family unit and the health of the ind i v i d u a l are interdependent... (Rakel, 1977, p.342). 3. family's location within the community (geographic and socio-economic) further defines the family. Family function i s the most dynamic of the three parameters because i t includes the family behaviors which define and redefine family rules and roles to ensure the family's continuance as an organized and stable system. Stages of family development relate to marriage or the beginning family, child-rearing, individuation of members, departure of children, retirement and death of a spouse (Fisher, 1977). I t i s assumed that "families must attend to the tasks of one stage before they can adequately master the task of the next" (Solomon, 1973, p.183). With a framework for understanding what families are and how they function, i t i s possible for health care professionals to a f f e c t the health of a l l family members regardless of which family member i s the current i d e n t i f i e d 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. It usually 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 period of disequilibrium and disorganization (Olsen, 1970). C r i s i s i n i t s simplest terms i s defined as 'an upset i n a steady state'...the habitual problem-solving a c t i v i t i e s are not ade-quate and do not lead r a p i d l y to 4. the previously achieved balanced state (Rapoport, 1965, p.24). The various phases of i l l n e s s (onset, sick r o l e , convales-cence) and chronicity or impending death have inherent adaptive tasks which may p r e c i p i t a t e a c r i s i s depending upon the person's perception of these events and factors such as physical and emotional status (Murrary and Zentner, 1975). The family's response to the c r i s i s has implications for the course of i l l n e s s . Should the family decompensate and f a i l to support... the i l l member...convalescence (may be) prolonged (Rakel, 1977, p.343). The family's response also has implications for i t s own health. Successful experience with c r i s i s tests and strengthens a family, but defeat i n c r i s i s i s punitive on family structure and morale ( H i l l , 1965, p.46). POTENTIAL SIGNIFICANCE OF THE STUDY A c r i s i s i s not necessarily a bad experience. I t can be an opportunity to learn new problem-solving s k i l l s and devise creative solutions for d a i l y l i v i n g . S a t i s f a c -t i o n and lev e l s of functioning may eventually exceed pre-c r i s i s l e v e l s . Following an adaptive experience, future c r i s e s may be handled i n a superior manner (Glasser and Glasser, 1970). It i s during a c r i s i s that individuals and families are most amenable to help and change (Aguilera, 5. Messick, F a r r e l l , 1974). By helping families cope e f f e c -t i v e l y with physical i l l n e s s of a family member, nurses can promote optimal recovery of the sick i n d i v i d u a l and safeguard the i n t e g r i t y of the family (Livsey, 1972). How do nurses help families cope? Before we can begin to prescribe how to help families cope, nurses must have a better understanding of how families function and what a family experiences when a member i s i l l . I t i s hoped that information e l i c i t e d i n thi s study w i l l add to exist i n g knowledge about how families experience c r i s i s and how nurses can give e f f e c t i v e care to patients and th e i r families as they cope with the c r i s i s of i l l n e s s . PROBLEM STATEMENT The focus of this study i s the family's experience of the c r i s i s of i l l n e s s . S p e c i f i c a l l y , the study attempts to e l i c i t information about fami l i e s ' reactions when they are faced with the c r i s i s of having a member who i s i l l and about what families perceive to be he l p f u l during t h i s c r i s i s . For purposes of t h i s study fathers experiencing 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 of a family member. This study focuses specif-i c a l l y on the family c r i s i s of having to incorporate the disabled father back into the family. 6. PURPOSE The purpose of this study i s two-fold. The f i r s t purpose i s to describe reactions that occur i n families when fathers 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 ho s p i t a l for one to three weeks. The second i s to describe what people and services families report to be help f u l during t h i s one to three week period. ASSUMPTIONS 1. I t i s assumed that i l l n e s s and d i s a b i l i t y of a family member produces disequilibrium i n a family. 2. I t i s assumed that variables such as previous learning experiences, i n d i v i d u a l personality factors, and socio-economic levels influence the response of the family 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 are put forth and then tested using rigorously c o n t r o l l e d procedures. I t does not focus on relationships between variables or causa 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 to obtain a random sample hence the res u l t s are not generalizeable beyond the families of the study. 3. The size of the sample was li m i t e d by a v a i l a b i l i t y of e l i g i b l e families and by l i m i t s of time. 4. The effects of extraneous variables were not controlled. The purpose of the study was to categorize variables and examine relat i o n s h i p s . 7. 5. The family description of reactions may be distorted through e f f e c t of time and/or family rules regarding disclosure, e l i g i b l e spokespersons, degree of individuation of members. The family rules that represent family functioning (e.g. mother always speaks for the family) are less a l i m i t a t i o n to the study than the d i s t o r t i o n s that do not represent family functioning, (e.g. mother i s the spokesperson for t h i s one occasion). 6 . A difference of opinion among family members may have been l o s t i n t h e i r consensus of a family description of reactions. More sophisticated methods of obtaining a family's perception of change are not known to t h i s investigator. 7. The semi-structured interview schedule may have r e s t r i c t e d some content. DEFINITIONS c r i s i s - a period of disorganization and emotional upset that occurs when customary problem-solving a c t i v i t i e s do not produce a steady state. family - a s o c i a l system composed of mother, father, and at least one c h i l d (natural or adopted) l i v i n g i n the same household i n the Vancouver area; a family can include persons related by blood or marriage who have l i v e d i n the household three months or more. f i r s t myocardial i n f a r c t i o n - the father's f i r s t known and treated myocardial 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. helpf u l - people and services perceived by the family to be .useful i n regaining a steady state. reactions - verbal statements of cognitive (thoughts), a f f e c t i v e (feelings), and behavioral (observeable behaviors) changes that occurred i n and among family members during the one to three week period following father's return home. 8. steady state - a system's l e v e l of functioning characterized by a dynamic balance between accommodating change and maintaining status quo. I I . LITERATURE REVIEW This review focuses on publications related to family c r i s i s , i l l n e s s as a c r i s i s , the effects of i l l n e s s on families, and the e f f e c t of families on i l l n e s s . Although the example of i l l n e s s i n thi s study i s the convalescent phase of a physical i l l n e s s , the dearth of studies warrants a review which includes a variety of phases and types of i l l n e s s . FAMILY CRISIS The family, 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 res i s t a n t to randomness. Jackson used the term "homeostasis" to describe t h i s tendency i n his early writings about family systems (Jackson, 1957). The family also has a great capa-c i t y to accommodate the many maturational and s i t u a t i o n a l changes of i t s members and i t s environment. The term "steady state" i s currently used to describe a system i n dynamic balance - both changing and maintaining i t s e l f . I t does not imply that a fix e d minimal•level of stress must be main-tained. A steady state dictates a l e v e l of functioning within a range of acceptable l i m i t s which can accommodate the realms of play, 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. (Bertalanffey, 1968). Families can experience c r i s i s when there i s "an upset i n a steady state" (Rapoport, 1965, p.24). Caplan, who pioneered much of the development of c r i s i s theory, defines c r i s i s as occurring when obstacles to important l i f e goals have not been e f f e c t i v e l y resolved with customary problem solving methods. There i s a r i s e i n inner tension, anxiety, and disorganization of function which i s referred to as " c r i s i s " (Aguilera, Messick, and F a r r e l l , 1974, p.6). The phases and c h a r a c t e r i s t i c s of p a r t i c u l a r kinds' of c r i s e s i n i ndividuals have been studied. Bowlby focused on separa-t i o n trauma of children entering h o s p i t a l and Lindeman observed g r i e f reactions following bereavement (Rapoport, 1965). C r i s i s theory was applied to families by H i l l (1965) in his studies of war separations and war reunions. With war separation families, H i l l described family c r i s i s and adjustment as a period of shock followed by disorganization, lack of enthusiasm for role enactment, and strained r e l a -tionships. Then, through t r i a l and error or thoughtful planning, new routines are developed and things begin to improve. This process was not evident i n the study of war reunions, however ( H i l l , 1965, p.49). According to H i l l (1965), there are three variables which determine whether a s i t u a t i o n constitutes a c r i s i s for the family: the hard-ships accompanying the event, the family's d e f i n i t i o n of the event (threatening or non-threatening to status and goals), 11. and the family's resources (role structure, f l e x i b i l i t y , previous experience with c r i s i s ) . Parad and Caplan (1965) studied families i n cr i s e s p r e c i p i t a t e d by premature b i r t h , congenital anomaly, and tuberculosis i n a family member. They used the categories of l i f e s t y l e (including value systems, communication network, and role system), problem-solving mechanisms, and need-response patterns which r e l a t e to the needs of i n d i v i d u a l members, to organize and analyze t h e i r data. They found that the family's l i f e s t y l e influences i t s ' perception of the c r i s i s i n the impact phase. The family's attempts to problem-solve must be balanced with family members' needs for love, support, and independence; freedom and control; and r o l e models. Parad and Caplan support a current rather than retrospective approach to the study of c r i s e s because "...useful information about the c r i s i s (can) be obtained only by interviewing the family while i t (is) a c t i v e l y engaged i n i t s coping e f f o r t s " (Parad and Caplan, 1965, p.54). Langsley and Kaplan (1968) applied the c r i s i s model to families in a study exploring family c r i s i s therapy as an alternative to patient h o s p i t a l i z a t i o n for mentally i l l patients. They describe c r i s i s as a struggle to master a sit u a t i o n i n which previous coping mechanisms have been i n e f f e c t i v e and a state of imbalance p e r s i s t s . They deter-mined that stress outcomes are related to the stressor, the individual's personality factors, 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 includes a variety of 12. s o c i a l subsystems which influence the struggle for stress mastery (Langsley and Kaplan, 1968). Glasser and Glasser (1970) looked at families exper-iencing the s i t u a t i o n a l c r i s e s of poverty, disorganization, i l l n e s s and d i s a b i l i t y . They found that the impact of stress may be accompanied by psychological stress or family demor-a l i z a t i o n . For r e l i e f , the family may have to make: ...alterations i n group structures and processes ... for example, s h i f t s i n the family power structure, means of communication, a f f e c t i o n a l r e l a -tionships, tasks assigned members, or ways of solving problems and resolving c o n f l i c t s . Without such modifications, disequilibrium w i l l continue and family functioning i s l i k e l y to become less e f f e c t i v e and less e f f i c i e n t (Glasser and Glasser, 1970, p.6). The time frame of family c r i s i s i s less than clear i n the l i t e r a t u r e . Caplan said c r i s i s i s s e l f - l i m i t i n g with ind i v i d u a l s , l a s t i n g from four to six weeks (Aguilera, Messick, and F a r r e l l , 1974). S i m i l a r l y , Kaplan (1973) spec-i f i e d that coping responses of parents informed of t h e i r child's leukemia would be evident within one to four weeks. Other writers have said that the duration of the disorganized state i s dependent upon variables such as family organization ( H i l l , 1965) and family members' a b i l i t y to communicate (Smilkstein, 1975). There are two types of c r i s e s : Developmental cris e s are t r a n s i t i o n points, the periods that every per-son experiences i n the process of biopsychosocial growth and develop-ment and that are accompanied by 13. changes i n thoughts, feelings, and a b i l i t i e s (Murray and Zentner, 1975, p.208). This concept i s not incompatible with the maturational changes relevant to family systems. Families experience stages of development characterized by developmental tasks. For example, the task i n the chil d - r e a r i n g stage i s the sa t i s f a c t o r y development of mother-father roles (Tomm, 1977a). Families are l i k e l y to experience some disorgani-zation at each, stage of 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 external event or s i t u a t i o n , one not neces-s a r i l y a part of normal l i v i n g , often sudden, unexpected, and unfortunate ...(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 "...precipitated by l i f e hazard...accompanied by heightened demands on the individual..."