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Loss as experienced by spouses of myocardial infarction patients Gauchie, Patricia 1982

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LOSS AS EXPERIENCED BY SPOUSES OF MYOCARDIAL INFARCTION PATIENTS by PATRICIA MARIE GAUCHIE B . S c , The U n i v e r s i t y o f A l b e r t a , 1972 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September 1982 C ) P a t r i c i a M. Gauchie, 1982 MASTER OF SCIENCE i n In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t o f the r e q u i r e -ments f o r an advanced degree a t the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head o f my depart-ment or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f /\(cxJ>Srn The U n i v e r s i t y o f B r i t i s h Columbia Vancouver, B. C. Y6T 1W5 ABSTRACT i 1 i LOSS AS EXPERIENCED BY SPOUSES OF  MYOCARDIAL INFARCTION PATIENTS This e x p l o r a t o r y study examined the phenomenon of l o s s as expressed by the spouses of myocardial i n f a r c t i o n p a t i e n t s . The pur-pose of the study was t o d e s c r i b e the thoughts, f e e l i n g s , a c t i o n s and observable behaviours of the spouses from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n and to develop a framework, based on the l i t e r a t u r e , which r e l a t e d the concept of l o s s to the experience of spouses of M.I. p a t i e n t s . The study was conducted with a convenience sample of 12 spouses, ten women and two men, whose partne r s had experienced t h e i r f i r s t myocardial i n f a r c t i o n . Using a s e m i - s t r u c t u r e d i n t e r v i e w guide with open-ended q u e s t i o n s , the i n v e s t i g a t o r i n t e r v i e w e d each s u b j e c t f o u r times over a s i x week p e r i o d ; from the i n i t i a l impact of i l l n e s s to approximately s i x weeks post myocardial i n f a r c t i o n . Each i n t e r v i e w covered three content areas: thoughts, f e e l i n g s and a c t i o n s . Broad open-ended questions were used to e l i c i t data on the spouses thoughts, f e e l i n g s and a c t i o n s . During the i n t e r v i e w the i n v e s t i g a t o r observed the verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus o f conversation) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance) behaviours of the spouses. An e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. Data coding and a n a l y s i s were approached using the constant comparative method, an i n d u c t i v e method of d i s c o v e r i n g grounded theory developed by Glaser and Strauss (1967). The f i n d i n g s i v revealed t h a t the spouses experienced behaviours i n response to l o s s that were common and formed a p a t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : Phase I The Event and I n i t i a l Spousal Response; Phase II Reaction to the Event; Phase III Impact of the Event. The phases were d e s c r i b e d f u r t h e r i n l i g h t of the c o n s t r u c t s formulated from the l i t e r a t u r e review: (1) Reactions to Loss; (2) The Elements of Loss; (3) The Meaning of Loss. T h i s study was designed to provide i n s i g h t i n t o understanding the event of a myocardial i n f a r c t i o n w i t h i n the context of the phenomenon of l o s s . The f i n d i n g s supported the use of a l o s s framework f o r a s s e s s i n g the r e a c t i o n s of spouses who are threatened with the death of t h e i r p a r t n e r . Nurses are i n a c r i t i c a l p o s i t i o n to a s s i s t spouses experiencing l o s s . I m p l i c a t i o n s and recommendations f o r nursing educa-t i o n , p r a c t i c e and research were d e l i n e a t e d i n l i g h t of the c o n c l u s i o n s of the present study. TABLE OF CONTENTS v Page ABSTRACT I i i TABLE OF CONTENTS v LIST OF TABLES i x LIST OF FIGURES x ACKNOWLEDGEMENTS x i CHAPTER 1 Int r o d u c t i o n 1 Background of the Study 1 S i g n i f i c a n c e of the Study 1 Statement of the Problem 2 Assumptions 3 L i m i t a t i o n s 3 D e f i n i t i o n o f Terms 4 CHAPTER 2 Review of the Related L i t e r a t u r e 6 Reactions to Loss 6 The Elements of Loss 16 The Meaning of Loss 17 Nursing Studies Related to Loss 19 Reactions to Loss by Spouses o f Myocardial I n f a r c t i o n P a t i e n t s 22 Summary 28 TABLE OF CONTENTS (Continued) v i Page CHAPTER 3 Methodology 30 I n t r o d u c t i o n : An Overview 30 The Research S e t t i n g 32 Sample S e l e c t i o n 32 Data C o l l e c t i o n 34 Data Coding and A n a l y s i s 40 R e l i a b i l i t y and V a l i d i t y Issues 41 CHAPTER 4 F i n d i n g s o f the Study 44 PHASE I The Event and I n i t i a l Spousal Response 44 PHASE I—T h o u g h t s 45 PHASE I - - F e e l i n g s 52 PHASE I — A c t i o n s 56 PHASE II Reaction to the Event 62 PHASE I I — Thoughts 62 PHASE I I - - F e e l i n g s 69 PHASE I I — A c t i o n s 71 PHASE III Impact o f the Event 75 PHASE I I I — T h o u g h t s (Group A F i n d i n g s ) 75 PHASE I I I — F e e l i n g s 78 PHASE I I I — A c t i o n s 82 PHASE III (Group B F i n d i n g s ) 84 PHASE I I I — T h o u g h t 85 TABLE OF CONTENTS (Continued) v i i Page PHASE 111--Feelings 88 PHASE I I I — A c t i o n s 89 Summary 93 CHAPTER 5 D i s c u s s i o n 94 PHASE I The Event and I n i t i a l Spousal Response 94 PHASE II Reaction to the Event 104 PHASE I I I Impact of the Event (Group A) 108 PHASE III Impact of the Event (Group B) 115 Summary 118 CHAPTER 6 Summary, Con c l u s i o n s , Im p l i c a t i o n s and Recommendations . . . . 119 Overview o f the Study 119 A Loss Framework 122 Impl i c a t i o n s 124 Recommendations 129 BIBLIOGRAPHY 130 APPENDICES Appendix A: Consent Form 135 Appendix B: Information Relted to Cardiac Research Study . . 137 Appendix C: Data C o l l e c t i o n Tool 139 TABLE OF CONTENTS (Continued) v i i i Page Appendix D: Sample o f Data Coding and A n a l y s i s Procedure . . 141 Appendix E: Overview of the Fi n d i n g s 143 Appendix F: Overview of the I n t e r p r e t a t i o n of the Findi n g s . 145 LIST OF TABLES i x Page Table 1 Age and Sex of P a t i e n t s and Spouses 35 2 Number of Days a f t e r Myocardial I n f a r c t i o n t h a t Interview Took Place 38 LIST OF FIGURES x Page Figure 1 The Meaning of Loss 109 2 A Loss Framework f o r Spouses o f Myocardial I n f a r c t i o n P a t i e n t s 125 ACKNOWLEDGEMENTS xi I wish to express my s i n c e r e a p p r e c i a t i o n to my t h e s i s a d v i s o r s , Rose Murakami (Chairperson) and Carol J i l l i n g s f o r t h e i r w i l l i n g and h e l p f u l guidance i n the development of t h i s t h e s i s . Thanks are a l s o due to the head nurses, s t a f f members and p a t i e n t s on the u n i t s where the study was conducted f o r being so understanding and h e l p f u l . A s p e c i a l thanks i s extended to the spouses who shared t h e i r personal experiences. T h e i r p a r t i c i p a t i o n was most a p p r e c i a t e d . The support o f the f o l l o w i n g i n d i v i d u a l s i s g r e a t f u l l y acknowl-edged: Michael Doyle and Barbara Wright f o r t h e i r expert a s s i s t a n c e with the p r e p a r a t i o n of t h i s manuscript; and, f i n a l l y my c l o s e f r i e n d s and f a m i l y who have continued to o f f e r encouragement i n the p u r s u i t o f my academic g o a l s . CHAPTER 1 INTRODUCTION Background o f the Study Nurses i n t h e i r p r a c t i c e are c o n t i n u a l l y c a r i n g f o r p a t i e n t s and f a m i l y members who have f a c e d some degree of l o s s ranging from a minor d i s r u p t i o n t o the death o f a l o v e d one. T h i s study used a phenomeno-l o g i c a l approach t o examine l o s s as expressed by the spouses of myo-c a r d i a l i n f a r c t i o n (M.I.) p a t i e n t s . Because of the importance of the p a t i e n t ' s r e l a t i o n s h i p t o a spouse, the need t o examine f u r t h e r the impact o f the p a t i e n t ' s i l l n e s s upon M.I. spouses p r o v i d e d the impetus f o r t h i s study. S i g n i f i c a n c e o f the Study Nurses have many o p p o r t u n i t i e s t o help persons a n t i c i p a t i n g , or alread y e x p e r i e n c i n g l o s s ( C a r l s o n , 1978). Studies have shown t h a t a myocardial i n f a r c t i o n has c o n s i d e r a b l e i n f l u e n c e on the spouse, u s u a l l y the w i f e , and her r e a c t i o n s , c a p a c i t i e s and a t t i t u d e s are g e n e r a l l y c r i t i c a l t o the p a t i e n t ' s r e h a b i l i t a t i o n (Gulledge, 1975). L i t t l e r esearch was found, however, which r e l a t e d the phenomenon of l o s s to spouses of myocardial i n f a r c t i o n p a t i e n t s . A need to i d e n -t i f y r e a c t i o n s t h a t spouses e x p e r i e n c e d i n response to l o s s was ev i d e n t . T h i s knowledge may a s s i s t the nurse i n p r o v i d i n g spouses with the necessary guidance and support with subsequent b e n e f i c i a l e f f e c t on the p a t i e n t . 2 Statement of the Problem Loss was d e s c r i b e d as "a s t a t e o f being deprived of or of being without something one has had" ( P e r e t z , 1970, p. 4 ) . While d i f f e r e n c e s i n the magnitude of l o s s may change the q u a l i t y of the subsequent emotional r e a c t i o n s , there was c o n s i d e r a b l e evidence to suggest s i m i l a r i t i e s i n the recovery process f o l l o w i n g major l o s s e s (Bowlby, 1961; Engel, 1962; Fink, 1967; Kubler-Ross, 1969, Parkes, 1972; Shontz, 1975). F u r t h e r , a number of a d d i t i o n a l s t u d i e s have v e r i f i e d t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s r e a c t s i g n i f i c a n t l y t o t h e i r p a r t -ner's i l l n e s s , as evidenced by a n x i e t y , g u i l t , d e p r e s s i o n , h o s t i l i t y and o v e r p r o t e c t i v e behaviour (Adsett and Bruhn, 1968; Royle, 1973; Crawshaw, 1974; L a r t e r , 1976). T h e r e f o r e , f o r the nurse p r a c t i t i o n e r , more knowledge was r e q u i r e d of spousal behaviour i n order to b e t t e r understand the phenomena o f l o s s , and thus care more e f f e c t i v e l y f o r heart attack p a t i e n t s . Within the context of t h i s problem statement, the purpose of t h i s study was: - to e l i c i t d e s c r i p t i o n s from spouses o f M.I. p a t i e n t s o f t h e i r r e a c t i o n s i n response to l o s s from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n . - to observe spousal r e a c t i o n s i n response to l o s s from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n ; - to develop a framework, based on l i t e r a t u r e , which r e l a t e d the concept of l o s s to the experience of spouses of M.I. p a t i e n t s ; 3 - to make recommendations f o r change i n nursing education, p r a c t i c e and research drawn from the study. Assumptions I t i s assumed t h a t the husband-wife dyad i s s i g n i f i c a n t and t h a t l o s s experienced by one person i n the r e l a t i o n s h i p has c o n s i d e r a b l e impact on the p a r t n e r (Lindemann, 1944; M a r r i s , 1958; Parkes, 1969). Spouses o f h e a r t a t t a c k p a t i e n t s share common needs and concerns i n response to t h e i r p a r t n e r ' s i l l n e s s ( A dsett and Bruhn, 1968; Royle, 1973; Skelton and