(Caplan, 1964, p.35). In t h e i r l i s t of examples of s i t u a t i o n a l c r i s e s , Murray and Zentner l i s t i l l n e s s and h o s p i t a l i z a t i o n (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 that manifests i t s e l f through observable and/or f e l t changes i n the body, causing an impairment of capacity to meet minimum physical, p h y s i o l o g i c a l , and psychosocial requirements for appropriate functioning at the l e v e l designated for the person's age, sex, and development, or handicapped state (Wu, 1973, p.23). 14. An individual's behavioral responses to the changes are d i r e c t l y related to his perception of his i l l n e s s (Wu, 1973). I l l n e s s can be viewed by the patient as a challenge, 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 interpersonal strategy, irreparable loss or damage, or a value because i t makes health more appreciated (Lipowski, 1970). Certain aspects of i l l n e s s can have d i f f e r e n t meanings as well. The meaning to (each) patient of his symptoms, le s i o n , diagnostic lable, loss of function, doctor's statements, and so fo r t h , i s determined by multiple factors, i n t e r n a l and external (Lipowski, 1970, p.1198) . The temporal aspects of i l l n e s s (onset, course, and duration) w i l l also assume character and meaning from past experiences, cognitions, and understandings (Wu, 1973). Il l n e s s and phases of i l l n e s s have also been viewed in terms of adaptive tasks. Murray and Zentner (1975) i d e n t i f y the adaptive tasks of convalescence as reassess-ment of l i f e ' s meaning, reintegration of body image, and resolution of role changes or reversals. Moos (1977) says serious i l l n e s s or injury sets f o r t h seven adaptive tasks: dealing with pain and incapacitation, dealing with hospital environment and treatments, developing adequate relationships with professional s t a f f , preserving emotional balance, pre-serving a s a t i s f a c t o r y self-image, preserving relationships with family and friends, and preparing for an uncertain future. Moos notes, "... family members and friends, as well as patients, are affected by the c r i s i s (of i l l n e s s ) , (and) encounter many of the same or closely related adaptive tasks..."(Moos, 1977, p.8). I t would seem that when the perceived challenge or threat of i l l n e s s exceeds the coping c a p a b i l i t i e s and resources of an in d i v i d u a l or family, i l l -ness constitutes a c r i s i s . The family system may become mass-i v e l y disrupted when a member becomes seriously i l l with an organic disease, and the family's response to the i l l n e s s may dras-t i c a l l y a f f e c t the outcome for the sick member... (Olsen, 1970, p.237) . Livsey says, "Serious i l l n e s s i n an i n d i v i d u a l creates a family c r i s i s " (Livsey, 1972, p.237). She stresses the in t e r r e l a t i o n s h i p of i l l n e s s and family even further, "Stress i n human relationships i s believed to 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 structure" includes factors which define the family through i t s membership and the nature of i t s connec-tions across the family boundary. Family membership spec-i f i e s the composition -of the family; who i s and i s not a member, the alignments and s p l i t s among members. Family connections with the environment include the quantity and quali t y of relationships with other i n s t i t u t i o n s such as 16. workplace and school, with t h e i r s o c i a l network, and the family's socio-economic and geographic p o s i t i o n i n the community (Tomm, 1977a). I l l n e s s can a l t e r family household membership i n di f f e r e n t ways. The i l l person may have to leave the house-hold to obtain treatment (Livsey, 1972). The separation may be lengthy and the distance great. If a parent i s h o s p i t a l -ized i t may be necessary for children to leave the household to be cared for by friends and r e l a t i v e s . I t may be necessary to have individuals j o i n the family to provide assistance (Parsons and Fox, 1968). Members may rea l i g n when there i s i l l n e s s i n the family. For example, when a father becomes i l l , an older son may al i g n with his mother as another adult-parent (Olsen, 1970). Family members might a l i g n against the i l l member because of his/her demands f o r attention (Livsey, 1972). H i l l (1965) describes family connections with community i n s t i t u t i o n s : ...the closed nature of the family i s s e l e c t i v e l y opened for tran-acting business with other agencies, including kin and professionals... agencies can be ranked on t h e i r a c c e s s i b i l i t y to the... family: immediate kin highest, family friends and neighbors next, the family phy-c i a n , . . . p a s t o r a n d so on... Other agencies enter the family with greater d i f f i c u l t y and often through ...family members who act as l i a i s o n s for the family: the school, the employer, the health c l i n i c , the case-work agency, and other such formal agencies CHI11, 1965, p.33). I l l n e s s can a l t e r these connections. For example,, connec-tions with school and workplace might decrease while con-nections with health and s o c i a l service agencies might increase. H i l l goes on to note that families have changed. Once a self-contained economic and s o c i a l unit buttressed by kinship supports, the family now has i n t e r -dependent relationships with many other associations i n working out i t s problems ( H i l l , 1965, p.34). Parsons and Fox (1968) say the family i s es p e c i a l l y vulner-able to the effects of i l l n e s s because today's families are iso l a t e d from kin relationships and therefore must become more dependent on s o c i a l i n s t i t u t i o n s . MacVicar and Archbold say, "The number of persons available to provide assistance... i s an indicator of potential hardship imposed by i l l n e s s " (MacVicar and Archbold, 1976, p.187). They agree with Parsons that assistance from kinship systems i s usually neither stable nor permanent. Further support for the importance of family connections within the community i s given by Yokes i n his discussion of patients with myo-ca r d i a l i n f a r c t i o n : Those families who have close t i e s within the primary family, with r e l a t i v e s and with mem-bers of the l o c a l community, seem to have a cushion of ab-sorbtion of the emotional and sometimes f i n a n c i a l shock ex-perienced when a family member has an acute myocardial i n f a r c -tion (Yokes, 1973, p.395). Il l n e s s can also drain family f i n a n c i a l reserves. 18. Reduced f i n a n c i a l reserve and consequent alt e r e d l i f e s t y l e add to the adjustments required from the family with an i l l member (MacVicar and Archbold, 1976). In the l i t e r a t u r e , reactions to the c r i s i s of i l l -ness tend to be described i n terms of the patient or family subsystems. A common approach has been to look at the reactions of spouses. In a study of patients with chronic i l l n e s s and t h e i r spouses, i t was found that 56% of spouses noted an increase i n tension during the i l l n e s s of the other. The interpersonal tension from i l l n e s s i n one member led to psychophysiologic d i s t r e s s (symptoms) i n both partners (Klein, 196 7). In another study looking at reactions of spouses, S i l v a (1977) reports that 23 out of 36 presurgical spouses scored higher on the State Anxiety Inventory than did the preoperative patients themselves. Skelton and Dominian (1973) studied the reactions of 6 5 wives of myocardial i n f a r c t i o n patients during the hus-band's hos p i t a l stay, then three, six, and twelve months following discharge. Within the f i r s t three months af t e r discharge, 2 5 wives reported feelings of tension, anxiety, depression, and sleep disturbance. They were distressed because of t h e i r "loss" of a "strong" husband and fear of recurrence. They found t h e i r husbands dependent and i r r i t -able which contributed to feelings of tension and sometimes h o s t i l i t y . In a si m i l a r more recent study, 82 wives of myo-ca r d i a l i n f a r c t i o n patients were interviewed while t h e i r 19. husbands were i n h o s p i t a l , and again at two months and twelve months af t e r discharge (Mayou, Foster, and Williamson, 1978). During the f i r s t few weeks afte r discharge 80% of the wives experienced anxiety, depression, fatigue, i r r i t a b i l i t y , poor concentration, and insomnia. "In the f i r s t few weeks the men were very dependent... the men had to modify t h e i r jobs...more often than the wives had foreseen. .." (Mayou, Foster:;' and Williamson, 1978, p. 700). The marital subsystem (husband and wife) has been the focus of two studies. Kaplan (1973) assessed fami l i e s ' coping behaviors by assessing the coping mechanisms observed i n parents of leukemic children. Unfortunately, the a r t i c l e does not reveal the methodology of the study except to say i t was a c l i n i c a l review of 50 families from the day of confirmed diagnosis u n t i l two months af t e r the c h i l d died. The marital subsystem was also the focus of a study of burn patients. Patients and t h e i r spouses were asked to discuss t h e i r post-hospital experiences i n a group with other burn patients and t h e i r spouses (Granite and Goldman, 1975). Their discussions centred on concerns about family r e l a t i o n -ships, work, recreation and integration into the larger community. Some a r t i c l e s appear to have generalized i n d i v i d u a l member reactions to family reactions. The reactions are usually i d e n t i f i e d as feelings, defence mechanisms or other emotional responses. For example, Epperson (1977) found that families i n the acute c r i s i s stage, when f i r s t coming to a 20. c r i t i c a l c a r e u n i t t o s e e a n i n j u r e d f a m i l y member , d e m o n -s t r a t e p e r i o d s o f h i g h a n x i e t y , d e n i a l , a n g e r , r e m o r s e , g r i e f , a n d f i n a l l y r e c o n c i l i a t i o n . She g o e s o n t o s a y t h a t f a m i l i e s may e l i m i n a t e s t a g e s a n d d i f f e r e n t members may be e x p e r i e n c i n g d i f f e r e n t s t a g e s a t t h e same t i m e . H e n c e , t h e s t a g e s h a v e l i t t l e p r e d i c t i v e v a l u e . S i m i l a r l y , W i l l i a m s a n d R i c e (1977) l i s t h o s t i l i t y , a n g e r , g u i l t , a n d g r i e f a s p o s s i b l e r e a c t i o n s o f f a m i l i e s o f i n t e n s i v e c a r e u n i t p a t i e n t s . I t i s n o t c l e a r t h a t t h e s t u d i e s b y E p p e r s o n (1977) a n d W i l l i a m s a n d R i c e (1977) h a v e , i n f a c t , i d e n t i f i e d f a m i l y a f f e c t i v e o r e m o t i o n a l r e s p o n s e s t o a c u t e i l l n e s s s i t u a t i o n s . P e r h a p s more c o r r e c t l y , t h e y h a v e i d e n t i f i e d common a f f e c t i v e o r e m o t i o n a l r e s p o n s e s i n i n d i v i d u a l f a m i l y m e m b e r s . E F F E C T OF I L L N E S S ON F A M I L Y F U N C T I O N I N G Family functioning i s concerned with the d e t a i l s of how individ u a l s actually behave i n r e l a t i o n to one another i n the process of f u l f i l l i n g the needs and goals of the family . and i t s members... functioning refers to routine a c t i v i t i e s of d a i l y l i v i n g involved i n s u r v i v a l . . . and i n the procurement and use of goods and ser-vices ... (functioning also) refers to the emotional, communicative, problem-solving, and control behaviors of family members (Tomm, 1977a, p.3). Almost a l l aspects of family functioning can be viewed as f o r m a l a n d i n f o r m a l r o l e a l l o c a t i o n s . A role can be defined as the pattern of wants and goals, b e l i e f s , f e e lings, attitudes, values and actions which members of a community expect should characterize the typ-i c a l occupant of a position (Robischon and Scott, 1962, p.52) . Informal roles r e f e r to prescribed patterns of behavior i d i o s y n c r a t i c to p a r t i c u l a r individuals in certain settings. Formal roles are those broadly agreed upon with-i n the community. Examples include the roles of mother, policeman, student,(Tomm, 1977c). Roles commonly determined by age and sex are uniquely defined within each family system (Anderson and Carter, 1974). By mutual consent, family members can be breadwinners, nurturers, d i s c i p l i n -arians, and clowns. Roles ex i s t i n paired positions. An i n d i v i d u a l can not adopt a "victim" role unless another member adopts the rec i p r o c a l role of "persecutor" (Robischon and Scott, 1969). A l t e r a t i o n of one role requires a l t e r a t i o n of the other. Although mutually agreed upon at some l e v e l of awareness, i t i s possible for a role to e x i s t , such as scapegoat, which i s functional for the family but disfunc-t i o n a l for the in d i v i d u a l (Bell and Vogel, 1968). Nye and Gecas i d e n t i f y eight parental roles i n t h e i r review of family l i t e r a t u r e : provider, housekeeper, c h i l d care, c h i l d s o c i a l i z a t i o n , sexual, r e c r e a t i o n a l , therapeutic, and kinship (Nye and Gecas, 1976, p.13). Role change i s l i s t e d as a very common family 22. occurrence following i l l n e s s of a family member. Anthony (1970) studied families i n which one of the parents was mentally or p h y s i c a l l y i l l . There i s no doubt that i l l n e s s brings about a disequilibrium within the family and a change in complementarity of roles (Anthony, 1970, p.60). Anthony (.1970) pointed out that the family must acclimatize i n i t i a l l y to i l l n e s s and then to the "wellness" of the patient. Shellhase and Shellhase (1972) state that the neces-sary reorganization of family objectives following physical d i s a b i l i t y of a member often r e s u l t s i n changes of ro l e s . They go on to say: Established patterns of decision-making a c t i v i t i e s are 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 of the now-disabled