Dominian, 1973; L a r t e r , 1976; Mayou, F o s t e r and Williamson, 1978). The spouse's r e a c t i o n s , c a p a c i t i e s and a t t i t u d e s are g e n e r a l l y c r i t i c a l i n the M.I. p a t i e n t ' s r e h a b i l i t a t i o n . I t i s a l s o assumed M.I. spouses experience s i m i l a r r e a c t i o n s to l o s s . These g e n e r a l i z a t i o n s about a phenomenon can provide nurses with knowledge and d i r e c t i o n f o r p r a c t i c e . However, adequate r e c o g n i t i o n of i n d i v i d u a l d i f f e r e n c e s among spouses i n response t o a l o s s event such as a heart attack were acknowledged. L i m i t a t i o n s The emphasis of the study was on q u a l i t a t i v e data r a t h e r than on r e l a t i o n s h i p s between v a r i a b l e s . The purpose was to d i s c o v e r and d e s c r i b e l o s s as experienced by spouses of M.I. p a t i e n t s r a t h e r than prove or d i s p r o v e a given hypothesis. The s e l e c t e d sample was l i m i t e d to spouses whose partners had experienced t h e i r f i r s t myocardial i n f a r c t i o n . A convenient 4 non-random sample of twelve spouses was s e l e c t e d . No attempts were made a t r e p r e s e n t a t i v e n e s s i n the s t a t i s t i c a l sense. D e f i n i t i o n of Terms The f o l l o w i n g terms are o p e r a t i o n a l l y d e f i n e d i n the d i s c u s s i o n o f the data presented. Reactions The thoughts, f e e l i n g s and a c t i o n s as d e s c r i b e d by the spouses of myocardial i n f a r c t i o n p a t i e n t s . Observable behaviours The responses o f the spouses as observed by the i n v e s t i g a t o r during the i n t e r v i e w . These responses are c a t e g o r i z e d as verbal (type, q u a l i t y and c h a r a c t e r i s t i c s of speech, focus of conversation) and nonverbal (e.g. a c t i v i t y , eye c o n t a c t , body language and appearance). Loss The d e p r i v a t i o n of any o b j e c t , person, possession or i d e a l t h a t was c o n s i d e r e d v a l u a b l e and had an investment of s e l f . Loss was considered a c t u a l , p o t e n t i a l or symbolic ( P r a n u l i s , 1972). Loss could be t o t a l , p a r t i a l , permanent, temporary, p r e d i c t a b l e , u n p r e d i c t a b l e , sudden or gradual ( P e r e t z , 1970). Loss was understood as having an o b j e c t i v e q u a l i t y r e l a t e d to an event and a s u b j e c t i v e q u a l i t y r e l a t e d to the meaning given a l o s s event by an i n d i v i d u a l . G r i e f The p s y c h o l o g i c a l , emotional and somatic responses experienced f o l l o w i n g the p e r c e p t i o n of l o s s . Reactions i n c l u d e f e e l i n g s of shock 5 and d i s b e l i e f , h e l p l e s s n e s s , hopelessness, a n x i e t y , sadness, g u i l t , d e s p a i r , anger and aggression (Lindemann, 1944; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972). Somatic symptoms i n c l u d e dyspnea, deep s i g h i n g , lumps or t i g h t s e n sation i n the t h r o a t , weakness, f e e l i n g s o f emptiness, exhaustion, decreased a p p e t i t e and insomnia (Lindemann, 1944; P e r e t z , 1970). I n i t i a l impact of i l l n e s s The f i r s t n i n e t y - s i x hours of the p a t i e n t ' s myocardial i n f a r c t i o n . This time represents the acute phase of the p a t i e n t ' s i l l n e s s and occurs during the h o s p i t a l i z a t i o n p e r i o d i n the coronary care u n i t (Roberts, 1978). P a t i e n t with an uncomplicated myocardial i n f a r c t i o n A p a t i e n t admitted to the coronary care u n i t with a d i a g n o s i s of myocardial i n f a r c t i o n who responds favourably to the p r e s c r i b e d coronary regime. The p a t i e n t maintains a s t a b l e p h y s i o l o g i c a l status and does not develop c a r d i a c f a i l u r e , thromboemoblism, extension o f i n f a r c t i o n , shock or c a r d i a c rupture. 6 CHAPTER 2 REVIEW OF THE RELATED LITERATURE A review of the l i t e r a t u r e r e v e a l e d few d i s c u s s i o n s of the concept o f l o s s as experienced by the spouses o f myocardial p a t i e n t s . There were numerous e m p i r i c a l and t h e o r e t i c a l - even c o n t r o v e r s i a l - s t u d i e s of l o s s from an emotional, p s y c h o l o g i c a l and p h y s i o l o g i c a l p e r s p e c t i v e . This chapter w i l l examine the concept of l o s s as found i n the l i t e r a -t u r e and w i l l o u t l i n e a framework f o r understanding the phenomenon of l o s s . The purpose of t h i s t h e o r e t i c a l background i s to provide the i n t e l l e c t u a l c o n text f o r the conduct of t h i s study. Loss has been s t u d i e d e x t e n s i v e l y from a behavioural viewpoint: much of the l o s s research has emerged from c l i n i c a l p s y c h o a n a l y s i s and has been developed by p s y c h i a t r i s t s and s o c i a l p s y c h i a t r i s t s (Freud, 1917; Lindemann, 1944; M a r r i s , 1955; Bowlby, 1961; Engel, 1962; Parkes, 1969; Kubler-Ross, 1969). In the l a s t two decades f u r t h e r research and theory have been developed f o c u s i n g on some of the concepts c e n t r a l to l o s s ( M a r r i s , 1958; Parkes, 1965; A v e r i l l , 1968; Lipowski, 1969; P e r e t z , 1970; Schoenberg, 1970). More r e c e n t l y nurse researchers have s t u d i e d the impact of i l l n e s s on the spouse (Hampe, 1975; Vachon, 1977; Dracup and Breu, 1978). Reactions to Loss A person may experience g r i e f and mourning r e g a r d l e s s of the degree of l o s s or i t s i m p l i c a t i o n (Freud, 1917; Bowlby, 1961; 7 Lipowski, 1969). To understand l o s s i t i s h e l p f u l to c o n s i d e r the behavioural response to l o s s , which o f t e n takes the form of a g r i e f r e a c t i o n . The l i t e r a t u r e r e v e a l e d d i f f e r e n c e s i n the use of the word g r i e f and r e l a t e d terms. G r i e f , g r i e v i n g , mourning, g r i e f work, and bereave-ment were a p p l i e d i n t e r c h a n g e a b l y : however, t h e o r i s t s commonly c a t e g o r i z e g r i e f and i t s r e l a t e d terms i n t o three major components: the p s y c h o l o g i c a l processes, the emotional responses and the somatic symptoms experienced at the time of l o s s . The h i s t o r i c a l development of l o s s began with the psychodynamic aspects of l o s s and g r i e f . In 1917, Freud f i r s t p u b l i s h e d Mourning and  Melancholia which viewed mourning as a r e g u l a r c h a r a c t e r i s t i c f o l l o w i n g the l o s s o f a l o v e d one. Freud f e l t t h a t mourning was a process t h a t normally continued to a p r e d i c t a b l e outcome. The process of mourning was a continuum o f mental f e a t u r e s t h a t were symptomatic to every per-son who g r i e v e d . These f e a t u r e s were p a i n f u l d e j e c t i o n , abrogation of i n t e r e s t i n the o u t s i d e world, l o s s of the c a p a c i t y to l o v e , and i n h i -b i t i o n of a l l - a c t i v i t y . Freud f e l t , however, t h a t i f c e r t a i n f a c t o r s were present i n the c h a r a c t e r s t r u c t u r e of the g r i e v i n g person, the process of mourning could turn i n t o the p a t h o l o g i c a l s t a t e of melancholia. He i d e n t i f i e d three f a c t o r s t h a t i n f l u e n c e d t h i s type of outcome: l o s s of s e l f -esteem, strong dependency needs and ambivalence toward the l o s t o b j e c t . According to Freud, the development of melancholia i s not an exagger-ated g r i e v i n g process; r a t h e r i t i s a phenomenon which a r i s e s because of in h e r e n t t r a i t s i n the i n d i v i d u a l . 8 Stemming from Freud's attempts to l i n k mourning and m e l a n c h o l i a , w r i t e r s have s t u d i e d the e f f e c t s of bereavement i n a d u l t l i f e as well as the e f f e c t s of s e p a r a t i n g c h i l d r e n from t h e i r mothers. Lindemann (1944) p u b l i s h e d one of the most d e f i n i t i v e papers on g r i e f which d e s c r i b e d the c h a r a c t e r i s t i c s i g n s o f g r i e f based on an American study of 101 bereaved. He d e s c r i b e d acute g r i e f as a d e f i n i t e syndrome with p s y c h o l o g i c a l and somatic symptoms i n c l u d i n g somatic d i s t r e s s , preoccupation with the image of the deceased, g u i l t , h o s t i l e r e a c t i o n s , l o s s of h a b i t u a l p a t t e r n s of conduct, and with some frequency, the appearance of t r a i t s o f the deceased. Lindemann found t h a t persons i n acute g r i e f demonstrated q u i t e a uniform p i c t u r e and s t a t e d : Common to a l l i s the f o l l o w i n g syndrome: sensations of somatic d i s t r e s s o c c u r r i n g i n waves l a s t i n g twenty minutes to an hour a t a time, a f e e l i n g o f t i g h t n e s s i n the t h r o a t , choking with a shortness of breath, need f o r s i g h i n g , an empty f e e l i n g i n the abdomen, lack of muscular power, and an i n t e n s e s u b j e c t i v e d i s t r e s s d e s c r i b e d as t e n s i o n or mental pain (Lindemann, 1944, p. 141). Lindemann found i n d i v i d u a l s moved through a course of normal g r i e f r e a c t i o n s . He d e s c r i b e d t h i s process as g r i e f work, namely emanci-p a t i o n from the bondage to the deceased, readjustment to the e n v i r o n -ment i n which the deceased i s m i s s i n g , and the formation of new r e l a t i o n s h i p s . He found duration of the g r i e f r e a c t i o n depended upon the success with which a person completed the g r i e f work. Lindemann was the f i r s t to d e s c r i b e the concept of a n t i c i p a t o r y g r i e f . In h i s study of f a m i l i e s o f servicemen who had departed f o r 9 war, he found t h a t these i n d i v i d u a l s threatened with the l o s s of a l o v e d one experienced genuine g r i e f r e a c t i o n s which he l a b e l l e d as a n t i c i p a t o r y g r i e f . Lindemann suggested t h a t i n d i v i d u a l s who experienced a n t i c i p a t o r y g r i e f moved through the same process of g r i e f work as those who experienced g r i e f a f t e r an a c t u a l l o s s . The p a t i e n t i s so concerned with her adjustment a f t e r the p o t e n t i a l death o f f a t h e r or son t h a t she goes through a l l the phases of g r i e f d e p r e s s i o n , heightened preoccupation with the departed, a review of a l l the forms o f death which might be-f a l l him and a n t i c i p a t i o n of the modes o f readjustment which might be n e c e s s i t a t e d by i t . (Lindemann, 1944, p. 147). The r e a c t i o n s observed i n Lindemann's (1944) study were s i m i l a r to those d e s c r i b e d i n bereaved i n d i v i d u a l s . Most of the r e a c t i o n s were a s s o c i a t e d with d e p r e s s i o n , somatic symptoms o f exhaustion, l a c k of energy, s i g h i n g , r e s p i r a t i o n s , and d i g e s t i v e symptoms. Other f e e l i n g s of anger, i r r i t a b i l i t y , g u i l t and r e s t l e s s n e s s were rep o r t e d . Lindemann noted t h a t heightened preoccupation with the deceased was experienced by the bereaved as well as those a n t i c i p a t i n g the l o s s of a l o v e d one. This need f o r i n t e n s e preoccupation was f i r s t d i s c u s s e d by Freud (1917). He i n d i c a t e d that i t was a method which enabled the i n d i v i d u a l to e v e n t u a l l y give up the l o s t person. Werner (1970), i n a study of f a t a l l y i l l c h i l d r e n , observed t h a t the parents had an i n s a t i a b l e need to know e v e r y t h i n g about t h e i r c h i l d ' s c o n d i -t i o n . T h is search f o r i n f o r m a t i o n became an a l l consuming preoccupa-t i o n . The c h i l d became a constant focus i n t h e i r l i v e s and l i t t l e i n t e r e s t was shown f o r other a c t i v i t i e s . Reviewing the forms of death t h a t might b e f a l l the i n d i v i d u a l was 10 the t h i r d c h a r a c t e r i s t i c d e s c r i b e d by Lindemann. This r e a c t i o n i s s i m i l a r to t h a t experienced i n an actual l o s s , where the bereaved reviewed the events l e a d i n g up to and surrounding the death o f a l o v e d one ( M a r r i s , 1958; Parkes, 1972). Although Lindemann s t r e s s e d the s i m i l a r i t i e s between the r e a c t i o n s o f the bereaved and the r e a c t i o n s of those a n t i c i p a t i n g a l o s s , an important d i f f e r e n c e was mentioned by A l d r i c h (1975). Conventional g r i e f g e n e r a l l y d i s s i p a t e s with time, whereas a n t i c i p a t o r y g r i e f w i l l o f t e n i n t e n s i f y as the expected l o s s comes c l o s e r . Several authors have s t u d i e d the meaning of l o s s to i n d i v i d u a l s at v a r i o u s stages of the l i f e c y c l e from i n f a n c y to senescence (Anthony, 1940; P i a g e t , 1952; R o c h l i n , 1959; Nagy, 1959; Bowlby, 1961; Gesson, 1968; Burnside, 1969). John Bowlby (1961) r e f e r r e d to mourning as the p s y c h o l o g i c a l processes t h a t f o l l o w a l o s s of a s i g n i f i c a n t or valued o b j e c t , or t h a t f o l l o w the r e a l i z a t i o n t h a t such a l o s s may occur. The working through of these processes u s u a l l y leads to a g i v i n g up of the l o s t o b j e c t . He has s p e l l e d out i n great d e t a i l the way i n which young c h i l d r e n respond to the l o s s of a mother or mother s u b s t i t u t e . Bowlby b e l i e v e d t h a t the ego i s developed before the age of one y e a r and, t h e r e f o r e , the c h i l d i s capable of mourning at an e a r l y age. In drawing a d i r e c t r e l a t i o n s h i p between sepa r a t i o n l o s s and g r i e f , Bowlby argued t h a t c h i l d r e n and a d u l t s show s i m i l a r responses to the e x p e r i -ence o f l o s s whether act u a l or a n t i c i p a t e d . Some w r i t e r s have d e s c r i b e d phases or stages t h a t f o l l o w the death of a l o v e d one or major l i f e - t h r e a t e n i n g event ( M a r r i s , 1958; Engel, 1962; F i n k , 1967; Parkes, 1969; Kubler-Ross, 1969; Shontz, 1975). 11 Despite the t h e o r e t i c a l and d e s c r i p t i v e d i f f e r e n c e s between the v a r i o u s approaches, these w r i t e r s appeared to have many thoughts i n common about the nature o f g r i e f . They d e s c r i b e d the same elements although they gave d i f f e r e n t " l a b e l s " to the phases or stages. T h e i r g r i e f t h e o r i e s have provided a framework f o r understanding the phenomenon of l o s s . M a r r i s (1958) d e s c r i b e d g r i e v i n g or g r i e f work as the psycholog-i c a l sequence or process r e q u i r e d to a d j u s t to l o s s . The process i s evoked when a b i l i t i e s are threatened. M a r r i s conducted a systematic study o f the e f f e c t of bereavement on seventy-two London widows, ranging i n age from 25 t o 56. The widows complained o f d e t e r i o r a t i o n i n h e a l t h , insomnia, l o s s o f c o n t a c t with r e a l i t y , o b s e s s i v e memories and a sense of t h e i r dead husband's presence. M a r r i s d e s c r i b e d the widows' p r e v a i l i n g mood as a p a t h e t i c . He i d e n t i f i e d a c h a r a c t e r i s t i -c a l l y ambivalent response i n the behaviour of the bereaved where the women withdrew from people and t r i e d to escape from a l l reminders of the l o s s y e t i n the same breath seemed d e s p e r a t e l y l o n e l y and com-p l a i n e d i f people avoided them. The widows c u l t i v a t e d memories o f the dead, d e s i r i n g people to nurture those memories, y e t r e b u f f e d t h a t sympathy when i t was o f f e r e d . They i n s i s t e d t h a t t h e i r l i f e was mean-i n g l e s s now t h a t they had l o s t t h e i r husbands, however, they h u r r i e d back to t h e i r jobs while c a r i n g f o r t h e i r c h i l d r e n and homes with p r a c t i c a l e f f i c i e n c y . According to M a r r i s , i t i s d i f f i c u l t f o r others to know how to .. a s s i s t the new widows: sympathy aggravates the d i s t r e s s ; e x h o r t a t i o n s to be p r a c t i c a l and look to the f u t u r e seem g l i b and i n s e n s i t i v e ; s o l i c i t o u s n e s s seems o f f i c i o u s . Nothing seems r i g h t , causing f r i e n d s and f a m i l y to withdraw f u r t h e r . C l o s e l y l i n k e d to the works of Lindemann and Marris are the documented s t u d i e s o f g r i e f i n a d u l t l i f e by C o l i n Murray Parkes, (1965, 1972). Parkes has d e s c r i b e d g r i e f r e a c t i o n s i n d e t a i l , and has attempted to measure bereavement r e a c t i o n s using i n d i c a t o r s such as r a t e s of p h y s i c a l and mental i l l n e s s along with m o r t a l i t y s t a t i s t i c s . In 1959, f o l l o w i n g h i s d i s s e r t a t i o n on morbid g r i e f r e a c t i o n s , Parkes (1965) began a systematic i n v e s t i g a t i o n of 115 bereaved p s y c h i a t r i c p a t i e n t s whose i l l n e s s had developed w i t h i n s i x months a f t e r the death of a c l o s e f a m i l y member. He compared the r e a c t i o n s o f the bereaved to t y p i c a l g r i e f r e a c t i o n s as d e s c r i b e d by Marris (1958) i n h i s London widow study. Parkes found t h a t h i s p a t i e n t s had symptoms t h a t d i f f e r e d , i n i n t e n s i t y and d u r a t i o n which l e d him to c l a s s i f y g r i e f i n t o c a t e g o r i e s : t y p i c a l g r i e f , c h r o n i c g r i e f , i n h i b i t e d g r i e f and delayed g r i e f . Subsequently, Parkes (1971) undertook a l o n g i t u d i n a l study of the t y p i c a l g r i e f r e a c t i o n s o f London widows to the death o f t h e i r husbands. Parkes d e s c r i b e d the components of t y p i c a l g r i e f as alarm, s e a r c h i n g , m i t i g a t i o n , anger, g u i l t and g a i n i n g a new i d e n t i t y . During the alarm phase, the widows repor t e d r e s t l e s s n e s s and i n c r e a s e d muscle t e n s i o n , episodes of f e e l i n g panicky, i r r i t a b i l i t y , insomnia, l o s s o f a p p e t i t e , stomach upsets, and headaches. F o l l o w i n g the alarm phase, the widows experienced acute and e p i s o d i c "pangs" which were episodes of severe anxiety and p s y c h o l o g i c a l pain. Parkes termed t h i s phase s e a r c h i n g , and found i t occurred w i t h i n a few hours or days of bereave-ment and u s u a l l y reached a peak of s e v e r i t y w i t h i n f i v e to fourteen days. The widows s t r o n g l y missed t h e i r husbands, and would sob or c r y aloud f o r them, o f t e n preoccupied with thoughts of the l o s t person. Parkes f e l t the widows experienced p i n i n g , "... the s u b j e c t i v e and emotional component of the urge t o search f o r a l o s t o b j e c t " (Parkes, 1972, p. 40). The t h i r d phase d e s c r i b e d i s m i t i g a t i o n , which many o f the widows achieved by m a i n t a i n i n g a f e e l i n g or impression t h a t the bereaved person i s nearby, although he may not be seen or heard. The widows f e l t the p a i n was l e s s e n e d i f they had a c l e a r sense o f the continued presence of the deceased and became preoccupied with the thoughts of him. An o p p o s i t e r e a c t i o n was observed with other widows, who chose to m i t i g a t e the pain by d e n i a l . They t r i e d to b e l i e v e t h a t the l o s s had not o c c u r r e d and attempted to a v o i d people and s i t u a t i o n s t h a t would remind them o f the l o s s . Parkes found t h a t most widows expressed anger at some time during the f i r s t y e a r of bereavement. Sometimes the anger was d i r e c t e d towards the h o s p i t a l s t a f f o f t e n i t was expressed over a wide v a r i e t y of matters, many of them q u i t e t r i v i a l . He found r e p o r t s o f anger tended to be at a height during the f i r s t month, and to be reported only i n t e r m i t t e n t l y t h e r e a f t e r . Parkes termed the l a s t component of g r i e f " g a i n i n g a new iden-t i t y , " and r e p o r t e d the widows g r a d u a l l y learned a new r e p e r t o i r e of problem-solving s k i l l s i n order to cope with the u n f a m i l i a r tasks f a c i n g them. Widows repor t e d t h e i r r o l e s changing to i n c l u d e p r i n c i p a l wage earner, f a m i l y a d m i n i s t r a t o r and d i s c i p l i n a r i a n of the c h i l d r e n . At times the widows i d e n t i f i e d c l o s e l y with t h e i r former husbands, f o r 14 t h i s seemed to f a c i l i t a t e the r o l e changes and i n some way allowed them to keep a hold on t h e i r l o s t husbands. This coping mechanism, however, was only i n t e r m i t t e n t l y e f f e c t i v e . Episodes of comfortable c l o s e n e s s were followed by periods of g r i e v i n g and l o n e l i n e s s . The widows g r a d u a l l y found t h e i r new i d e n t i t y emerging from the a l t e r e d l i f e s i t u a t i o n s which they had to f a c e , and new f r i e n d s and workers provided the r o l e models. Several widows remarked t h a t t a l k i n g t o other widows was most h e l p f u l because they shared a common experience. Although many o f the bereavement s t u d i e s concentrated on the l o s s of a loved one, Marc F r i e d (1963) examined the concept of l o s s from a d i f f e r e n t p e r s p e c t i v e when he s t u d i e d the r e a c t i o n s of 789 Boston s i urn-dwellers who were moved from the west end of Boston under an urban renewal scheme. The f a m i l i e s were interviewed before the compulsory rehousing took place and again two years l a t e r . In h i s paper e n t i t l e d " G r i e v i n g f o r a Lost Home", F r i e d has drawn a c o n c i s e comparison between bereavement and the d e s t r u c t i o n of a neighbourhood and d i s p e r s a l of i t s r e s i d e n t s . He s t a t e d t h a t the m a j o r i t y gave evidence of f a i r l y severe g r i e f r e a c t i o n s . Intense p i n i n g f o r the l o s t home along with p s y c h o l o g i c a l , s o c i a l and somatic d i s t r e s s and o u t b u r s t s o f anger were t y p i c a l and there was a tendency to i d e a l i z e the o l d environment and to d e n i g r a t e the new. F o l l o w i n g F r i e d ' s work, Parkes (1972) and M a r r i s (1975) have expanded the