member. In addition to the e a r l i e r purpose of the family ...the family i s now required to devise and implement an accommodar tion fo the r e a l i t y of the d i s -a b i l i t y within the family group (Shellhase and Shellhase, 1972, p. 549) . Besides role changes, another noticeable area of change following i l l n e s s of a family member may be i n a family's patterns of int e r a c t i o n . Families e s t a b l i s h pat-terns of inte r a c t i o n to organize family functioning into a reasonably stable system. These patterns i d e n t i f y what i s acceptable and not acceptable regarding how, when, and to whom to re l a t e in a wide variety of content areas (Watzlawik, 23. Beavin, and Jackson, 1967). Jackson (1964) coined the term "family rules" to i d e n t i f y these governings of family l i f e . Repetitive patterns of interaction among family members define family rules which, i n turn, govern patterns of inter a c t i o n . Haley (.19 62) said the focus of a family study should be on the t o t a l family and the interactions between family members rather than the interactions between family members and the interviewer or tester. But r a r e l y i s reference made to i n t e r a c t i o n a l changes as a response to i l l n e s s of a family member. Shellhase and Shellhase (1972) report that, in response to traumatic injury of a family member, "...the f u l l range of a c t i v i t i e s and transactions which contribute to the maintenance of the family as a group undergoes exten-sive change" (Shellhase and Shellhase, 1972, p.549). EFFECT OF FAMILIES ON ILLNESS Families have an e f f e c t on the course of i l l n e s s and r e h a b i l i t a t i o n . Power (19 76) observedchronically i l l patients and th e i r families and determined that the feelings and attitudes of the patient's family are a v i t a l factor i n the adjustment to i l l n e s s . This was strongly supported i n a two year study of patients, 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 frequently a sign of uncooperative family strategies such as undermining the experts or 24. c o n t r o l l i n g the patient's i n i t i a t i v e . The variable of time probably has an e f f e c t on the importance of family to patient progress. The low s i g n i -ficance i n the r e l a t i o n s h i p between family s o l i d a r i t y and r e h a b i l i t a t i o n in Litman"s (19 66) study i s most l i k e l y due to the early, c r i t i c a l stage of the orthopedic injury when i t i s f e a s i b l e that family s o l i d a r i t y would have l i t t l e e f f e c t on early t r a i n i n g of the patient. Closer to the end of the fifteen-month period of t r a i n i n g i t was found that the family did play an i n f l u e n t i a l r o l e In the patient's convalescence. Litman concluded that, " I t appeared that therapy may be enhanced i f performance i s conceived i n terms of re-entry into an established family c o n s t e l l a t i o n rather than an i n d i v i d u a l or personal matter" (Litman, 1966, p.216). Using a questionnaire., Levinson (1976) determined that the family resources of r e l i g i o u s b e l i e f , education, and income were more s i g n i f i c a n t than marital s a t i s f a c t i o n i n reducing stress and increasing coping a b i l i t y i n the c r i s i s related to having a mentally retarded c h i l d . A methodological shortcoming was t h i s project's retrospective approach to the study of the coping process. Family factors predicting home placement of severely disabled p o l i o patients were the kinds arid degree of role changes which the d i s a b i l i t y imposed. Where large d i f f e r -ences existed i n pre and p o s t - i l l n e s s family roles, the patients were more l i k e l y to remain i n hospital (Deutsch and Goldston, 1960). 25. The family also has an e f f e c t on i l l n e s s suscep-t i b i l i t y . The family contributes not only to genetic predisposition but also to the actual etiology of s p e c i f i c diseases through the transmission of s o c i a l values, the s o c i a l i z a t i o n process of the c h i l d , and the family pattern of 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 to maintain a steady state but can experience c r i s i s . Caplan's d e f i n i t i o n of c r i s i s as an experience of a f f e c t i v e change and disorganization of function appears to be widely accepted (Aguilera, Messick, and F a r r e l l , 1974, p.6). However, the study of families i n c r i s i s i s com-pl i c a t e d by two factors. The focus of the early' develop-ment of c r i s i s theory was the i n d i v i d u a l . Attempts to d i r e c t l y apply c r i s i s theory to family systems ignores the complexity of a system comprised of many ind i v i d u a l s . Secondly, investigators and writers have used numerous approaches and points of view i n th e i r attempts to under-stand the family. Consequently the phases, c h a r a c t e r i s t i c s , and temporal aspects of c r i s i s in families are d i f f i c u l t to determine from the readings. The l i t e r a t u r e supports the view that i l l n e s s can constitute a c r i s i s i n a family. The family's response to 26. the c r i s i s has an e f f e c t on the course of i l l n e s s and implications for the family's i n t e g r i t y . The l i t e r a t u r e most frequently describes family reactions i n terms of an i n d i v i d u a l or family subsystem. This i s e s p e c i a l l y true i n the studies describing a f f e c t i v e or emotional responses. Other responses to i l l n e s s have been described as changes i n family structure, r o l e s , and occasionally as changes i n patterns of in t e r a c t i o n . Using existing knowledge of family dynamics and c r i s i s , t h i s study then, i s designed to further explore the family's responses to i l l n e s s of a family, member. I I I . METHODOLOGY The f i r s t purpose of t h i s study was to describe reactions that occur i n families when fathers 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 hospital for one to three weeks. The second purpose was to describe what people and services these families report to be help f u l during t h i s one to three week period. This information could be added to exis t i n g knowledge about how families experience c r i s i s and how nurses can give e f f e c t i v e care to patients and th e i r families as they cope with the c r i s i s of i l l n e s s . The purposes of t h i s study and the lack of s i g n i f i c a n t research i n the area directed the investigator to an exploratory descriptive research design (Brink and Wood, 1978). This chapter describes the various aspects of the methodology used to carry out t h i s study. Discussed i n the following pages are sample selection, 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 sample was s e l e c t e d from a: p o p u l a t i o n o f c o r o n a r y p a t i e n t s C n o n - s u r g i c a l ) i n two l a r g e urban 27. 28. general hospitals. In both settings the patients spend one to seven days i n a coronary acute care area before being transferred to the post acute coronary care units where they remain u n t i l discharge. The head nurses on both post acute units (8 and 18 beds respectively) reported that t h e i r bed occupancy was almost always 100%. For purposes of homogeneity of developmental stage, the 10 families i n the sample had at lea s t one c h i l d l i v i n g 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 father had recently experienced his f i r s t known myocardial i n f a r c t i o n - the family l i v e d i n the lower mainland, and was accessible for a home v i s i t - parents and children nineteen years or older would be able to read and respond to the l e t t e r s of consent Each week t h i s investigator spoke with the head nurses of both units to get a l i s t of e l i g i b l e patients about to be discharged from h o s p i t a l . The investigator v i s i t e d each e l i g i b l e patient i n the ho s p i t a l . The content of the l e t t e r of consent was discussed and consent was sought to pa r t i c i p a t e in the study and to approach other family members (See Appendix A). Telephone verbal consents were sought from other family members and an appointment made f o r a home v i s i t . Written consents were obtained on the occasion of the home v i s i t before the interview began (See Appendix B). One patient refused to pa r t i c i p a t e i n the study. He was very anxious in. h o spital and about discharge i n 29. p a r t i c u l a r . He asked to have two weeks to "take i t easy" and then he would consider i t . (When contacted by the investigator, a l l family members agreed to participate.) The method of sample selection did not provide a random sample hence the re s u l t s of the study are not generalizeable beyond the families of the study. It i s assumed that variables such as previous learning experiences, i n d i v i d u a l personality factors, and socioeconomic lev e l s influence the response of the family system to i l l n e s s . The e f f e c t s of these extraneous v a r i -ables were not controlled except for the variable of previous learning experience. This study s p e c i f i e s that the patient w i l l have experienced his f i r s t known myocardial i n f a r c t i o n . Since the focus of this study was on q u a l i t a -t i v e data rather than proving or disproving a hypothesis, t h i s l i m i t a t i o n was not a major concern. DATA COLLECTION The method chosen for c o l l e c t i o n of the data was a semi-structured interview to avoid r e s t r i c t i o n of responses but to ensure that comparable data were coll e c t e d (Brink and Wood, 1978). A combination of open-ended and closed-ended questions and scale items was used as advised by Kerlinger (1973). Five content areas were covered by the interview schedule. Four content areas were related to family reac-tions i n the realms of a f f e c t , i n t e r a c t i o n , roles and 30. structure. The f i f t h content area was related to what people and services the family perceived to be h e l p f u l . The interview schedule was examined by thesis com-mittee members and revised. It was submitted to two experts (a member of the nursing f a c u l t y and a nurse c l i n i c i a n i n a community mental health centre) for review. Adjustments were made to eliminate ambiguities and inade-quate wording. The revised interview schedule was pretested with two e l i g i b l e families and minor f i n a l adjustments were made. The interview schedule i n i t s f i n a l form i s presented i n Appendix C. One to three weeks af t e r the father had been d i s -charged from hospital, each family was interviewed once i n the i r home. This provided them with a f a m i l i a r and com-fortable setting. I t also provided opportunities for the investigator to observe interactions, non verbal cues, and environmental factors which validated family responses. The investigator used the interview schedule with each family. The interviews were tape recorded and the content of the tape recordings was compared to notes written during the interview to ensure that the written data were complete and accurate. Additional notes of observations were made immediately after each interview. Members of the thesis committee monitored random sections of tape recordings with the interview schedules to ensure v a l i d i t y of the investigator's judgements. Obj e c t i v i t y of the participant investigator was fostered 31. by the thesis committee's monitoring of tape recordings and interview schedules, the use of a standard interview schedule, and the investigator's s e l f - s c r u t i n y . The interviews ranged from 30 to 6 0 minutes with the average being approximately 50 minutes. The t o t a l time spent with each family was about 75 minutes. A l l interviews took place i n the family home, 8 i n the evening and 2 i n the afternoon. Only one family member, an 11 year old, reported f e e l i n g s e l f conscious with the tape recorder once the interview had ended. DATA ANALYSIS Descriptive analysis was planned for the data since the purposes of the study were to describe reactions and people and services perceived to be h e l p f u l . The information from the study would be added to exis t i n g knowledge. Des-c r i p t i v e analysis was also appropriate since, without a random sample, the conclusions of the study refer only to the study sample (Brink and Wood, 19 78). The abundant data from the semi-structured i n t e r -views were summarized into categories and descriptive 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. This approach i s defined by H o l s t i as content analysis. Content analysis i s any technique for making inferences by objecti v e l y and systematically 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). IV. RESULTS The f i r s t purpose of t h i s study was to d e s c r i b e r e a c t i o n s 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 m yocardial 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 to three weeks. The second purpose of the study was to d e s c r i b e what people and s e r v i c e s f a m i l i e s r e p o r t to be h e l p f u l d u r i n g t h i s p e r i o d . T h i s chapter w i l l d e s c r i b e the sample and r e p o r t the f i n d i n g s of the study. DESCRIPTION OF THE SAMPLE As shown i n Table 1, the sample c o n s i s t e d of 10 f a m i l i e s and i n c l u d e d 41 f a m i l y members. Fa t h e r s ranged i n age from 40 to 58 years, mothers from 34 to 55, and c h i l d r e n from 2 to 23. A l l o f the f a t h e r s i n the sample were on p a r t i a l or f u l l s a l a r y a t the time o f the i n t e r v i e w . Two wives worked p a r t - t i m e (up to three days a week), and three wives worked f u l l time. 33. TABLE 1 Ages of 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, 15 a 6 44 42 15 7 50 48 9 8 58 55 23 9 52 49 17, 23 10 43 39 8 cl Lives i n household but was not available for interview. The number of days fathers spent i n hospital ranged from 8 to 15. The length of time between date of discharge and the family interview ranged from 8 to 19 days (See Table 2) . 