research on g r i e f by conducting s t u d i e s to determine the r e a c t i o n s to s i g n i f i c a n t l o s s e s , other than the death of a loved one. Parkes i n t e r v i e w e d t h i r t y - s e v e n men and nine women under the age of 70, a t one and t h i r t e e n months a f t e r e x p e r i e n c i n g the l o s s of. an arm or a 15 l e g . He found t h a t the g r i e f a t the l o s s o f a loved person resembled the r e a c t i o n s f e l t by the amputees: It does seem t h a t the psychosocial t r a n s i -t i o n from being an i n t a c t person to being an amputee i s a p a i n f u l and time consuming p r o c e s s , which i s i n many ways s i m i l a r t o the t r a n s i t i o n from a married person to widow or widower (Parkes, 1972, p. 189). In a review a r t i c l e , M arris (1975) d i s c u s s e d h i s v a r i o u s s t u d i e s d e a l i n g with such d i v e r s e themes as the e f f e c t s o f bereavement on London widows, slum c l e a r a n c e i n America and N i g e r i a , students' e x p e r i -ence of u n i v e r s i t y education and American experiments i n s o c i a l reform. In each study the i n d i v i d u a l s were faced with a c r u c i a l t r a n s i t i o n . M a r r i s found the concept o f g r i e v i n g a p p l i c a b l e to many s i t u a t i o n s of change other than the death of a loved one. Whenever i n d i v i d u a l s experienced l o s s , even though they might d e s i r e change, t h e i r r e a c t i o n s expressed i n t e r n a l c o n f l i c t . The nature o f t h i s c o n f l i c t was fundamentally s i m i l a r to the working out o f g r i e f . The a n x i e t i e s o f change centered upon the s t r u g g l e to defend or to recover a meaningful p a t t e r n o f r e l a t i o n s h i p . Marris concluded t h a t "the impulse to defend the p r e d i c t a b i l i t y o f l i f e i s a fundamental and u n i v e r s a l p r i n c i p a l o f human psychology" ( M a r r i s , 1975, p. 3). Studies of the r e a c t i o n to l o s s by death o f a loved person have thrown c o n s i d e r a b l e l i g h t on the nature o f g r i e f and the process of adjustment which normally f o l l o w s a major bereavement. The t r a n s i t i o n begins with denial or numbness through a b i t t e r p i n i n g and f r u s t r a t e d search f o r the l o s t person. T h i s i s succeeded by depression and apathy when the bereaved person f i n a l l y g i v e s up the d e s i r e o f r e c o v e r i n g the l o s t person or o b j e c t . Next, a f i n a l phase of r e o r g a n i z a t i o n when new 16 plans and assumptions about the world and the s e l f are b u i l t up. The Elements of Loss Loss was c h a r a c t e r i z e d as a gradual p r e d i c t a b l e event and as a sudden traumatic experience. Loss, whether i n the past, present or f u t u r e , c o u l d be f e l t as a c t u a l , symbolic, or a n t i c i p a t e d (Lindemann, 1944; Schoenberg, 1970; Peretz, 1970; C a r l s o n , 1970). Loss was a l s o conceived as two events o c c u r r i n g simultaneously. To the observer t h e r e was a s p e c i f i c o b j e c t i v e or r e a l event t h a t s i g n a l e d an actual or p o t e n t i a l l o s s ; t o the i n d i v i d u a l e x p e r i e n c i n g the l o s s the event was a very s u b j e c t i v e one ( P e r e t z , 1970). In a narrow co n t e x t , l o s s was c a t e g o r i z e d as b i o l o g i c a l . B i o l o g -i c a l l o s s i n c l u d e d l o s s o f f u n c t i o n , p a r t or whole, and ranged from temporary a l t e r a t i o n of a system's f u n c t i o n to complete removal or l o s s of t h a t system. Psychosocial l o s s occurred i n c o n j u n c t i o n with b i o l o g -i c a l l o s s or, i n some cases, independently y e t both were e q u a l l y s i g n i f i c a n t (Parkes, 1972; Shontz, 1975; Roberts, 1978). I l l n e s s , l o s s of a limb or death, are concrete and observable whereas l o s s can a l s o take a more a b s t r a c t form and perhaps only be known to the i n d i v i d u a l . Loss of h e a l t h , f o r example, may l e a d to l o s s of a job as breadwinner r e s u l t i n g i n r e a l or a n t i c i p a t e d l o s s o f r e s p e c t from others ( P r a n u l i s , 1972). Peretz (1970) i d e n t i f i e d a b s t r a c t l o s s as l o s s of p o s i t i v e s e l f meaning the l o s s of a t t r a c t i v e -ness, p r i d e , esteem, independence and c o n t r o l . M a r r i s (1958) c i t e d the l o s s of freedom, happiness, hope, dreams, c e r t a i n t y , and p r e d i c t a b i l i t y as a b s t r a c t i n nature. Lipowski (1969) v o i c e d the same thoughts. He s a i d l o s s r e f e r r e d not j u s t to body pa r t s and f u n c t i o n s a c t u a l l y l o s t , but a l s o to d e p r i v a t i o n s of p e r s o n a l l y s i g n i f i c a n t needs and v a l u e s . The l a t t e r , he continued, were r e l a t e d c h i e f l y to s e l f - e s t e e m , s e c u r i t y and s a t i s f a c t i o n . P r a n u l i s (1972) viewed t h i s combination of concrete and a b s t r a c t l o s s with a broader f o c u s . She f e l t i n d i v i d u a l s were a s s a i l e d with l o s s on several l e v e l s a t d i f f e r e n t p o i n t s i n time. Peretz s t a t e d , with an even broader p e r s p e c t i v e , t h a t "Each l o s s c a r r i e s with i t the t h r e a t of a d d i t i o n a l or f u t u r e l o s s e s " ( P e r e t z , 1970, p. 4 ) . The Meaning of Loss Unlike the s t u d i e s d i s c u s s e d i n the previous s e c t i o n , a substan-t i a l number of w r i t i n g s were found t h a t presented l e s s d e f i n i t i v e opinions and t h e o r i e s r e l a t e d to l o s s . Although t h e o r i s t s v a r i e d i n t h e i r d e f i n i t i o n s o f l o s s , there was agreement t h a t an element, o b j e c t or event must be endowed with some s i g n i f i c a n t meaning i n order to be p e r c e i v e d as a l o s s . F u r t h e r d i s c u s s i o n on g r i e f , mourning, s e p a r a t i o n and other r e l a t e d concepts has c o n t r i b u t e d to the development of the theory of " o b j e c t r e l a t i o n s " which r e l a t e s mental i l l n e s s to the development of u n s a t i s f a c t o r y modes o f coping with l o s s throughout the course o f the l i f e s p a n (Lewin, 1935; E r i k s o n , 1959; Bowlby, 1961). Peretz (1970) used the term " o b j e c t l o s s " to r e f e r to the l o s s of an o b j e c t which has s p e c i a l value and emotional meaning to a person. Peretz conceived o b j e c t r e l a t i o n s h i p s as the r e l a t i o n s between an i n d i v i d u a l and the 18 t h i n g s i n h i s environment which have emotional s i g n i f i c a n c e i n c l u d i n g r e l a t i o n s between the i n d i v i d u a l and other persons, the i n d i v i d u a l and h i m s e l f , and the i n d i v i d u a l and inanimate o b j e c t s ( P e r e t z , 1970, p. 7). Moreover, l o s s was any s i t u a t i o n e i t h e r a c t u a l or p o t e n t i a l i n . which a valued o b j e c t was rendered i n a c c e s s i b l e to an i n d i v i d u a l or a l t e r e d i n such a way t h a t i t no longer had the q u a l i t i e s t h a t were valued. The l o s s o f a valued o b j e c t was con s i d e r e d to be the event preceding the s u b j e c t i v e s t a t e s of g r i e f and the p s y c h o l o g i c a l processes of g r i e v i n g (Peretz, 1970; C a r l s o n , 1970). Only the i n d i v i d u a l e x p e r i e n c i n g l o s s can know i t s f u l l meaning, although an observer may be able to d e f i n e some o f the o b j e c t i v e char-a c t e r i s t i c s of a l o s s . There was a tendency to a s s i g n g e n e r a l i z e d meaning to o b j e c t i v e d e s c r i p t i o n s of l o s s even though the e x p e r i e n c i n g person might d e f i n e the events q u i t e d i f f e r e n t l y ( C a r l s o n , 1978). According to Lipowski (1969) an i n d i v i d u a l ' s emotional and behav-i o u r a l response to l o s s was d i r e c t l y r e l a t e d to h i s p e r c e p t i o n of the event: The process of e v a l u a t i o n r e s u l t i n g i n meaning begins with the f i r s t p e r c e p t i o n of a p a t h o l o g i c a l process or i n j u r y and continues unabated throughout the course of i l l n e s s and i t s sequelae. The meaning i s the core of the person's p s y c h o l o g i c a l response to h i s d i s e a s e . I t i s of c r u c i a l importance f o r h i s emotional and behavioural response (Lipowski, 1969, p. 1198). A v e r i l l (1968) noted t h a t the nature and meaning of any l o s s experience was a f u n c t i o n of the p e c u l i a r h i s t o r y and present circumstances o f each i n d i v i d u a l as well as c u l t u r a l and b i o l o g i c a l determinants. 19 Writers have continued to i d e n t i f y f a c t o r s t h a t may i n f l u e n c e an i n d i v i d u a l ' s p e r c e p t i o n of l o s s . Age, r e l i g i o n , m a r i t a l s t a t u s , personal goals and v a l u e s , previous l o s s e s and e x t e r n a l support systems were some of the v a r i a b l e s noted i n the l i t e r a t u r e (Freud, 1917; Lindemann, 1944; M a r r i s , 1965; Parkes, 1974). Parkes (1974) viewed l o s s as causing d i s r u p t i o n i n the s t r u c t u r i n g and p r e d i c t a b i l i t y o f one's view of the world. " G r i e f work" was the process of r e - e s t a b l i s h i n g the congruence of present i n t e r n a l percep-t i o n s with the e x t e r n a l r e a l i t i e s of the l o s s . C a r l s o n (1978) d e f i n e d l o s s to r e f l e c t the importance of an i n d i -v i d u a l ' s goals i n one's p e r c e p t i o n of l o s s . The thwarting of d e s i r e s , hopes or goals seemed to be i n h e r e n t i n most l o s s events or e x p e r i -ences. Loss was an i n t e r r u p t i o n i n goal achievement - a change i n the i n d i v i d u a l ' s s i t u a t i o n t h a t reduced the p r o b a b i l i t y of a c h i e v i n g i m p l i c i t or e x p l i c i t g o a l s . As a r e s u l t , the meaning of l o s s was experienced uniquely by each i n d i v i d u a l depending upon the value placed upon the o b j e c t . Nursing Studies Related to Loss as Experienced by Spouses Since the e a r l y 1970's, nurse researchers have conducted c l i n i c a l s t u d i e s e x p l o r i n g the impact o f i l l n e s s on spouses as well as develop-i n g and implementing n u r s i n g i n t e r v e n t i o n s which help spouses cope with l o s s . These s t u d i e s o f f e r e d a new p e r s p e c t i v e to l o s s research which h i g h l i g h t e d the needs and concerns of spouses. Hampe (1975) focused on the g r i e v i n g spouses o f c h r o n i c a l l y ill oncology p a t i e n t s . From a comprehensive l i t e r a t u r e search o f l o s s and g r i e f Hampe i d e n t i f i e d e i g h t needs of the g r i e v i n g spouses which were c l a s s i f i e d under two headings. In the f i r s t category were those needs centered on the spouses' r e l a t i o n s with the dying person. The need t o f e e l h e l p f u l to the il l p a r t n e r , to be assured of the comfort o f the dying person, and to be kept informed o f the dying person's c o n d i t i o n and impending death were found. The second category o f needs r e l a t e d to the needs of the g r i e v i n g spouse: to v e n t i l a t e emotions, to r e c e i v e comfort and support from f a m i l y members, and to r e c e i v e acceptance, support and comfort from the h e a l t h p r o f e s s i o n a l s . The m a j o r i t y of spouses i n t e r v i e w e d by Hampe i d e n t i f i e d a l l e i g h t needs drawn from the l i t e r a t u r e . Hampe found t h a t although these needs were o f t e n recognized, they were inadequately met by nurses. Dracup and Breu (1978) used Hampe's e i g h t i d e n t i f i e d needs to design and implement a s p e c i f i c nursing care plan to meet the needs of g r i e v i n g spouses o f c r i t i c a l l y i l l c a r d i o v a s c u l a r p a t i e n t s . The researchers i n t e r v i e w e d twenty-six men and women to o b t a i n b a s e - l i n e data and found t h a t the e i g h t needs i d e n t i f i e d by Hampe were a l s o rep o r t e d by t h i s p o p u l a t i o n . Using the b a s e - l i n e data and t h e o r e t i c a l knowledge of l o s s and g r i e f , they designed and implemented s p e c i f i c nursing i n t e r v e n t i o n s f o r one-half of the sample. The remaining t h i r -teen spouses r e c e i v e d the usual nursing i n t e r v e n t i o n s , which were unstructured and i n c o n s i s t e n t at times. The researchers found the needs of the spouses i n the experimental group were met more c o n s i s t -e n t l y and completely. These f i n d i n g s were a t t r i b u t e d to the success o f the s t a n d a r d i z e d n u r s i n g care plan intended f o r the g r i e v i n g spouses of c a r d i o v a s c u l a r p a t i e n t s . 21 Vachon (1977) explored the problems of g r i e f and bereavement of wives of t e r m i n a l l y i l l cancer p a t i e n t s . Seventy-three women whose husbands had d i e d o f cancer a t the age of s i x t y - s e v e n or l e s s were in t e r v i e w e d f i v e times over a twenty-four month p e r i o d f o l l o w i n g bereavement. Vachon c a t e g o r i z e d the women i n t o two groups depending on how they viewed the i l l n e s s . One group saw t h e i r husbands' f i n a l i l l n e s s as terminal l e a d i n g slowly but i n e x o r a b l y to death. Other women viewed t h e i r husbands' i l l n e s s as p r i m a r i l y c h r o n i c wherein death was not a n t i c i p a t e d and came as a shock. In both groups, the widows reported the s t r e s s of l i v i n g with cancer was f a r worse than the s t r e s s of widowhood. During the f i n a l i l l n e s s there were many patterns of emotional r e a c t i o n s r e p o r t e d by the cancer widows. Widows reported great a n x i e t y over how much to d i s c u s s with t h e i r husbands about the i l l n e s s and i t s outcome. Widows reported f e e l i n g g u i l t y f o r wishing t h e i r husbands would d i e so as to end the s u f f e r i n g f o r a l l concerned. As w e l l , anger was d i r e c t e d towards husbands and h e a l t h p r o f e s s i o n a l s . Some l i m i t a t i o n s were noted with these s t u d i e s . The research focused mainly on spouses o f cancer p a t i e n t s . There was a need to explore the r e a c t i o n s of spouses i n many d i f f e r e n t i l l n e s s s i t u a t i o n s . More q u a l i t a t i v e data needs to be obtained about the immediate time-period t h a t f o l l o w s the l o s s event. The spouses' d e s c r i p t i o n s i n Vachon's study were obtained up to two years a f t e r the death of t h e i r husbands. R e t r o s p e c t i v e data have l i m i t a t i o n s i n terms of v a l i d i t y when one can not a c t u a l l y observe and d e s c r i b e the r e a c t i o n s a t the time of the l o s s . 22 Reactions to Loss by Spouses of Myocardial I n f a r c t i o n P a t i e n t s During the l a s t ten y e a r s , several i n v e s t i g a t o r s have s t u d i e d the spouses of myocardial p a t i e n t s i n more d e t a i l . T h i s research was p r e c i p i t a t e d by a growing awareness t h a t a heart attack has a s i g n i f i -cant impact upon the spouse. In response to the r e c o g n i t i o n t h a t some myocardial i n f a r c t i o n p a t i e n t s have s p e c i a l p s y c h o l o g i c a l adjustment d i f f i c u l t i e s , Adsett and Bruhn (1968) i n s t i t u t e d a short-term psychotherapy program f o r post-myocardial i n f a r c t i o n p a t i e n t s and t h e i r wives. The researchers found the myocardial i n f a r c t i o n p a t i e n t s were predominantly concerned with the l o s s of s e l f - e s t e e m whereas the spouses were concerned with g u i l t f e e l i n g s . They questioned what they might have done to c o n t r i b u t e to t h e i r p a r t n e r s ' h e a r t a t t a c k . Many of the wives f e l t i n h i b i t e d about expressing t h e i r f e e l i n g s s i n c e the heart a t t a c k . They f e l t g u i l t y about past negative or aggressive f e e l -ings and behaviours towards t h e i r p a r t n e r s . The women saw themselves as feeders and p r o t e c t o r s of t h e i r husbands and behaved i n an o v e r l y p r o t e c t i v e , non-demanding manner. Adsett and Bruhn found the wives to be anxious regarding the u n c e r t a i n f u t u r e while showing as much or more -depressive f e e l i n g s as t h e i r husbands. Although the spouses' r e a c t i o n s during the acute phase of t h e i r partner's i l l n e s s were not reported i n d e t a i l , r e a c t i o n s of c o n s i d e r a b l e anxiety and depression were d e s c r i b e d by the spouses one y e a r or more a f t e r t h e i r husbands' i l l n e s s . The r e s u l t s of the study showed t h a t both the p a t i e n t s and spouses appeared to achieve an improved ps y c h o s o c i a l adaptation but the c l i n i c a l f o l l o w -up was too b r i e f to evaluate the long-term e f f e c t s . The study was f u r t h e r l i m i t e d by the small sample and the s e l e c -t i o n of p a t i e n t s already demonstrating p s y c h o l o g i c a l maladjustment to the h e a r t a t t a c k . One rese a r c h e r who focused more on the acute as well c o n v a l e s c e n t phases o f a myocardial i n f a r c t i o n was Royle (1973). She st u d i e d what myocardial i n f a r c t i o n p a t i e n t s and t h e i r spouses under-stood and f e l t about the i l l n e s s and the treatment p r e s c r i b e d . Royle found t h a t d u r i n g the acute phase the p a t i e n t s and t h e i r spouses showed an awareness of the di a g n o s i s but t h e i r a b i l i t i e s to accept t h i s were i n f l u e n c e d by f e e l i n g s o f f e a r , anger, and d e n i a l . Although p a t i e n t s and spouses showed a t t i t u d e s of acceptance during the convalescent p e r i o d a t home, a c o n t i n u i n g element of f e a r was f e l t . Spouses repo r t e d anxiety i n regard to t h e i r own a b i l i t y to f o l l o w the p r e s c r i b e d d i e t a r y measures. A major source o f apprehension f o r the p a t i e n t s was the l i m i t a t i o n i n p h y s i c a l a c t i v i t y . Royle found t h a t the needs o f the p a t i e n t s and spouses f o r r e l e -vant i n f o r m a t i o n about heart d i s e a s e , h o s p i t a l environment, therapy, as well p r e p a r a t i o n f o r t r a n s f e r and discharge were not adequately i d e n t i -f i e d or met during t h e i r h o s p i t a l i z a t i o n or i n i t i a l p e r i o d a t home. P a t i e n t s and spouses repo r t e d r e c e i v i n g v a r i a t i o n s i n s p e c i f i c i t y o f i n s t r u c t i o n s . Medication i n f o r m a t i o n was c l e a r and s p e c i f i c , d i e t a r y r e s t r i c t i o n s were d e s c r i b e d i n general terms but accompanied by p r i n t e d i n s t r u c t i o n sheets. I n s t r u c t i o n s about p h y s i c a l a c t i v i t y were very vague. Royle concluded t h a t nurses need to a s s i s t p a t i e n t s and t h e i r spouses to adapt t o h e a r t d i s e a s e by i d e n t i f y i n g and meeting p a t i e n t and spousal l e a r n i n g needs at a l l the stages o f i l l n e s s and recovery. 24 This c o n c l u s i o n i s r e s t r i c t e d i n scope s i n c e none of the spouses were int e r v i e w e d during the h o s p i t a l i z a t i o n phase o f t h e i r p a r t n e r s ' i l l n e s s . A d e s c r i p t i v e study examining the r e a c t i o n s of wives of myocardial i n f a r c t i o n p a t i e n t s from the e a r l y h o s p i t a l i z a t i o n phase to one year post-myocardial' i n f a r c t i o n was conducted by Skelton and Dominian (1973). The s u b j e c t s s t u d i e d were a r e p r e s e n t a t i v e sample of s i x t y - f i v e wives. T h e i r husbands were consecutive p a t i e n t admissions to a coronary care u n i t with t h e i r f i r s t myocardial i n f a r c t i o n . Interviews were conducted a t l e a s t twice d u r i n g the husband's stay i n h o s p i t a l , then at t h r e e , s i x , and twelve months follow-up. Wives reacted to the i n i t i a l impact of the husband's i l l n e s s with c o n s i d e r a b l e d i s t r e s s . The suddenness of the i l l n e s s l e f t them with a sense of numbness and panic; many s t r e s s e d a f e e l i n g of u n r e a l i t y at t h i s time. G r i e f r e a c t i o n s and psychosomatic symptoms were common dur-ing t h i s p e r i o d of i n i t i a l impact. The women experienced f e e l i n g s o f l o s s , depression and anxiety and f r e q u e n t l y complained of s l e e p and a p p e t i t e d i s t u r b a n c e s . Psychosomatic symptoms were f e l t which the wives r e l a t e d to t h e i r husbands' i l l n e s s and reported as heart symptoms: chest p a i n s , t i g h t n e s s across the c h e s t , p a l p i t a t i o n s , f a i n t i n g and nausea. Many wives found the e a r l y convalescent p e r i o d - before the hus-bands' r e t u r n to work - very s t r e s s f u l . Spouses s u f f e r e d from f e e l i n g s of great a n x i e t y , d e p r e s s i o n , t e n s i o n and sleep d i s t u r b a n c e . They r e l a t e d t h e i r d i s t r e s s to t h e i r sense o f l o s s , f e a r of recurrence and the problems caused by the husbands' r e a c t i o n s a f t e r r e t u r n i n g home. 25 The women f e l t g u i l t y and f e a r f u l of l o s i n g t h e i r husbands and thus behaved i n an o v e r - p r o t e c t i v e manner. They reported t h e i r husbands as being more dependent and i r r i t a b l e . Skelton and Domini an d e s c r i b e d the t e n s i o n these f a c t o r s caused: T h i s combination of dependency and i r r i t a -b i l i t y r e s u l t e d i n f e e l i n g s o f t e n s i o n sometimes h o s t i l i t y i n the e a r l y weeks. If the wives showed concern they were accused of being o v e r p r o t e c t i v e and smothering but i f they showed l e s s concern they were f e l t to be unsympathetic. When they showed sympathy some husbands became more h e l p l e s s and demanding but i f they responded by firmness then they f e l t g u i l t y (Skelton and Dominian, 1973, p. 102). At one y e a r p o s t - i n f a r c t i o n , over o n e - t h i r d of the sample had made s