34. TABLE 2 Duration of Hospitalization and Number of Days After Discharge That Interview Took Place Number of Days Subject Acute Care Post Acute Care After Discharge 1 3 10 11 2 1 12 8 3 6 9 10 4 3 11 19 5 4 8 14 6 1 11 9 7 2 6 11 8 4 11 8 9 7 7 12 10 1 12 8 Eight fathers were being v i s i t e d by home care nurses twice a week at the time of the interview. One father was attending a physiotherapy program. FINDINGS The l i t e r a t u r e review suggested that families exper-iencing i l l n e s s of a family member would manifest reactions or changes i n family rol e s , patterns of int e r a c t i o n , a f f e c t , 35. and structure. Items 1 through 4 of the interview schedule were designed to gather these data. The 10 families i n t e r -viewed described changes i n a l l 4 areas, as shown i n Table 3. TABLE 3 Areas of Change Described by Families Changes Family Role Interactions A f f e c t Structure 3 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 Social Contact and Family Membership but excludes reduced contact with father's co-workers. More d e t a i l s regarding these areas of change are described i n subsequent sections of this chaper. 36. Changes i n Roles (Item 1). Table 4 shows the changes i n roles i n descending order of frequency. Of the 10 fami l i e s , one reported changes i n 4 roles, 5 reported changes i n 3, one reported changes i n 2, and 3 reported changes i n one r o l e . TABLE 4 Changes i n Roles Described by Families Family Roles 2 3 4 5 6 7 8 9 10 Household chores(la) X F i n a n c i a l (If) management X Looking aft e r feelings (le) X D i s c i p l i n i n g children (lb) X Decision making (Id) I n i t i a t i n g (lc) s o c i a l a c t i v i t i e s X X X X X X X X X X X X X X X X X X The roles included were those i d e n t i f i e d by Nye (1976) except for the sexual role which was not explored by the investigator nor mentioned by family members. A l l 10 families experienced changes i n household chores. The changes were minimal i n some fa m i l i e s : Dad didn't do anything (before the heart attack) anyway. The only change i s Mom did some gardening one day and the boys usually do i t . One mother said: I'm doing less because I'm spending time with 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 . Nevertheless, a l l 10 families reported that wives and c h i l -dren were doing more work to reduce father's workload around the house. However, 4 fathers assumed new household respon-s i b i l i t i e s : (Father's) doing more around the house because he's home and i t ' s easier because he has l o t s of time. Dad i s helping more with dishes and cooking because he's bored. One father assumed r e p o n s i b i l i t y for waking his wife and daughter "...to get her to school on time. Usually Mom sleeps i n . " And children reported of t h e i r father, "He makes us snacks now for a f t e r school." Five families reported changes i n the f i n a n c i a l management of the family. In a l l 5, the wives had increased t h e i r p a r t i c i p a t i o n from no involvement to "... doing more leg work" and to "...going to s t a r t paying the b i l l s and doing the banking." Four families reported changes i n who looks aft e r people's hurt feelings and concerns. One mother said she had less time to provide r e l i e f for her children because 38. she had to be nurse-companion to her husband. In the other 3 families, the children reported going to Dad less than they used to. The changes reported by 3 families i n regards to d i s c i p l i n i n g the children were varied. One mother reported: I'm doing 100% now to ease the stress for Dad. One father reported having increased involvement with the children: I can't put up with the screaming and y e l l i n g . I'm forever putting the children i n t h e i r rooms. And the youngest (15 years) of 3 boys in a family reported: Dad y e l l s less now. I'm doing some y e l l i n g now - keeping (older brothers) i n l i n e . Only 2 families reported a change i n decision making role s . In one family, the boys described the usual family pattern: Usually 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 recent episode when the youngest c h i l d was believed to be l o s t , the oldest boy "took over" and mother calmed the father. In the second family, the wife got a driver's learner permit without discussing i t with her husband and thi s was a change. Families who hadn't exper-ienced having to make a major decision as yet did not a n t i -cipate a change i n the decision making i n the family. None of the families reported a change i n the role 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 family. 39. Another r o l e that emerged i n the interviews was one which 7 wives i d e n t i f i e d . They reported a c t i v i t i e s and con-cerns related to t h e i r perceived health care worker respon-s i b i l i t i e s . Some t y p i c a l comments made were: It takes me a long time to shop because the d i e t has changed for everyone and I know I have to get i t r i g h t . I'm nagging more...Don't do t h i s . Leave that alone. I'm trying to keep the kids quiet, stop them from acting up while he's home - but i t ' s hard. If he's having aches or pains or problems, I sink 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 into the habit of lying around. It's hard to know what to do. Last week I slept l i g h t l y i n case he needed something. I f e e l more responsibile for making him f e e l O.K. Changes i n Patterns of Interactions (Item 2) Table 5 shows that of the 10 fam i l i e s , 9 reported changes i n the amount of. talking they were doing, and a l l 10 reported changes i n the kinds of things they talked about. Data yielded from item 2c of the interview schedule were redundant and omitted from the analysis. 40. TABLE 5 Changes i n Patterns of Interaction Described by Families Family Patterns of Interaction 1 2 3 4 5 6 7 8 9 10 Amount of Talking (2a) + + - + - + + . V -Topics (2b) X X X X X X X X X X Note. V indicates d i f f e r i n g responses from family members In 8 families discussion of s t r e s s f u l topics was reduced. Children required less d i r e c t i o n and were obedient quickly. There was less arguing between s i b l i n g s , parents, and parents and children. In 2 of these families parents avoided t a l k i n g about f i n a n c i a l matters and i n one family, f i n a n c i a l matters were the one "serious" topic they did discuss. Very frequently, i t was the' wife who was edi t i n g subject matter i n the family: Don't bug father with that r i g h t now or he'11..get upset. Only one father reported withholding information to control stress l e v e l s of his 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 to hide i t . Six families reported that they were ta l k i n g more about health-related topics: diet, weight, exercise. Only 41. 4 families reported that the father's heart attack per se had been discussed i n the family but th i s question was not asked of a l l families. In one family there was more joking and loving looks exchanged between the parents than had been the case before the heart attack, and one father said he was ta l k i n g about school with his children more than he had before. In terms of the amount of talking being done, 5 families reported they were talking more than they had before the father had had his heart attack and 3 families reported t a l k i n g less than they used to. In one family 3 members said the family was talking the same amount and one member said the family was talking l e s s . While discussing changes i n patterns of in t e r a c t i o n , 4 families commented on new perspectives the heart attack had brought about in the family: ...more aware that l i f e i s r e a l l y short. Don't waste precious time arguing about s i l l y things. I've done lo t s of thinking that I've never done before... things are better now, more l i k e they used to be (more loving, time together). (Husband) I used to be strong, steadfast, a rock. I f e e l closer and more intimate towards (my wife). I'm much more conscious of how much I need her. (Wife) It's been the same for me. I appreciate him a l o t more...He's more important to me than I thought. The family i s n ' t quite as permanent as I thought. 42. Perhaps we were drawn closer together when Dad had th i s heart attack. Makes you forget the l i t t l e things and we try to get around i t rather than get on each other's nerves. We don't take anyone for 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 of frequency. Six families reported changes i n a l l 5 areas of a f f e c t , 3 families reported changes i n 4- areas, and one family in one area of a f f e c t . With the affects of "impatience", "hopefulness", "fearfulness", 9 families reported changes. With the affects of "happiness" and "nervousness", 8 families reported changes. TABLE 6 Changes i n Af f e c t Described by Families Family A f f e c t 1 2 3 4 5 6 7 8 9 10 Impatience (3b) -Hopefulness + (3c) Fearfulness + (3e) Happiness (3a) V Nervousness V (3d) V V V V V V V + + V . V v V + + + + V + v V V + + - V + + V V V V V + + V Note. V Indicates d i f f e r i n g responses from family members. 43. In 7 of the 9 families experiencing changes i n "impatience," family members reported trying to be nicer, more relaxed and tolerant Of one another. As one c h i l d -s i b l i n g put i t : Our family i s more subdued, less reactive, less boisterous. In one family the 4 children reported that t h i s more patient behavior occurs, "...only when Dad's around." Increased impatience with diet and a c t i v i t y r e s t r i c t i o n s was reported by 4 of the 7 fathers. In the 2 families where less impatience was reported o v e r a l l , some family members reported increased impatience with the children. In one of these families, the father thought he was " b i t c h i e r " but the mother thought he was the same. In one family, the oldest son reported increased impatience with his father's i n f r a c -tion of die t and a c t i v i t y l i m i t s . Of the 9 families reporting changes i n ^hopefulness i " 5 families said they were fe e l i n g more hopeful. In the remaining 4 families, there were differences expressed. Fathers expressed hopefulness while mothers and children were less hopeful. (Father) I'm more hopeful. I f e e l stronger every day. (Mother) I'm s t i l l insecure, e s p e c i a l l y i f he's not f e e l i n g well. (Father) At the end, I ' l l be back to normal. (Mother, Children) We're s t i l l nervous about i t . (Father) When I was in hospital I thought, "What w i l l happen next time?" But now I'm just thinking about getting better. (Mother) It 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) It might happen again. I guess that f e e l i n g w i l l wear o f f . Family members i n 9 families said the family was more f e a r f u l than i t had been before the heart attack. One father said: No one can t e l l you when i t ' s going to happen again...if i t ' s going to happen. In 4 families where mothers expressed increased fearfulness, d i f f e r i n g views were presented by other family members. One son expressed the view of father and two of the children Think of i t as a one shot deal. It won't happen again. But the t h i r d son i n the family said: Sometimes you forget he had one (heart attack). Everything's fine and dandy. Then I remember, something could happen. In response to his 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 interview, this same father had said about a c t i v i t y : The physical strength might be there but I'm a f r a i d to use i t . Another father said: I disagree. There's no change (in fearfulness). Another father said: I know they're (wife and son) : more f e a r f u l but I couldri't say for myself. I'd have to think on i t . Of the 8 families reporting a change i n happiness 2 families reported being less happy and 2 were- more so. In 4 families there were varying responses from family members. Wives and children reported more happiness because, "He's here with us,"and posi t i v e changes i n family relationships and health habits had taken place. In these families one wife expressed her ambivalence about happiness: It's hard to generalize u n t i l the doctor says he's O.K. Two fathers.said there hadn't been any change i n family hap-piness and one father said the family was less happy because of the r e s t r i c t i o n s on everyone. In thi s l a s t family, the 2 children said there was no change i n happiness. Three families reported an increase i n nervousness and 5 families reported varying responses. In these 5 famil i e s , the mothers reported increased nervousness due to having to manage the children's problems alone, reduced finances, father's health, and..other new r e s p o n s i b i l i t i e s . As one woman said: There's more pressure and s t r a i n to do things. And there are deadlines. In these 5 fami l i e s , 2 fathers and th e i r children reported no change in nervousness, 2 fathers reported less nervous-ness, and one son said, "There's less tension because i t goes away a l o t faster now." Of 43 responses i n regards to changes i n a f f e c t , 24 were varied responses where family members stated d i f f e r e n t opinions on more, les s , or no change. There were other expressions of a f f e c t i n r e l a t i o n to adjustment to the i l l n e s s . One father c l e a r l y expressed a sense of lo s s : You have to give up everything (food, cigarettes, a c t i v i t y ) a l l at once. I've had to give up a helluva l o t ' And another father expressed anger towards himself: I'm r e a l l y mad. I should have done i t (stop smoking, diet) e a r l i e r . Only one marital pair said the husband's increased dependence on the wife was "...something new for both of us ...not f r u s t r a t i n g , just inconvenient." Some children were demonstrating marked changes i n behavior. In one family, the 15 year o l d son did not come home for the evening interview. His parents thought he was deliberately avoiding the discussion. They described him as ...changed completely. He used to run around a l o t (before the heart attack). Something's bothering him. He's much quieter, s e t t l e d down. The school counsellor c a l l e d but (the son) won't confide i n him. In another family where the father and daughter reportedly never got along, the daughter f e l t unable to argue with her father about keeping a part time job that was very important to her. U n c h a r a c t e r i s t i c a l l y , she complied and gave up her job without argument. In another family, the daughter planned to stop seeing her boyfriend because her father had disapproved of him. She had been dating the boy for several months and her father had not mentioned i t since coming home from h o s p i t a l . The daughter thought she should do i t "...to make Dad happy." Statements of shock and d i s b e l i e f were expressed by 4 fathers during interviews that took place on the eighth, tenth, eleventh, and fourteenth days post discharge: Why me? I had only one on the ri s k scale - heredity. The biggest thing was the shock. I never get sick. I never miss work. Nothing could happen to me! I have a mental block. I'm only 44 years old. I shouldn't be here. I've never been sick. I s t i l l can't believe i t . . . I ' v e always been so healthy. Of these 4 fathers, 2 had experienced d i f f i c u l t i e s i n the f i r s t week home from h o s p i t a l . One father reported: I had a sort of f l u for four days: nausea and vomiting, headache, shakes, and crying jags. I s t i l l have an eye inflammation-and a headache. One son reported and a l l members agreed: In the f i r s t few days Dad was picky, edgy, almost explosive. Now he's a l o t quieter. 