a t i s f a c t o r y adjustment. The wives reported t h a t t h e i r own mood, a t t i t u d e and r e l a t i o n s with t h e i r husbands were s i m i l a r to t h e i r pre-i l l n e s s experience. A f u r t h e r o n e - t h i r d of the spouses were reasonably adjusted and s t i l l f e l t there were changes i n t h e i r f e e l i n g s and way o f l i f e causing some anxiety and apprehension. Less than o n e - t h i r d rep o r t e d c o n s i d e r a b l e d e p r e s s i o n , anxiety and sleep d i s o r d e r s a f t e r one y e a r . This poor adjustment caused a p p r e c i a b l e d i s t r e s s , both to them-s e l v e s and to t h e i r f a m i l i e s . Skelton and Dominian succeeded i n gathering a wealth of d e s c r i p -t i v e data concerning spouses r e a c t i o n s to t h e i r p a r t n e r s ' heart a t t a c k . Some l i m i t a t i o n s were noted. The study sample was e x c l u s i v e l y female. L i t t l e r esearch was found which examined male spousal r e a c t i o n s to t h e i r partners' heart a t t a c k . F u r t h e r , data were gathered from e a r l y h o s p i t a l i z a t i o n to one y e a r post-discharge y e t the time span of " e a r l y discharge" from h o s p i t a l was not s t u d i e d u n t i l three months p o s t - d i s c h a r g e . The r e s e a r c h e r s d i d not use a t h e o r e t i c a l framework r e l a t i n g to l o s s research or l o s s theory. L a r t e r (1976) examined the a t t i t u d e s of "M.I. Wives" toward the changes brought on by the husband's i l l n e s s . L a r t e r found many worries plagued the women. Concern regarding the p a r t n e r ' s o v e r e x e r t i o n , f e a r of recurrence and p o s s i b l e death were v o i c e d . The women f e l t they would u n i n t e n t i o n a l l y p r e c i p i t a t e the husband's death. They worried about the e f f e c t of sexual i n t e r c o u r s e and a l s o about t h e i r own h e a l t h . L a r t e r found t h a t expressions of anxiety were demonstrated i n a number of m a n i f e s t a t i o n s : worry over a n t i c i p a t e d problems, i r r i t a -b i l i t y , p a l p i t a t i o n s , shortness of breath, insomnia, worry over t r i v i a , headaches, c r y i n g e a s i l y and stomach upsets. The wives rep o r t e d t h a t the two areas o f t h e i r l i v e s most a f f e c t e d by t h e i r husbands' heart a t t a c k s were communication and sex r e l a t i o n s . The research examined the wives' r e a c t i o n s anywhere from one to t h i r t y - f i v e months a f t e r the occurrence o f t h e i r husbands' i l l n e s s through means o f a s t r u c t u r e d q u e s t i o n n a i r e by telephone or m a i l . The l e n g t h of time a f t e r the heart attack and the means of data c o l l e c t i o n may l i m i t the u s e f u l n e s s of t h i s study. More r e c e n t l y , research has been done by Mayou, F o s t e r and Williamson (1978). S i m i l a r to the study done by Skelton and Domini an, the researchers d e s c r i b e d spousal r e a c t i o n to t h e i r husband's myo-c a r d i a l i n f a r c t i o n from the i n i t i a l h o s p i t a l i z a t i o n to one year post-d i s c h a r g e . The i n f l u e n c e of wives i n determining the q u a l i t y o f outcome f o r a l l concerned was a l s o examined. Eighty-two wives whose husbands had s u f f e r e d t h e i r f i r s t h eart attack were i n t e r v i e w e d d u r i n g h o s p i t a l i z a t i o n , a t two months and one yea r p o s t - d i s c h a r g e . The semi-s t r u c t u r e d i n t e r v i e w s were conducted i n the s u b j e c t s ' home and tape recorded. The wives were seen s e p a r a t e l y from t h e i r husbands who were a l s o i n t e r v i e w e d i n regard to t h e i r a t t i t u d e s . During t h e i r husbands' h o s p i t a l i z a t i o n , the wives r e p o r t e d being moderately or s e v e r e l y d i s t r e s s e d . Crying and dist u r b a n c e s o f sleep and a p p e t i t e were common reported systoms but some women d e s c r i b e d f e e l i n g s o f numbness, u n r e a l i t y and a tendency t o c l i n g t o other people. During the f i r s t few weeks a f t e r the p a t i e n t s ' d i s c h a r g e , 80 percent o f the wives repo r t e d a n x i e t y , d e p r e s s i o n , f a t i g u e , i r r i t a -b i l i t y , poor c o n c e n t r a t i o n and insomnia. The re s e a r c h e r s found the spouses' complaints were as common and as severe as the p a t i e n t s ' r e p o r t s . At one year p o s t - i n f a r c t i o n , wives s t i l l showed c o n s i d e r a b l e p s y c h o l o g i c a l d i f f i c u l t i e s but were l e s s i r r i t a b l e than t h e i r husbands. F o r t y percent of wives complained of i l l h e a l t h a yea r a f t e r t h e i r husbands' i n f a r c t i o n . P r a c t i c a l problems faced by the wives while t h e i r husbands were i n the h o s p i t a l i n c l u d e d coping with v i s i t s to the h o s p i t a l , accommodating t h e i r time to the h o s p i t a l r o u t i n e , d i f f i c u l t y i n t r a n s p o r t a t i o n , e x t r a household chores and added r e s p o n s i b i l i t i e s e s p e c i a l l y with c h i l d c a r e . The women found the p r a c t i c a l and emotional support of f r i e n d s and r e l a t i v e s a great a s s i s t a n c e p a r t i c u l a r l y d u r i n g t h i s h o s p i t a l i z a t i o n p e r i o d . The re s e a r c h e r s found t h a t the wives had great i n f l u e n c e i n the p a t i e n t s ' readjustment during convalescence and t h a t the wives' a t t i t u d e s and behaviour were important determinants o f the ra t e and 28 e x t e n t of the p a t i e n t s ' recovery. T h i s research was s i m i l a r to Skelton and Dominian's work both i n i t s c o n t r i b u t i o n and l i m i t a t i o n s . These r e s u l t s emphasize the c o n s i d -e r a b l e i n f l u e n c e a myocardial i n f a r c t i o n has on the spouse. A truism i n the l i t e r a t u r e was t h a t the p a t i e n t may recover from h i s coronary but t h a t h i s wife may not. Summary I n v e s t i g a t o r s and w r i t e r s have used numerous methods and p o i n t s of view i n t h e i r attempts to understand l o s s . In the past century the study of l o s s has broadened from a f a i r l y narrow p s y c h o l o g i c a l or behavioural focus to encompass a more phenomenological p e r s p e c t i v e . Many s t u d i e s have focused on g r i e f r e a c t i o n s f o l l o w i n g a major l o s s and r e v e a l e d commonalities i n i n d i v i d u a l s ' behavioural responses to l o s s . (Freud, 1917; Lindemann, 1944; M a r r i s , 1958; Bowlby, 1961; Parkes, 1965). In a d d i t i o n to these s t u d i e s f u r t h e r research and theory have been developed f o c u s i n g on some of the concepts c e n t r a l to l o s s with p a r t i c u l a r emphasis on c h a r a c t e r i s t i c s o f l o s s and the i n d i v i d u a l s ' p e r c e p t i o n of the l o s s event ( A v e r i l l , 1968; Lipowski, 1969; Peretz, 1970; Schoenberg, 1970). More r e c e n t l y nurse researchers have s t u d i e d the impact of i l l n e s s on the spouse (Hampe, 1975; Vachon, 1977; Dracup and Breu, 1978). These s t u d i e s have y i e l d e d v a l u a b l e i n f o r m a t i o n on l o s s as experienced by spouses and o f f e r e d a new p e r s p e c t i v e to l o s s r e s e a r c h . Although the concept of l o s s has been well d e s c r i b e d i n the l i t e r -a ture there has been l i t t l e research done to r e l a t e l o s s to spouses of 29 myocardial i n f a r c t i o n p a t i e n t s . Several r e s e a r c h e r s have documented the r e a c t i o n s t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s e x p e r i -enced i n response to t h e i r p a r t n e r s ' i l l n e s s ( A d s e t t , Bruhn, 1968; Royle, 1973; S k e l t o n , 1973; L a r t e r , 1976; Mayou, F o s t e r and Williamson, 1978). The spouses' r e a c t i o n s were not s p e c i f i c a l l y r e l a t e d to a l o s s framework, but the emotional and somatic responses d e s c r i b e d by the i n v e s t i g a t o r s r e f l e c t e d a remarkable resemblance to the g r i e f reac-t i o n s , as reported i n the l o s s s t u d i e s . From the evidence o f t h i s l i t e r a t u r e review i t seems reasonable to expect t h a t f u r t h e r d e t a i l e d d e s c r i p t i o n s of spousal r e a c t i o n s to the p a r t n e r s ' heart a t t a c k w i l l c o n s t i t u t e a useful and meaningful a d d i t i o n to understanding to the event of a myocardial i n f a r c t i o n w i t h i n the context of the phenomenon o f l o s s . Nurses need to e x p l o r e spouses' r e a c t i o n s beginning with a concep-t u a l grasp of l o s s then moving on to examine the problem from a new and d i f f e r e n t f o c a l p o i n t . Drawing from the l o s s l i t e r a t u r e the i n v e s t i g a t o r o u t l i n e d three main c o n s t r u c t s which d e c r i b e d the author's t h e o r e t i c a l or conceptual way of viewing l o s s . These c o n s t r u c t s were i d e n t i f i e d as (1) r e a c t i o n s to l o s s ; (2) elements of l o s s ; (3) meaning o f l o s s . This framework o f f e r e d a p e r s p e c t i v e on l o s s as experienced by spouses of myocardial i n f a r c t i o n p a t i e n t s i n t h a t i t provided a p i c t u r e o f the s i t u a t i o n w i t h i n which the problem under study was viewed. 30 CHAPTER 3 METHODOLOGY In t r o d u c t i o n : An Overview The e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. In order t o understand l o s s as experienced by spouses of M.I. p a t i e n t s , d e t a i l e d data o f a q u a l i t a t i v e nature were d e s i r e d . The l i t e r a t u r e provided a s c a r c i t y o f in f o r m a t i o n on the phenomenon of l o s s as experienced by spouses o f M.I. p a t i e n t s . More q u a l i t a t i v e data were r e q u i r e d so t h a t t h i s phenomena c o u l d be d e s c r i b e d , analyzed and co n c e p t u a l i z e d i n more depth. A non-experimental e x p l o r a t o r y design i s a method o f cho i c e when the purpose i s . to i n c r e a s e understanding o f human behaviour. In f a c t , d i s c o v e r y o f unexpected f i n d i n g s may r e s u l t from t h i s approach because the researcher uses the p e r s p e c t i v e s o f h i s s u b j e c t s on the phenomenon, not h i s own preconceived notions as o p e r a t i o n a l i z e d by r i g i d research techniques ( F i l s t e a d , 1970). D e s c r i p t i v e , e x p l o r a t o r y and fo r m u l a t i v e s t u d i e s l i t e r a l l y look f o r ways to c a t e g o r i z e , c l a s s i f y or concept-u a l i z e s i t u a t i o n s . P a r t i c i p a n t and n o n - p a r t i c i p a n t observations are the predominant primary data c o l l e c t i o n procedures. D i e r s s t a t e d , "... the notion o f r i c h n e s s guides the data c o l l e c t i o n methods. P a r t i c i p a n t o b s e r v a t i o n , where the i n v e s t i g a t o r becomes p a r t of the events themselves, provides some dimensions t h a t can e n r i c h the concepts s i n c e i n f o r m a t i o n on the p a r t i c i p a n t s ' own f e e l i n g s become a v a i l a b l e " ( D i e r s , 1979, p. 112). 