48. Changes i n Family Contact (Item 4), The parameter of family structure has two aspects. The f i r s t i s family contact with outside groups and the second i s family membership. Table 7 shows that of the 10 families, one family experienced changes in the amount of contact they had with 6 groups, 5 families with 4 groups, and ;4 families with 2^groups. Table 7 shows the changes i n contact i n des-cending order of frequency. TABLE 7 Changes i n Family Contact with Groups Family Groups 1 12 3 4 5 6 7 8 9 10 Friends (4ai) + + - + - + + + + Community Agency People (4avii) + + + + + + . - . + + Family Members (outside house-hold) (4aii) + + NA NA + . . + + + Neighbors ( 4 a i i i ) + - . + + . . . . + Clergy (4avi) . . . . . . . . -People from school (4av) . . . . + . . . . People from work (excl. father) (4aiv) NA NA NA - NA - . . NA Note. NA indicates not applicable. Families did not have extended family i n Canada or family members, other than fathers, who worked. 49. By group, 10 families experienced changes with friends, 8 with community agency people, 6 of 8 families with extended family members experienced changes, 5 exper-ienced changes with neighbors, 2 with clergy, one with people from school, and 2 of 5 families with working members other than fathers experienced changes. A l l 10 families experienced changes i n the amount of contact they had with friends. In 7 cases, friends had been seen more. In 2 of the 3 families where friends had been seen l e s s , the families remarked that friends seem to be "hesitating - a f r a i d to t i r e him (father! I guess." Eight families had contact with home care nurses. Of these 8, 2 had contact with a d i e t i c i a n , and one had contact with a physiotherapist as well. Bank managers had been seen by 2 of these fa m i l i e s . Two families' did not have other r e l a t i v e s i n Canada. Of the 8 remaining, 6 families had increased contact with extended family members and one family said the heart attack had brought the whole family "closer." Half of the families reported no change i n the amount of contact they had with neighbors. "We never saw them any-way." "I doubt that they even know Dad had a heart attack." Of the 5 families reporting a change i n contact, 2 said they didn't know the neighbors but the neighbors had asked how the father was f e e l i n g . S i m i l a r l y , 5 families reporting no change i n the amount of contact with clergy remarked that they didn't have 50. any contact anyway. Two families reported less contact because of i n a b i l i t y to get to church services. One wife continued to attend church as before. Two families reported no change and made no further comment. Only one school counsellor contacted the parents about t h e i r son's behavior and possible adjustment to the father's i l l n e s s . The most frequent comment made by th_e family in response to the question was, "No change. I doubt they (teachers, counsellors) even know (about the heart attack)." Of the 5 families where someone other than the father was employed, one member reported having less contact with people from work and t h i s was related to her having changed the s h i f t she worked. Another member took a leave of absence from work to be home with her husband. In r e l a t i o n to the amount families were going out of the home, (Item 4b), 6 families reported they were going out le s s . In 3 families, t h i s was due to father's li m i t e d physical a c t i v i t y and mother's i n a b i l i t y to. drive the family car. With 4 families, mothers and children reported " s t i c k i n g closer to home." In one family, fathers and some children were going out less while mothers and some children were going out the same amount. In one family parents were going out less and t h e i r c h i l d was going out the same amount as before the heart attack. This question prompted 4 families to say they planned to spend much more time together once father was well. 51. Only one family experienced a change i n family membership (Item 4c). The two children had spent a few days with r e l a t i v e s "...to give the kids a break." Family Perceptions of Help (Item 5) Table 8 shows the f a m i l i e s ' reports of the amount of help they received since the father was discharged from ho s p i t a l . Table 9 shows which person(s) families perceived as o f f e r i n g the most help to the family since father had been discharged from hospital. TABLE 9 Person(s) Offering the Most Help to Families Family Person(s) 1 2 3 4 5 6 7 8 9 10 Friends (5ai) X. X X X . . X X • Relatives (5aii) • • NA NA X • X • • Clergy ( 5 a i i i ) Nurses (5aiv) X X X X X X Doctors (5av) • X Community (5avi) Others (5avii) . x b . • • • Note. NA indicates not applicable. Extended family members were not i n Canada. a F a m i l i e s 1-6, 9, 10 had home care nurses twice a week. Di e t i c i a n . TABLE 8 Amount of Help Received by Families No Help Very L i t t l e Some Help Quite A B i t A Great Deal Family Help of Help of Help 1 ••• • • • ••• X 2 ••• X ••* ••• ••• 3 « * • ••• X ••• (4) X X ••• ••• 5 ••• ••* • • • • • • X (6) • • • . . . X X 7 X • • • ••• • . • ••• 3 ••• X ••• • • • ••• (9) . . • ... X ... X 10 ••• ... X a F a m i l i e s i n parentheses indicate d i f f e r i n g responses from family members. 53. Of most help to families during t h i s period (Items 5b, 5c, 5d) was information and someone to l i s t e n and reassure family members. Seven families said getting i n f o r -mation was the most helpful or would have been the most helpf u l service. Of these 7, 3 families said i t would have been helpful i f the information they received from the nurses, c a r d i o l o g i s t , and general p r a c t i t i o n e r had been less c o n f l i c t i n g and more understandable. Being reassuring, cheerful, a good l i s t e n e r , a calming e f f e c t was l i s t e d by 5 families as being h e l p f u l . Two families s p e c i f i c a l l y i d e n t i f i e d that i t was h e l p f u l to have someone to reassure and support mothers. Just knowing that help had been offered and was available was reported by 3 families as h e l p f u l . F i n a n c i a l assistance was i d e n t i f i e d by 2 families as being h e l p f u l . S p e c i f i c services such as transportation, babysitting, and providing meals were mentioned by 3 f a m i l i e s . Four families made statements indicating and valuing the family's independence. Help's been offered but I've never accepted. We didn't need i t . We're pretty s e l f - s u f f i c i e n t . We don't ask for help. We're independent. V. ANALYSIS A l l 10 families described changes that had occurred i n the areas of family roles, interactions, a f f e c t and struc-ture since the father had returned home from h o s p i t a l . In terms of the help they perceived receiving during t h i s time, one family reported "no help," 2 families reported "very l i t t l e help," one reported "some help," and 3 reported "a great deal of help." A difference of opinion among family members occurred in 3 families reporting "no help - very l i t t l e help," "quite a b i t of help - a great deal of help," and "some help - a great deal of help." Friends and home care nurses were most frequently seen as the persons o f f e r i n g the most help to the fami l i e s . Receiving information and reassurance were seen as help f u l during t h i s time. This chapter contains the discussion of these findings and the i r r e l a t i o n s h i p to the conceptual framework and existing knowledge. The chapter concludes with implica-tions and recommendations for nursing practice, education, and research. 55. INTERPRETATION OF FINDINGS This study was of an exploratory nature using a convenience sample of 10 myocardial i n f a r c t i o n patients and t h e i r families. Hence, the findings are not generalize-able beyond the families i n the sample. Considering these l i m i t a t i o n s , discussion of the possible meanings of the findings w i l l be organized under the headings family focus, family reactions, family perceptions of help, and i l l n e s s as a family c r i s i s . Family Focus Many authors in nursing and medicine suggest that a family evaluation should be an i n t e g r a l part of any patient assessment (Olsen, 1970; Livsey, 1972; MacVicar and Archbold, 1976; E i c h e l , 1978). The findings of t h i s study support a family focus i n health care. Families had indeed experienced changes i n response to the father's heart attack. The families were also very a c t i v e l y involved i n father's con-valescence. The findings of Mayou, Foster, and Williamson (19 78) concur. They advise that the whole family be given advice and help throughout the convalescence of the myocar-d i a l i n f a r c t i o n patient. It i s to be expected that most families focus on the i l l member, expending time and energy i n that d i r e c t i o n . But i t seems clear that other family members may need extra support during this d i f f i c u l t time as w e l l . In t h i s study, mothers appear to be very stressed with concerns about the father and the pressures of added r e s p o n s i b i l i t i e s . Many wives (38%) i n the study conducted by Skelton and Dominian (1973) had also found the period a f t e r discharge very stress-f u l . Consider the son who was reportedly demonstrating marked behavior changes and did not p a r t i c i p a t e i n the interview. What of the daughter unable to vent her feelings of anger towards her father and her feelings of loss about the part time job? In the near or distant future, these members' reactions may influence t h e i r health, the current patient's health, and the health of the family system. A concern often accompanying a proposal for a whole family system study i s , "Family members won't be able to express themselves with everyone present." Willingness to engage i n a family interview i s indicated by the fact that only one patient declined when approached by the inves-t i g a t o r . Families w i l l i n g to p a r t i c i p a t e in such a study probably have the a b i l i t y to express t h e i r thoughts and feelings to some extent. They may also be seeking t h i s opportunity because they perceive i t may be h e l p f u l to the family. These motivations to par t i c i p a t e are sim i l a r to those for individuals consenting to pa r t i c i p a t e i n an in d i v i d u a l focused study. Further, the li m i t a t i o n s inherent i n interviewing families are not d i s s i m i l a r to those of interviewing i n d i v i d u a l respondents. In both, the subjective data are f a l l i b l e but continue to be important sources of 57. information. . The most t e l l i n g argument for the family members' a b i l i t y to express themselves i n a family i n t e r -view i s the richness of the data i n the previous chapter. Although w i l l i n g to pa r t i c i p a t e i n a family i n t e r -view, some families needed a cat a l y s t to be able to talk together as a family. Four families had discussed the heart attack and subsequent events only 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 that many family members gained t h i s information. Yokes (1973) suggests that interpersonal relationships may suffer i f family members do not talk with the patient about the heart attack. The data c o l l e c t i o n interview was also he l p f u l to some fam i l i e s . Only one wife had expressed surprise that the entire i n t e r -view would take place with a l l family members. She said she wouldn't be able to discuss her annoyance with her husband for "maybe getting too used to doing nothing." She admitted being unable to 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 i n her alternating overprotectiveness and withdrawal from her husband. She was also nervous about asking him how he was f e e l i n g . During the interview the husband spoke of his fatigue, his fear-fulness, and determination to comply with the doctor's orders to "take i t easy." Both wife and daughter asked him questions and a l l three talked about the degrees of over-protectiveness demonstrated i n the past two weeks. The wife said l a t e r of the interview, " I t was good. I r e a l l y enjoyed i t once we got into i t . " Given the opportunity, family 58. members can pa r t i c i p a t e i n a family discussion, expressing themselves and c l a r i f y i n g perceptions. Children were active and valuable p a r t i c i p a n t s . Parents seemed to welcome the opportunity to hear t h e i r children discuss t h e i r observations and reactions. In response to the opening question, "What changes have you noticed i n the family i n the past two weeks?," i t was a 6 year old who said, "Dad can't smoke and eat much anymore. Mom c r i e s a l o t . And we don't have much money." To think of children as unaware and unable to report Is a gross underestimation of t h e i r c a p a b i l i t i e s . The attentiveness and p a r t i c i p a t i o n of a l l family members indicate the poten-t i a l need for families to have opportunities to discuss t h e i r changed s i t u a t i o n together. Ther>e were many opportunities to validate interview content with d i r e c t observations. A father who had reported f e e l i n g impatient with his children l i f t e d and carr i e d his 2 year old daughter to her room because she had changed her position i n the s i t t i n g arrangement. Another family with 3 sons had reported that a l l family members were helping around the house. The house was immaculate, the diet cookies served had been baked by the 15 year old, and the oldest son talked from the kitchen while making lunch for his evening job. Family members do not always agree. Disagreement can range from healthy individuation of members to patho-l o g i c a l c o n f l i c t (Satir, 1967). Differences of opinion are often based on d i f f e r e n t perceptions. These perceptions are influenced by available information, i n d i v i d u a l needs, and previous experiences. This was the si t u a t i o n when family members were asked to i d e n t i f y changes i n patterns of interaction and a f f e c t and asked to score the amount of help they had received. The occurrence of differences of opinion was normalized i n the opening comments of the interview. During the interview, differences of opinion were explored and individuals were asked to c l a r i f y t h e i r views. Family members either agreed or disagreed with views presented and the investigator continued the interview. Opportunities to gain new perspectives were u t i l i z e d but each member's view was accepted. Family Reactions Changes in Roles. A l l 10 families experienced role change as a response to i l l n e s s of a family member as defined i n t h i s study. The major impetus for the adjustment i n roles was the family's attempts to l i m i t physical a c t i v i t y and control le v e l s of stress for the fathers. This was expressed i n the rol e changes for household chores, f i n a n c i a l management, looking after feelings, d i s c i p l i n i n g children, and decision making. A l l family members perceived these l i m i t a t i o n s as necessary for keeping father well and a l l members were involved to some extent. Another motivating factor could be the wives' 60. r e a l i z a t i o n of th e i r dependence on a husband who might not always be there. One woman who was becoming more involved in the family's f i n a n c i a l management said: When I was single I was r e a l l y independent... took care of b i l l s , insurance, a l l that s t u f f . Ever since we've been married I've l e f t a l l that to him. Everything, everything i n my l i f e , decisions, I've just l e t him take care of everything i n my l i f e . I r e a l i z e I have to stand on my own two feet. It's r e a l l y hard...a big change. I have no confidence l e f t . Another woman who hadn't worked for 22 years said: I wish I was working now...for the money and the independence. This attempt to reduce dependence on the husband prompted thi s woman to get her driver's learner permit. I'm learning to drive and that's . a big step for me...We had talked about i t before but nothing was firm...I kept putting i t o f f u n t i l now. The father's sick role i n i t s e l f necessitated the development of a corresponding health-care worker r o l e i n families. Most wives and many children shared t h i s respon-s i b i l i t y for monitoring the diet, observing father's con-d i t i o n , reminding him to do and not do things, creating a therapeutic environment. None of the families reported a change in the role 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 . In fact, most families were experiencing a marked decrease i n s o c i a l a c t i v i t i e s and the resumption of same was seen as something for the future. One man said he couldn't answer the question because he didn't know how 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 i n the family. He was unable to anticipate how i t would be done in the future. His lack of awareness of t h i s p a r t i c u -l a r pattern of i n t e r a c t i o n i s contrasted with his son who f e l t they did very l i t t l e together as a family, and his wife who said she i n i t i a t e s the a c t i v i t i e s and would continue to do so. Although some couples spoke of f e e l i n g closer to one another, none of the families mentioned l i m i t a t i o n s on sexual a c t i v i t y . The question had been purposely omitted because of possible parental discomfort with children present. It i s also possible that, l i k e s o c i a l a c t i v i t i e s , sexual a c t i v i t y was not a p r i o r i t y for these couples during the time of t h i s study. The variance i n the number and degree of r o l e changes among families i s most l i k e l y related to the variance between pre and post i l l n e s s roles i n each family. In 3 families only one. role change was reported - household chores. In one of these 3 f a m i l i e s , the father's role was characterized by r e l a t i v e l y l i t t l e involvement and few role r e s p o n s i b i l -i t i e s . He appeared somewhat passive and compliant i n contrast to his wife who was very dominant during the interview. These c h a r a c t e r i s t i c s are similar to those of a sick role hence i l l n e s s of the father i n t h i s family may produce min-imal changes (Wu, 1973). In another family, the father's p r e - i l l n e s s role was largely that of being an ample wage 62. earner and having the " f i n a l word" in major decisions. I l l -ness had affected neither of these roles thus far and the family did not anticipate changes. The t h i r d family reporting only one role change points out the influence of/ the family's readiness and a b i l i t y to r e a l i s t i c a l l y acknowledge the father's d i s a b i l i t y - i t s nature, extent, prognosis, consequence. The father frequently said: I've had a heart attack but there's no d r a s t i c change i n our l i v e s . This family's report contained several contradictions sug-gesting t h e i r own perceptions were confused and contradic-tory. The father denied being more f e a r f u l but reported taking nitroglycerine on several occasions for chest pain. He drove the car a f t e r being t o l d i t was not safe for him to do so. He said he was on holiday time not sick time so he would have been home anyway. Maintaining p r e - i l l n e s s functions as much as possible seemed important in t h i s family and the illness-imposed changes were minimized i n t h e i r report more than i n fa c t . Changes in Patterns of Interaction. Alterations i n patterns of interaction occurred in a l l 10 f a m i l i e s . The major factor again appeared to be the family's attempts to control the levels of stress experienced by the father. As one mother said: I know stress can bring on a heart attack. I b i t e my tongue and think, "Is i t r e a l l y worth i t ? " A son said: We're more aware of when we're doing something wrong. This i s going to k i l l my Dad. Before the father returned home from h o s p i t a l , mothers of younger children had already impressed upon them the need to be cooperative, obedient, and quiet. With older children there was also a conscious e f f o r t to be h e l p f u l and less argumentative. It would seem that a l l family members assume some r e s p o n s i b i l i t y for father's health during t h i s period of time. Members were also involved i n the convalescent regime. They monitored father's d i e t and exercise. These seemed to be tangible things over which members could exert some control to keep father well. The life-threatening., nature of the i l l n e s s i n t h i s study also prompted a re-evaluation of family values and goals. The q u a l i t y of relationships and having time to-gether were two values which also influenced patterns of interaction i n the d i r e c t i o n of reducing c o n f l i c t . There was a r e a l i z a t i o n for most families that t h e i r time together was not unlimited. Changes in A f f e c t . A f f e c t changes were experienced by a l l 10 families. Of the 5 a f f e c t areas explored, 9 families reported changes i n 4 or 5 of them. The one family that reported having only one a f f e c t change o r i g i n a l l y said they hadn't experienced any a f f e c t change. The father l a t e r said he was getting more impatient to go out, go bowling, go to work. Several factors may have influenced t h i s lack of reaction to the father's i l l -ness. The father's involvement i n the family was l i m i t e d even before the heart attack. Both parents worked d i f f e r e n t s h i f t s and the wife seemed to be the main force i n the family. Another factor was the sense of d i s b e l i e f that the father had had a heart attack. He i s lean, a non-smoker, and hadn't had health problems. His wife i s an obese smoker who has had a series of i l l n e s s e s i n the past 10 years. Her i l l n e s s e s , which included a myocarditis, may have fostered family adaptive s k i l l s which manifested themselves as marked non-reactiveness to i l l n e s s . "His heart attack i s j u s t one more thing." A l l of these factors: s i m i l a r i t i e s between father's sick role and well r o l e , d i s b e l i e f and possible denial, and previous experiences may have influenced t h e i r non-reactiveness to father's heart attack. The families' attempts to control l e v e l s of stress to prevent father's relapse, and t h e i r renewed appreciation of one another contributed to t h e i r sense of being "less impatient" with one another. But fathers experienced impatience and a sense of loss regarding the imposed changes i n t h e i r l i f e s t y l e and t h e i r self-image. This was even more d i f f i c u l t for fathers who were f e e l i n g quite well. They looked well, f e l t quite well, but were lim i t e d i n what they could do. A l l family members, including the youngest children, seemed to be sharing a r e s p o n s i b i l i t y for making father 65. better and preventing him from dying. The extremes of a f f e c t were no longer acceptable in the family - no arguing, "mustn't l e t my tearfulness hurt him," "can't run i n from school and y e l l 'Hi, Dad!," no teasing. Family members tolerated l i t t l e deviation from the valued "good" behaviors. Unfortunately, these expectations are d i f f i c u l t for c h i l -dren to meet a l l of the time. Their normal developmental needs continue to e x i s t at. a time when a parent's needs seem greater' and parental resources are less available. Compliance with the convalescent regime was also highly valued in the f a m i l i e s . They expressed pleasure about new health habits which would prevent recurrence of a heart attack. Compliance was. remarked upon. Deviation from.the regime was a source of s t r a i n i n f a m i l i e s . It was father's l i f e that had been threatened and i t was important for him to see a future for himself and his family. Hence, fathers expressed more optimism and hopefulness than did mothers. Mayou, Foster, and Williamson (1978) also found wives to be more distressed than husbands i n t h e i r study of wives of myocardial i n f a r c -t i o n .patients. Fathers also seemed to have more d i f f i c u l t y saying they were a f r a i d of having another heart attack. Mothers experienced the pressures of an increased workload. They were having to attend to a l l others' 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 support system was diminished. They were also experiencing concerns for t h e i r husbands' l i v e s . Skelton and Dominian C19 7 3) suggest wives receive alternative r e l i a b l e sources to help them express t h e i r feelings. The more dependent the wife had been, probably the more frightening the prospect of being l e f t to deal with matters alone. This one to 3 week period following hospital d i s -charge seems to be a time of a f f e c t i v e ambivalence and contradiction. Family members can be happy and f e a r f u l , hopeful and a f r a i d , happy and impatient. A family member's l i f e has been threatened. He i s home recuperating. Con-valescence i s characterized by l i m i t a t i o n s to previous l i f e -s t y l e . He might have a heart attack without warning. It i s a time of exploring l i m i t s . How far can I walk? How much can I do? Can I get angry? Am I expecting too much? Where are the l i m i t s ? What i s O.K.? One daughter reported: I saw Dad reach up to cut a l i l a c . He didn't say anything but I know, i t hurt him. A father discovered l i m i t s . I thought I'd load the dishwasher to help out. And i t r e a l l y t i r e d me. I mean, I couldn't believe i t , you know? And one mother who i s s t i l l unsure said: They (father and son) k i d each other and I'm a f r a i d they're getting too rambunctious. It's not l i k e (my son) would h i t his father in the chest or anything. But now I don't bug (father) 'cause I figure he should know. Changes i n Structure. Five families experienced changes i n the amount of contact they had with more than 50% of the groups mentioned. 