31 The research technique used i n t h i s study was the constant compar-a t i v e method, an i n d u c t i v e method of d i s c o v e r i n g grounded theory d e v e l -oped by Glaser and Strauss i n 1967. This method i n i t s s i m p l e s t terms i s a process of moving from the data t o the concept. The i n t e n t i s t o c o n c e p t u a l i z e a given event or s i t u a t i o n as opposed to d e s c r i b i n g i t . Di e r s (1979) de s c r i b e s t h i s method as a p s y c h o l o g i c a l t h i n k i n g process, one of d i s c r i m i n a t i o n , d e f i n i t i o n and c l a s s i f i c a t i o n o f t e n c a l l e d i n f e r e n c e . The constant comparative method simply s t r u c t u r e s t h i s conceptual process with a l l i t s steps so t h a t one can see c l e a r l y how the concepts have been developed and thus make judgements about concept val i d i t y . Comparative a n a l y s i s emphasizes theory as a on-going process. The stages of development i n v o l v e s e q u e n t i a l f o r m u l a t i o n , t e s t i n g and redevelopment of p r o p o s i t i o n s u n t i l a theory i s generated. I t may then be operational!'zed f o r l a t e r t e s t i n g i n q u a n t i t a t i v e r e s e a r c h . Four stages are i n c l u d e d i n the constant comparative method: (a) comparing i n c i d e n t s a p p l i c a b l e to each category, (b) i n t e g r a t i n g c a t e g o r i e s and t h e i r p r o p e r t i e s , (c) d e l i n e a t i n g the theory, and (d) w r i t i n g the theory. The elements of theory t h a t are generated by comparative a n a l y s i s are the conceptual c a t e g o r i e s with t h e i r conceptual p r o p e r t i e s and the g e n e r a l i z e d r e l a t i o n s among the c a t e g o r i e s with t h e i r proper-t i e s . These f o r m a l i z e d steps i n the research process r e s u l t i n the development of a theory, which i s an a b s t r a c t i o n grounded i n data with s p e c i f i c d e f i n i t i o n s . I d e a l l y with the Glaser and Strauss method data are c o l l e c t e d , coded and analyzed so t h a t a l l concepts and t h e i r p r o p e r t i e s are " s a t u r a t e d " . This c o n s t a n t comparative a n a l y s i s and t h e o r e t i c a l sampling i m p l i e s an i n f i n i t e time investment. Time c o n s t r a i n t s i n t h i s study were a l i m i t a t i o n . The Research S e t t i n g The i n v e s t i g a t i o n was conducted at a l a r g e m e t r o p o l i t a n h o s p i t a l . The i n t e n s i v e care-coronary care u n i t c o n s i s t e d of twenty beds. The p a t i e n t s admitted with a d i a g n o s i s of acute myocardial i n f a r c t i o n were t r e a t e d i n the u n i t . If t h e i r recovery was s t a b l e and uncomplicated they were t r a n s f e r r e d i n three to f i v e days to an intermediate coronary c a r e u n i t . The i n t e r m e d i a t e u n i t had 25 beds comprised of 15 bed c a r d i a c surgery area and ten beds f o r myocardial i n f a r c t i o n p a t i e n t s . The p a t i e n t s convalesced on t h i s u n i t u n t i l t h e i r discharge on a p p r o x i -mately day twelve to day f o u r t e e n . Sample S e l e c t i o n A convenience non-random sample of twelve spouses were s e l e c t e d from 12 c o n s e c u t i v e p a t i e n t admissions and formed the s u b j e c t s of t h i s study. P a t i e n t s s e l e c t e d f o r the study were r e q u i r e d to meet the f o l l o w i n g c r i t e r i a : (a) the p a t i e n t was admitted to the coronary u n i t of a l a r g e Vancouver h o s p i t a l with the d i a g n o s i s o f an acute myocardial i n f a r c t i o n , (b) the p a t i e n t had experienced h i s / h e r f i r s t myocardial i n f a r c t i o n , (c) the p a t i e n t met the coronary care u n i t ' s c r i t e r i o n of an uncomplicated myocardial i n f a r c t i o n , and (d) the p a t i e n t ' s age i s between 40 and 69 y e a r s . Spouses s e l e c t e d f o r the study were r e q u i r e d to meet the f o l l o w i n g c r i t e r i a : (a) the s u b j e c t was l e g a l l y married and r e s i d e d with the p a t i e n t , (b) the s u b j e c t was g e o g r a p h i c a l l y l o c a t e d so t h a t follow-up v i s i t s are p r a c t i c a l , (c) the s u b j e c t was able to speak and understand E n g l i s h , and (d) the s u b j e c t ' s age was between 30 and 75 y e a r s . Both males and females were i n c l u d e d i n the sample. Based on the s e l e c t i o n c r i t e r i a a sample was obtained w i t h i n a four-month p e r i o d . Because of time c o n s t r a i n t s the c r i t e r i a were modi f i e d f o r two patient-spouse s e l e c t i o n s . The f i r s t exception was a p a t i e n t with a r e c e n t c a r d i o v a s c u l a r h i s t o r y who was diagnosed with a t r i p l e vessel d i s e a s e . The l a s t p a t i e n t and spouse s e l e c t e d d i d not hold a l e g a l m a r i t a l s t a t u s but had been l i v i n g common-law f o r two y e a r s . These m o d i f i c a t i o n s i n sample s e l e c t i o n were not considered s i g n i f i c a n t with r e s p e c t to the homogeneity o f the t o t a l sample. None of the spouses asked to terminate t h e i r p a r t i c i p a t i o n but i t was necessary to omit two of the s u b j e c t s from the study. In one case the s u b j e c t had a b r e a s t lump diagnosed and underwent a r a d i c a l mastectomy. In the second i n s t a n c e a male s u b j e c t was dropped because h i s wife had major c a r d i a c surgery w i t h i n a month of her i n i t i a l heart a t t a c k . The data from the f i r s t two i n t e r v i e w s o f these spouses were i n c l u d e d i n the f i n d i n g s as the circumstances t h a t a l t e r e d t h e i r s i t u a t i o n s d i d not occur u n t i l a f t e r the date of the second i n t e r v i e w . The procedure f o r o b t a i n i n g the sample i n v o l v e d three s t e p s . A p r e l i m i n a r y s o r t was done by the head nurse i n c o n s u l t a t i o n with the 34 c a r d i o l o g i s t s . The i n v e s t i g a t o r then reviewed the p a t i e n t s ' c h a r t i n d e t a i l and b r i e f l y d i s c u s s e d the study with the p a t i e n t to determine p a t i e n t and spouse e l i g i b i l i t y . A l l p a r t i c i p a n t s were given a f u l l e x p lanation o f the study both v e r b a l l y and i n an explanatory l e t t e r p r i o r to o b t a i n i n g t h e i r consent f o r i n c l u s i o n i n the study sample. An exp l a n a t i o n o f the study was given a t the same time, whenever p o s s i b l e , to both p a t i e n t and spouse. Once i n t e n t to p a r t i c i p a t e was e s t a b l i s h e d , w r i t t e n consents were obtained p r i o r to the commencement of the i n t e r v i e w . Two spouses r e f u s e d to p a r t i c i p a t e i n the study. The women f e l t they d i d not have enough " c o n t r o l " to deal with the in t e r v i e w s due to t h e i r "upset f e e l i n g s a t t h i s time". Demographic data s p e c i f i c to age and sex of the p a t i e n t s and spouses are shown i n Table 1. The sample c o n s i s t e d of 12 s u b j e c t s , 10 women and 2 men. The ages of the p a t i e n t s ranged from 51 to 69 ye a r s with a mean age of 57.9 y e a r s . The ages of the spouses ranged from 34 to 65 years with a mean age of 54.9 y e a r s . Of the 12 s u b j e c t s , 4 women and 1 man were working a t the time o f t h e i r p a r t n e r ' s heart a t t a c k . Of the 12 p a t i e n t s , 7 men and 1 woman were employed at the time o f t h e i r i l l n e s s . There were 4 r e t i r e d c o u p l e s . Three o f the 12 couples had c h i l d r e n r e s i d i n g at home. Data C o l l e c t i o n In t h i s study, data c o l l e c t i o n commenced with the process o f ob s e r v a t i o n . S p e c i f i c a l l y , p a r t i c i p a n t o b s e r v a t i o n was u t i l i z e d as the data c o l l e c t i o n procedure. Subjects were p u r p o s e f u l l y i n t e r v i e w e d 35 Table 1 Age and Sex of P a t i e n t s and Spouses P a t i e n t Age Sex Spouse Age Sex 1 55 F 1 55 M 2 52 . M 2 53 F 3 57 M 3 55 F 4 69 M 4 65 F 5 67 M 5 65 F 6 < 57 F 6 56 M 7 63 M 7 62 F 8 60 M 8 58 F 9 55 M 9 55 F 10 51 M 10 45 F 11 60 M 11 56 F 12 49 M 12 34 F with the i n t e n t o f g a t h e r i n g " r i c h data" regarding t h e i r r e a c t i o n s to l o s s from the i n i t i a l impact o f t h e i r p a r t n e r s ' i l l n e s s to s i x weeks post-myocardial i n f a r c t i o n . A data c o l l e c t i o n t o o l was developed to provide a c o n s i s t e n t organized approach with the i n t e r v i e w procedure. The i n i t i a l p a r t o f the instrument i n c l u d e d demographic data, the i n i t i a l s , age and sex of the spouse and the p a t i e n t ' s age and number o f days post M.I. The content areas of thoughts, f e e l i n g s , a c t i o n s and observable behaviours were addressed i n the t o o l . Observable behaviours were examined i n terms of verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus o f conversation) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance). Four broad open-ended questions were used to e l i c i t data on the spouses thoughts, f e e l i n g s and a c t i o n s . A copy of the data c o l l e c t i o n t o o l i s provided i n Appendix C. Since the purpose of the study was to explore the r e a c t i o n s o f spouses o f heart attack p a t i e n t s the i n t e r v i e w guide proved to be an e f f e c t i v e t o o l . The semi s t r u c t u r e d i n t e r v i e w provided enough d i r e c t i o n so t h a t s p e c i f i c content areas were covered i n each i n t e r v i e w , thus data c o u l d be compared from one i n t e r v i e w to another. At the same time there was f l e x i b i l i t y i n s t r u c t u r e a l l o w i n g f o r s h i f t i n sequence or t o p i c s i n keeping with the moods or needs of the spouses. A l l the interviewees' responses were audio taped. The subjects were assured t h e i r r e p l i e s would be kept i n s t r i c t confidence and t h e i r anonymity respected. None of the subjects objected to the t a p i n g . The i n v e s t i g a t o r i n i t i a t e d c o n t a c t with a few minutes of s o c i a l t a l k i n order to develop rapport and ease any apparent t e n s i o n . The i n v e s t i g a t o r was concerned t h a t the impact o f t h i s c r i t i c a l i l l n e s s would c r e a t e too g r e a t a s t r a i n f o r the spouses and they would be r e l u c t a n t to d i s c u s s t h e i r r e a c t i o n s so soon a f t e r the event. In f a c t , the opposite was found. The spouses were indeed w i l l i n g respondents. Many o f the s u b j e c t s expressed s u r p r i s e and p l e a s u r e t h a t they were being recognized and t h a t t h e i r r e a c t i o n s were con s i d e r e d of some importance. The res e a r c h e r approached the i n t e r v i e w i n an informal s u p p o r t i v e manner. The s u b j e c t s were encouraged t o f r e e l y d i s c u s s t h e i r r e a c t i o n s , with the assurance t h a t there was no r i g h t or wrong answer. Four i n t e r v i e w s were conducted with each s u b j e c t i n the study. The spouses were int e r v i e w e d from day three to day f i f t y - t w o of t h e i r partner's heart a t t a c k . This p e r i o d covered the time of the i n i t i a l impact of i l l n e s s to approximately s i x weeks post myocardial i n f a r c -t i o n . At the time of the l a s t i n t e r v i e w a l l p a t i e n t s had been discharged f o r a t l e a s t three to fo u r weeks. (See Table 2) The f i r s t i n t e r v i e w was scheduled w i t h i n n i n e t y - s i x hours of the hea r t attack and the second i n t e r v i e w f o l l o w e d during week two of the p a t i e n t ' s h o s p i t a l i z a t i o n . These two i n t e r v i e w s were arranged to c o i n -c i d e with the spouses' normal h o s p i t a l v i s i t i n g schedule. The researcher chose the s e t t i n g of a p r i v a t e o f f i c e to conduct the i n t e r -views. The t h i r d and f o u r t h i n t e r v i e w s were scheduled f o r one and three weeks post discharge of the p a t i e n t . During t h i s post h o s p i t a l i -z a t i o n p e r i o d the res e a r c h e r interviewed the spouses p r i v a t e l y i n the f a m i l i a r and comfortable s e t t i n g of t h e i r own homes. The i n t e r v i e w s ranged from 12 to 75 minutes with an average time of 35 minutes. 