67. A l l families experienced changes i n the amount of contact they were having with friends. Most families (80%) had increased contact with;community health care p r a c t i -tioners while 75% of the e l i g i b l e families had increased contact with t h e i r extended family. This study indicates that families are somewhat is o l a t e d from t h e i r neighbors. Even information was not r e a d i l y shared with neighbors. Few families i n t h i s study had regular contact with r e l i g i o u s i n s t i t u t i o n s either. The children's school was another r e l a t i v e l y closed system with which families had l i t t l e contact. These data suggest that friends, family, and com-munity health agencies have much more access to the families than do neighbors, clergy and people from school. It can be expected that the openness of the family system to certain groups w i l l also define the family's support system. Since the families are going out of the household less than they used to, the increased contacts are occurring in the family home. Although several families mentioned that the increased number of v i s i t s from friends could be t i r i n g , they were pleased that people v i s i t e d . I t provided diversion for the r e l a t i v e l y home-bound family and was seen as a demonstration of caring. Family households appear to cope with i l l n e s s of a family member without a l t e r i n g family membership. For some families having help by a l t e r i n g membership would diminish the i r independence. Other families couldn't c a l l on friends 68. or family for help because they were perceived as being too busy with their own l i v e s and concerns. Family Perceptions of Help Most families (6) reported they had received at least some help. There was no apparent c o r r e l a t i o n between families who had made statements asserting t h e i r inde-pendence and those who had received very l i t t l e or no help. Three families had members who d i f f e r e d i n t h e i r opinions of the amount of help received. The differences of opinion related to differences i n circumstances and i n d i v i d u a l need. One father found the home care nurses very helpful but other family members had not met them. One wife found the nurses very helpful i n providing her with information. I t was information the husband had received i n hospital so he perceived the nurses as less h e l p f u l . One father perceived the off e r of help as he l p f u l while other family members did not. Most families indicated friends and nurses were the most helpful and t h i s concurs with services i d e n t i f i e d as being most he l p f u l : reassurance and information. This also correlates with the increased contact families reported having with friends and community agencies (home care nurses). Although contact with r e l a t i v e s had increased for 6 of the 8 families with r e l a t i v e s i n Canada, only 2 families per-ceived family as being very h e l p f u l . Perhaps extended family 69. members were too anxious themselves about the i l l member to be of much support to the household family. I l l n e s s as a Family C r i s i s The findings c l e a r l y indicate that i l l n e s s as defined in t h i s study a f f e c t s the family. A l l families experienced some change i n t h e i r r o l e s , interactions, a f f e c t , and structure. Inasmuch as these changes are a period of disequilibrium and disorganization of function, the changes indicate that i l l n e s s i s a c r i s i s . Caplan (19 64) also defined c r i s i s as an a f f e c t i v e change, a period of increasing tension and anxiety. A f f e c t changes did occur i n 10 families. But within the l i m i t a -tions of t h i s study i t seems doubtful that a "family mood" or a f f e c t can be measured i f i t exists at a l l . From 40-100% of the a f f e c t changes reported by each of the 10 families included d i f f e r i n g responses from i n d i v i d u a l family members. Their perceptions of other family members and the events, and t h e i r own personal needs governed t h e i r own a f f e c t i v e responses. The m u l t i p l i c i t y of variables a f f e c t i n g each family member makes i t u n l i k e l y that the family, that i s a l l family members, could report the same a f f e c t at the same time. Without a measureable en t i t y of family a f f e c t , i s there such a phenomenon as family c r i s i s ? More research i s required. This study indicates that c r i s i s theory as developed for individuals may not d i r e c t l y apply to family 70. systems. Literature describing family emotional responses to situations must be read c r i t i c a l l y . To date, the best d e f i n i t i o n for a family c r i s i s may be the simplest as re-corded by Rapoport (1965, p.24): , C r i s i s in i t s simplest terms i s defined as 'an upset i n a steady state'... Findings are inconclusive and more research i s required to 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 family c r i s i s . Several families suggested that each week afte r the father returned home was becoming easier - people becoming more settl e d and relaxed. Routines had been established, resources were known, roles were enacted, and some l i m i t s had been tested. Two families anticipated s l i p p i n g back into pre-i l l n e s s patterns soon. This implies that families experience the most disequilibrium and disorganization closest to the time of the imposed change - father returning home. Negotiating new family rules and roles appears to be one of the family's adaptive tasks when a member becomes i l l . The sooner these negotiations are completed to the 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 sooner the family returns to some l e v e l of system s t a b i l i t y . Families may require assistance i d e n t i f y i n g and c a l i b r a t i n g necessary changes. Assistance may be i n the form of f a c i l i t a t i n g a change in family cognition, a f f e c t , or behavior. These necessary r e c a l i b r a t i o n s are, i n fact, the opportunities for families to enhance t h e i r interactions, learn new sk i l l s > gain new perspectives. The converse i s also true. Dysfunctional families may respond to the demands of i l l n e s with increased r i g i d i t y and i n f l e x i b i l i t y . Old rules and roles are perpetuated, innovations and r i s k are not t o l e r -ated, and the cost to family and family member health i s high. For the families i n thi s study, i t could be assumed that the father's t r a n s i t i o n to "wellness" (as defined and perceived by the family) w i l l necessitate negotiation and r e c a l i b r a t i o n of family rules and roles again. For some families t h i s might constitute a c r i s i s and one can specu-late about i t s e f f e c t on the compliance behaviors charac-t e r i s t i c in t h i s study. S i m i l a r l y , how would the family's progressive non-compliant behavior (children begin to argue wife asks for support) a f f e c t father's t r a n s i t i o n to "wellness?" IMPLICATIONS Although the.design of the study i s such that the findings can only be considered tentative, they strongly suggest that the family i s an int e g r a l part of the patient' i l l n e s s and as such, w i l l a f f e c t and be affected by the i l l n e s s . This study holds some implications for nursing practice, education, and research. Nursing Practice In a l l health care settings the nurse should com-plete a family assessment regardless of which family member i s the current i d e n t i f i e d patient. The assessment should include the baseline data of p r e - i l l n e s s family structure, developmental stage, and level s of functioning. Family members should be asked for t h e i r perceptions of the i l l n e s s and t h e i r current s i t u a t i o n . A f t e r determining family reactions to the current s i t u a t i o n , the nurse should compare th i s data to the family's p r e - i l l n e s s state and i t s ' reac-tions i n other situations of change. The differences i n these family situations are most valuable data. The greater the difference or change between the current s i t u a t i o n and p r e - i l l n e s s state, the more help the family may need to cope with the adaptive tasks confronting i t . I t i s also important to assess the family's perception of the quantity and qu a l i t y of i t s ' support system and resources. Nurses should meet with family members regularly throughout the course of i l l n e s s . Understandable information and explanation should be provided to the family as i t s ' need and readiness to learn d i c t a t e s . Family members should be encouraged to verbalize t h e i r thoughts and feelings and the nurse should be available to l i s t e n . The family members need to hear acknowledgement of their d i f f i c u l t tasks and support of t h e i r e f f o r t s . The nurse should f a c i l -i t a t e i n t e r a c t i o n among family members to f u l l y u t i l i z e t h e i r knowledge and support of one another. The nurse, patient, and family members should i d e n t i f y problems and goals together. Outside resources should be provided as necessary. The family 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 for the improved health of a l l family members. Nursing Education A l l l e v e l s of nursing education should include the appropriate l e v e l s of knowledge and s k i l l s related to a family focus i n health care and the behavioral aspects of i l l n e s s . This would include a progressive application of an expanded base of knowledge from the natural and s o c i a l sciences and humanities. Included would be content related to the concepts of family dynamics, adaptation, role theory, interpersonal and communication theory, change theory, developmental theory. Nursing students would require super-vised opportunities to intera c t with and assess families i n various developmental stages and situations. They would also require opportunities to consider t h e i r own family experi-ences and coping processes. Community and hospital nursing services conjointly with nursing education should prepare and make available to nurses i n practice, a series of workshops designed to help them develop and apply a family focus i n t h e i r care. Nursing Research This study raises many questions and leaves many unanswered. How do family responses observed i n thi s study compare to t h e i r responses when the patient f i r s t came home? What was i t l i k e for the family when father was f i r s t hos^ pi t a l i z e d ? What w i l l happen to these co-operative, health-conscious, compliant families when father s t a r t s to smoke, the teenagers begin to argue? W i l l i t happen? When? How would data from this study compare to that from a sample of families i n which the patient was a c h i l d with leukemia, a mother with a high-risk pregnancy, a grandparent with a broken hip, an adult with multiple s c l e r o s i s ? How i s i t the same for families? How i s i t dif f e r e n t ? How can we account for the differences? What more can these studies t e l l us about family theory, family therapy, c r i s i s theory, behavior and i l l n e s s ? What constitute good and bad family responses? How do they a f f e c t the course of i l l n e s s ? The amount and the richness of the data i n t h i s study indicate that family system studies should include a l l family members. Given that a family system i s greater than the sum of i t s independent elements i t i s not appro-priate to present a family "score" which i s the mean of family member "scores." There i s a great need for the development of r e l i a b l e and v a l i d family study tools and approaches to analysis. U n t i l then, i t i s probably s t i l l most appropriate to have family members "average" t h e i r own "scores" through seeking consensus or continue to report the differences among members. This l a t t e r approach i s most representative of family functioning and retains p o t e n t i a l l y useful information. Depending upon the purpose of a study, i t may be appropriate for a family system study 75. to include both the family system and i n d i v i d u a l family members as respondents. In family system studies where family members are only interviewed 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 secrets may be revealed, that i s , information that i s not available to other family members. As secret information, the data have li m i t e d meaning and the family focus may be jeopardized because the investigator could not explore the e f f e c t s of the "secret" on the family nor the e f f e c t of the family on the i n d i v i d u a l and his secret. At best, the investigator would have to hypothesize the effects i n terms of family organization, interaction, values and goals. The parameters of roles, patterns of i n t e r a c t i o n , a f f e c t , and structure were useful and could be used i n other studies of similar design. The developmental stage of the family, the nature of the i l l n e s s , the setting, and the timing of the study would presumably y i e l d special categories and d i f f e r e n t data within these parameters. The semi-structured approach of the data c o l l e c t i o n was useful. With s p e c i f i c open and closed-ended questions, the families were able to report concrete changes and less concrete changes related to feelings and interactions. Allowing families to relate anecdotes also yielded valuable data related to the interview schedule. The f l e x i b i l i t y of open and closed-ended questions helped orient families to looking at themselves, was not r e s t r i c t i v e , and yielded comparable data. 76. RECOMMENDATIONS On the basis of the findings and implications of th 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 of patients and t h e i r families be a unique and in t e g r a l focus of nursing care i n a l l settings. 2. A l l leve l s of nursing education include the appropriate knowledge and s k i l l s required for nurses to practice with a family focus. 3. Research be conducted with various stages of numerous i l l n e s s e s i n di f f e r e n t settings to i d e n t i f y concepts relevant to relationships between family reactions and i l l n e s s . 4. Longitudinal studies be conducted to e f f e c t i v e l y i d e n t i f y relationships of time, family reactions, and i l l n e s s . VI. SUMMARY AND CONCLUSIONS This exploratory study was designed to e l i c i t i n f o r -mation about family reactions to the c r i s i s of i l l n e s s and what families perceive to be help f u l during t h i s c r i s i s . The study focused on the family c r i s i s of incorporating back into the family a father who had experienced his f i r s t myo-ca r d i a l infarction.. The study was conducted with a convenience sample of ten myocardial i n f a r c t i o n male patients, t h e i r wives, and children l i v i n g i n the household. A semi-structured interview schedule was used with each family one to three weeks following the father's d i s -charge from h o s p i t a l . The interviews took place i n the family's home and averaged 50 minutes i n length. The i n t e r -view covered four content areas related to family reactions i n the realms of a f f e c t , i n t e r a c t i o n , roles and structure. The f i f t h content area related to what people and services the family perceived to be he l p f u l . The interview data were summarized into categories and descriptive s t a t i s t i c s were used. A l l 10 families described changes that had occurred in the areas of family r o l e s , interactions, a f f e c t and structure since the father had returned home from h o s p i t a l . 78. In terms of the help they perceived receiving during this time, one family reported "no help," 2 families reported "very l i t t l e help," one reported "some help," and 3 reported "a great deal of help." A difference of opinion occurred in 3 families. Friends and home care nurses were most frequently seen as the persons o f f e r i n g the most help to families. Receiving information and reassurance were seen as helpful during t h i s time. Although the sample was small and not randomized, i t i s possible to draw some conclusions based on the data c o l l e c t e d . When a family member i s i l l , families may exper-ience changes i n th e i r roles, patterns of inte r a c t i o n , a f f e c t , and structure. The qu a l i t y and quantity of changes are related to several factors. Of considerable importance i s the family's perception of the nature of the i l l n e s s - i t s character, extent, e f f e c t , and prognosis. These perceptions and the enactment of the sick role by the patient produce changes which may contrast markedly or minimally with the family's p r e - i l l n e s s state. I l l n e s s , e s p e c i a l l y l i f e -threatening i l l n e s s , fosters a review of in d i v i d u a l and family values and goals. This review can also produce changes i n family r o l e s , patterns of inte r a c t i o n , a f f e c t and structure. It i s presumed that family reactions can have an ef f e c t on the patient's course of i l l n e s s . The e f f e c t i s dependent upon the family's perception of the i l l n e s s and t h e i r perception of the amount and kind of controls they 79. can exercise. Also related are the personal needs of i n d i v i d u a l family members. Family discussions of t h e i r changed s i t u a t i o n can serve many purposes. New information can be shared. Individuals' needs may emerge. Perceptions can be shared, c l a r i f i e d , and altered. Members can p o s i t i v e l y reinforce each other's e f f o r t s and negatively reinforce deviance. Solutions to problems can be explored and agreed upon. Family perceptions of the amount of help they receive and the people they f i n d h e l p f u l are influenced by the needs and perceptions of i n d i v i d u a l family members. Most families in t h i s study coped with i l l n e s s of a family member without a l t e r i n g membership of t h e i r household. Families f i n d clear information and reassurance from other he l p f u l when they are coping with i l l n e s s of a family member. More research i s required to i d e n t i f y the charac-t e r i s t i c s and temporal aspects of family reactions to i l l n e s s and family e f f e c t s on i l l n e s s . For these purposes innovative approaches to research design and methodology are required to ensure s c i e n t i f i c theory development and continued appreciation of the complexity of family systems. BIBLIOGRAPHY Aguilera, D.; Messick, J.; and F a r r e l l , M. C r i s i s Inter- vention . 2ed. St. Louis: C.V. Mosby, 1974. Anderson, R., and Carter, I. Human Behavior i n the Social Environment, A Social Systems Approach. Chicago: Aldine, 1974. Anthony, E. "Impact of Mental and Physical I l l n e s s on Family L i f e . " Am. J. Psychiatry 127 (August 1970):138-146. B e l l , N.,and Vogel, E., ed. A Modern Introduction to the  Family. New York: MacMillan, 19 68. Bertalanffey, L. "General Systems Theory - A C r i t i c a l Review," i n Modern Systerns Research for the Behavioral S c i e n t i s t . 11-30. Edited by W. Buckley. Chicago: Aldine, 1968. Brink, P., and Wood, M. Basic Steps in Planning Nursing  Research. North Scituate, Mass.: Duxbury Press, 1978. Caplan, G. Pr i n c i p l e s of Preventive Psychiatry. New York: Basic Books, 19 64. Deutsch, C , and Goldston, J. "Family Factors i n Home Adjustment of the Severely Disabled." Marriage and  Family L i v i n g 22 (November 1960):312-316. Ei c h e l , E l l e n . "Assessment with a Family Focus." Journal  of Psychiatric Nursing 16 (June 197 8)^:11-14. Epperson, M. "Families i n Sudden Crises: Process and Inter-vention i n a C r i t i c a l Care Center." Social Work i n Health Care 2 (Spring 1977):265-273. F e r r e i r a , A. "Family Myth and Homeostasis," i n A Modern  Introduction to the Family. 541-548. Edited by N. B e l l and E. Vogel. New York: MacMillan, 1968. Fisher, L. "On the C l a s s i f i c a t i o n of Families." Archives of  General Psychiatry 34 (April 1977):423-433. 80. 81. Freedman, A.; Kaplan, H.; and Sadock, B. Modern Synopsis of  Comprehensive Textbook of Psychiatry. 2ed. Baltimore: Williams and Wilkins, 1976. Glasser, P., and Glasser, L. Families i n C r i s i s . New York: Harper and Row, 19 70. Granite, U., and Goldmon, S. "Rehabilitation Therapy for Burn Patients and Spouses." Social Casework 56 (December 1975):593-598. Haley, J. "Family of the Schizophrenic - A Model System." J. of Nervous and Mental Disorders 129 (1962): 357-374. H i l l , R. "Social Stresses on the Family," in C r i s i s Inter- vention. Selected Readings. 32-52. Edited by H.J. Parad. New York: Family Services Association of America, 1965. H o l s t i , 0. Content Analysis For the So c i a l Sciences and  Humanities. Don M i l l s , Ontario: Addison-Wesley, 1969. Jackson, D. "Family Rules. Marital Quid Pro Quo." Archives  of General Psychiatry 12 (June 1965):589-599. Jackson, D. "The Question of Family Homeostasis." Psyc h i a t r i c Quarterly Supplement 31 (1957) :79-90. Jackson, D. "The Study of the Family." Family Process 41 (March 1964):l-20. Kaplan, D.; Grobstein, R.; Smith, A.; and Fischman, S. "Family Mediation of Stress." Social Work (July 1973):5-14. Kerlinger, F. Foundations of Behavioral Research. 2ed. Toronto: Holt, Rinehart, and Winston, 1973. Klein, D., and Bogdonoff, M. "Impact of I l l n e s s on the Spouse." J. Chronic Disease 20 (1967):241-248. Langsley, D., and Kaplan, D. The Treatment of Families in  C r i s i s . New York: Grune and Stratton, 19 68. Levinson, R. "Family C r i s i s and Adaptation. Coping with a Mentally Retarded C h i l d . " Dissertation, University of Wisconsin, 1976. Lipowski, Z.J. "Physical I l l n e s s , the Individual, and the Coping Process." International Journal of Psychiatry i n Medicine 1 (1970):91-101. 82. Litman, T. "The Family and Physical Rehabilitation." J. Chronic Disease 19 (1966):211-217. Livsey, C. "Physical I l l n e s s and Family Dynamics." Advanced  Psychosomatic Medicine 8 (19.72) : 237-251. MacVicar, M., and Archbold, P. "A Framework for Family Assessment in Chronic I l l n e s s . " Nursing Forum 15 (1976):180-194. Mayou, R.; Foster, A.; and Williamson, B. "The Psychological and Social Effects of Myocardial Infarction on Wives." B r i t i s h Medical Journal 1 (March 1978):699-701. Moos, Rudolf. Coping with Physical I l l n e s s . New York: Plenum Medical Book, 1977. Murray, R., and Zentner, J. Nursing Concepts for Health Promotion. Englewood C l i f f s , N.J.: Prentice-Hall, 1975. Nye, F. Role Structure and Analysis of the Family. Beverly H i l l s : Sage Publications, 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 Intervention i n Casework with the Cancer Patient and His Family." Social Work 12 (April 1967):44-52. Parad, H.J.,and Caplan, G. "A Framework for Studying Families in C r i s i s , " i n C r i s i s Interventions.  Selected Readings. 53-72. Edited by Parad. New York: Family Services Association of America, 1965. Parsons, T., and Fox, R. " I l l n e s s , Therapy, and the Modern Urban Family," i n A Modern Introduction to the  Family. 377-390. Edited by N. B e l l and E. Vogel. New York: MacMillan, 1968. Peck, B. "Physical Medicine and Family Dynamics: The D i a l e c t i c s of Re 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 Rehabilita-t i o n of the Chronically 111 Patient." J. A l l i e d  Health 5 (Spring 1976):42-50. 83. Quint, J. "The Case f o r Theories Generated from Empirical Data. "'• Nursing Research -16 (Spring 1967) : 109-114 . Rakel, R. P r i n c i p l e s of Family Medicine. Toronto: W.B. Saunders, 1977. Rapoport, L. "The State of C r i s i s : Some Theoretical Con-siderations," i n C r i s i s Intervention: Selected  Readings. 22-31. Edited by H.J. Parad. New York: Family Services Association of America, 1965. Robischon, P., and Scott, D. "Role Theory and Its Applica-tion i n Family Nursing." Nursing Outlook (July 1969): 52-57. Sa t i r , V. Conjoint Family Therapy. Palo A l t o : Science and Behavior Books, 196 7. Shellhase, L., and Shellhase, F. "Role of the Family i n Rehabilitation." Social Casework 53 (November 1972):544-550. S i l v a , Mary. "Spouses Need Nurses Too." The Canadian Nurse 73 (December 1977):39-41. Skelton, M., and Dominian, J. "Psychological Stress in Wives of Patients with Myocardial Infarction." B r i t i s h Medical Journal 2 (April 1973):101-103. Smilkstein, G. "The Family i n Trouble - How to T e l l . " J. of  Family Practice 2 (1975):19-24. Solomon, M. "A Developmental Conceptual Premise for 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, University of Calgary. Tomm, K. "Circular Pattern Diagramming." Notes from c l a s s , "The Family i n Health and I l l n e s s , 1977b, University of Calgary. Tomm, K. "Expressive Family Functioning Guide." February 19 77c, University of Calgary. Watzlawik P.; Beavin, J.; and Jackson, D. Pragmatics of  Human Communication. New York: W.W. Norton, 1967. Williams, C , and Rice, D. "The I.C.U. - Social Work Inter-vention with Families of the C r i t i c a l l y 111 Patient." Social Work i n Health Care 2 (Summer 1977):391-398. f 84. Wu, Ruth. Behavior and I l l n e s s . Englewood G l i f f s , N.J.: Prentice-Hall, 1973. Yokes, J. "Family Rehabilitation: an Adult with Myocardial Infarction," i n Family Health Care. 390-404. Edited by D. Hymovich. New York: McGraw-Hill, 19 73. 87. APPENDIX C Interview Schedule Introduction: 1. Explain the purpose of the study. 2. Obtain consents to p a r t i c i p a t e i n the study and consents to record. Engagement: 1. Speak to each member b r i e f l y i n s o c i a l conversation. Opening Comments: Your family has experienced a l o t of changes during the past few weeks. A recent 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 noticed i n the family during the past weeks since Mr. came home. What i s d i f f e r e n t in the family now as compared to how things were before Mr. went into the ho s p i t a l . Each of you might have d i f f e r e n t ideas on what the changes have been and that i s to be expec-ted. I'd l i k e to hear everyone's ideas. Body of the Interview: 1. When families experience major changes, they usually need time to reorganize the jobs and a c t i v i t i e s that keep a family running smoothly. What changes have you noticed i n the sharing of jobs and r e s p o n s i b i l -i t i e s i n the family? If necessary,.clarify: la) What changes have you noticed i n the area, of household chores? lb) of d i s c i p l i n i n g the children? 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 decisions? le) of looking a f t e r peoples' needs for a f f e c t i o n , t h e i r hurt feelings, concerns, etc.? If) of looking a f t e r the f i n a n c i a l needs of the family? Are there any other changes i n the sharing of jobs and r e s p o n s i b i l i t i e s that you would l i k e to add? 88. A l l families have patterns of who talks to whom about what. These patterns change p e r i o d i c a l l y depending on what i s happening i n the family. What changes have you noticed during the past weeks i n how you talk to one another i n the family? If necessary, c l a r i f y : 2a) Has there been a change in the amount of talk i n g that goes on? In what way? 2b) i n the kinds of things you talk about? In what way has i t changed? 2c) i n who talks to whom? In what way? Are there any other changes i n patterns of ta l k i n g you'd l i k e to add? Families usually experience a change of mood or fe e l i n g tone when they f i n d themselves i n new situations. Have you noticed changes i n the family's mood during the past weeks? If necessary, c l a r i f y : 3a) Would you say the family i s more happy, less happy, no change? 3b) ...more impatient, less impatient, no change? 3c) ...more hopeful, less hopeful, no change? 3d) ...more nervous, less nervous, no change? 3e) ...more a f r a i d , less a f r a i d , no change? Are there any other mood or f e e l i n g changes you'd l i k e to add? When experiencing major changes, families sometimes notice changes i n t h e i r own membership and the amount of contact they have with others. 4a) In the past weeks, have you had more or less contact with people other than family members? i)...seen more or less of friends? i i ) . . . o f family members outside of thi 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 of the home? i) more ii.) the same i i i ) less 89. 4c) Has the membership of the family changed during the past weeks? 5. What amount of help have you received during the past weeks from people or agencies outside of the household? 1 2 3 4 5 no help very some a f a i r a great l i t t l e help amount deal of help of help help ( A l l but #1) 5a) Who has been most help f u l to your family i n the past weeks? i) friends v) doctors i i ) r e l a t i v e s vi) community agencies i i i ) clergy v i i ) others iv) nurses 5b) In what ways were they helpful? 5c) What else would you have found he l p f u l during t h i s time? (Received no help) 5d) What would have been help f u l to your family during these past weeks? Termination: 1. Express appreciation. 2. Give them recognition for t h e i r e f f o r t s . 

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