38 Table 2 Number of Days A f t e r Myocardial I n f a r c t i o n That Interview Took Place Number of Days F i r s t Second T h i r d Fourth S u b j e c t I n t e r v i e w Interview Interview Interview 1 6 17 26 43 2 3 15 27 40 3 3 11 21 34 4 5 11 24 38 5 3 9 26 40 6 6 12 26 46 7 3 14 31 52 8 3 8 28 43 9 6 11 22 42 10 4 9 27 43 11 4 10 23 37 12 4 10 19 33 39 During the i n t e r v i e w s the i n v e s t i g a t o r observed the verbal and non-verbal behaviours o f the spouses. Notes of these o b s e r v a t i o n s were made i n p r i v a t e immediately a f t e r each i n t e r v i e w . The f o r t y - e i g h t semi s t r u c t u r e d i n t e r v i e w s y i e l d e d an abundance of data. A f t e r conducting an i n t e r v i e w with each s u b j e c t the i n v e s t i g a t o r l i s t e n e d to the tape to get a general o v e r a l l impression o f the m a t e r i a l . Nota-t i o n s were made of any ideas and themes. The i n v e s t i g a t o r used t h i s time to j o t down spontaneous ideas t h a t came to mind while l i s t e n i n g to the tapes. Notes from the spouses' observable behaviours were r e f e r r e d to c o n j o i n t l y with the audio tapes, thus p r o v i d i n g an accurate impres-s i o n of the i n t e r v i e w . In f a c t , the data c o l l e c t i o n phase was not i s o l a t e d from the data p r o c e s s i n g and a n a l y s i s . The researcher had many a b s t r a c t thoughts about the events observed and recorded. G l a s e r and Strauss advocate the w r i t i n g o f " a n a l y t i c memos" at s p e c i f i e d i n t e r v a l s throughout the data c o l l e c t i o n p e r i o d . Summaries of one's developing thoughts about the data from which concepts begin t o emerge or d i r e c t i o n s f o r f u t u r e data c o l l e c t i o n s t a r t to form ( G l a s e r and S t r a u s s , 1967). The data c o l l e c t i o n p e r i o d took approximately f i v e months t o complete. I d e a l l y i n the grounded theory approach, data c o l l e c t i o n i s s a i d to end when the f a c t o r s or c a t e g o r i e s are " s a t u r a t e d " , when new data no longer reveal new dimensions ( G l a s e r and S t r a u s s , 1967). This was not p o s s i b l e i n t h i s study due to the time c o n s t r a i n t s o f the researcher. With t h i s approach there are i n f i n i t e p o s s i b i l i t i e s f o r developing new concepts as more data become a v a i l a b l e . Even with the 40 volume of data c o l l e c t e d i n t h i s study only a f i n i t e aspect of the phenomenon or s i t u a t i o n were examined. Data Coding and A n a l y s i s F o l l o w i n g the data c o l l e c t i o n phase of the study the audiotapes were t r a n s c r i b e d and the raw data was examined, s o r t e d and coded i n t o as many c a t e g o r i e s as p o s s i b l e . In order to systematize the coding process each item of data was a l l o t t e d a c o l o u r . For example, spouses commented on t h e i r p h y s i c a l disturbances e.g. headaches, l o s s o f a p p e t i t e , insomnia, e t c . This raw data were then coded with a y e l l o w dot. I n i t i a l category c o n s t r u c t i o n was a simple process of c o l l e c t i n g a l l the data with the same c o l o u r (e.g. the y e l l o w d o t s ) . To f a c i l i -t a t e data c o m p i l a t i o n data were entered on r e f e r e n c e c a r d s . Three numbers were noted a f t e r each item of data, i n d i c a t i n g the respondent, the number of the i n t e r v i e w and the exact page number of the t r a n -s c r i b e d data. The c o l o u r o f the category was marked i n the upper right-h a n d corner of the c a r d . The i n v e s t i g a t o r then proceeded to d e f i n e and d e s c r i b e the c a t e -g o r i e s . These beginning s e t o f c a t e g o r i e s were a p p l i e d to the data. Often the same data were used to generate the category to check f o r " f i t " or c o n s i s t e n c y . The c a t e g o r i e s were reworked over and over u n t i l the concepts and t h e i r p r o p e r t i e s became c l e a r e r . The d e s c r i p t i o n s of the c a t e g o r i e s were a l s o t r a n s c r i b e d onto r e f e r e n c e c a r d s . The c o l o u r coding system was used to q u a n t i f y the data. The frequency of s p e c i f i c c a t e g o r i e s was noted by simply counting c o l o u r s . The q u a l i t a t i v e and q u a n t i t a t i v e data obtained were t r a n s c r i b e d onto a l a r g e matrix with each respondent r e p r e s e n t i n g a row and each category r e p r e s e n t i n g a column. The c o l o u r s of the category and i t s d e f i n i t i o n s were entered i n the columns and the frequency of the category entered i n each respondents row. The i n v e s t i g a t o r continued to examine the data, comparing and c o n t r a s t i n g c a t e g o r i e s with a purpose o f t h r e a d i n g the concepts and p r o p e r t i e s together i n t o some meaningful p a t t e r n . As the process evolved, more and more data were encompassed meanin g f u l l y under l a r g e r a b s t r a c t concepts. To f u r t h e r c l a r i f y the process of data coding and a n a l y s i s an example has been i n c l u d e d i n Appendix D. This overview i l l u s t r a t e s the a p p l i c a t i o n of the G l a s e r and Strauss method of constant comparative a n a l y s i s . Diers (1979) d e f i n e d t h i s method i n i t s s i m p l e s t terms as a process of d i s c r i m i n a t i o n , d e f i n i t i o n and c l a s s i f i -c a t i o n . R e l i a b i l i t y and V a l i d i t y Issues The s e l e c t e d methodology r a i s e s several i s s u e s r e l a t e d to r e l i a -b i l i t y and v a l i d i t y . D i e r s (1979, p. 112) s t a t e d t h a t the usual concerns about r e l i a b i l i t y and v a l i d i t y of the instruments used i n the study do not apply with t h i s study design. There i s more concern f o r the r e l i a b i l i t y of the sources of data and or the r e c o r d e r ..." t h a t i s the concern whether the sources of data represent well the developing concepts and whether the person r e c o r d i n g the data gets i t a l l down". To t e s t the v a l i d i t y of the data g a t h e r i n g instrument two subjects were interviewed i n a p i l o t study. The data gathered from t h i s p i l o t were adequate f o r the purpose o f the study. To ensure r e l i a b i l i t y of 42 the f i n d i n g s a data g a t h e r i n g instrument was u t i l i z e d and a l l i n t e r v i e w s were audiotaped. In a d d i t i o n , immediately f o l l o w i n g the i n t e r v i e w the i n v e s t i g a t o r made notes o f the spouses' observable behaviours i n order t o maintain accurate r e c a l l . The problem o f poor or s e l e c t i v e memory was minimized by i n t e r v i e w i n g the su b j e c t s on fo u r separate o c c a s i o n s , i n a s h o r t span o f time, from the i n i t i a l impact o f the i l l n e s s to s i x weeks a f t e r the heart a t t a c k . The concern t h a t the respondents would h e s i t a t e to d i s c l o s e t h e i r r e a c t i o n s because of the s e n s i t i v e nature o f the study d i d not m a t e r i a l i z e . The spouses were i n f a c t w i l l i n g respondents and f r e e l y d i s c u s s e d t h e i r thoughts and f e e l i n g s . S e l l i t z , Wrightsman and Cook (1976) pointed out t h a t the most important f a c t o r i n determining the frequency and v a l i d i t y o f response i s the s a l i e n c e o f the i n t e r v i e w t o p i c . With p a r t i c i p a n t o b s e r v a t i o n the i n v e s t i g a t o r ' s personal e x p e r i -ences and bia s e s can be a t h r e a t to the o b j e c t i v i t y o f the study. Di e r s (1979) s t a t e d t h a t the c r e a t i v e use of personal i n s i g h t s can g r e a t l y e n r i c h t h i s type o f study as long as proper p r e c a u t i o n s are taken to balance those kinds of data with other data which might d i s c o n f i r m one's own impressions. The i n v e s t i g a t o r was aware o f her personal b i a s e s and u t i l i z e d the t h e s i s committee as o b j e c t i v e resources to " t e s t " personal impressions. A s t a n d a r d i z e d procedure was used f o r data c o l l e c t i o n , coding and a n a l y s i s . This systematic approach provided a degree o f r e l i a b i l i t y to the study. To ensure f u r t h e r r e l i a b i l i t y o f data coding and a n a l y s i s a procedure f o r i n t e r r a t e r r e l i a b i l i t y was undertaken. The i n v e s t i g a t o r d e f i n e d the s i x t e e n c a t e g o r i e s i d e n t i f i e d i n the study. Those c a t e g o r i e s comprised the phases and the three elements of thoughts, f e e l i n g s and a c t i o n s f o r each phase. Four examples of i l l u s t r a t i v e data were chosen t o r e p r e s e n t each o f the c a t e g o r i e s . A t a b l e o f random numbers was used to determine which of the data would be s e l e c t e d f o r the r e l i a b i l i t y check. Of the s i x t y - f o u r pieces of data, twenty-eight were chosen. Two nurses with v a r i e d t e a c h i n g , c l i n i c a l and a d m i n i s t r a t i v e experiences were s e l e c t e d as r a t e r s . Using the d e f i n e d c a t e g o r i e s and the twenty-eight items of data the r a t e r s were asked to make two d e c i s i o n s . F i r s t l y , they had to s o r t each item of data i n t o one of the three phases. The second s o r t e n t a i l e d coding each item of data i n t o one of the three main elements comprising each category, thoughts, f e e l i n g s or a c t i o n s . In the f i r s t s o r t the percentage of agreement was 85.7. The r a t e r s found t h a t i n most i n s t a n c e s the phases were c l e a r l y d e s c r i b e d but there was some o v e r l a p p i n g , p a r t i c u l a r l y with the spouses' thoughts and f e e l i n g s . The second s o r t r e s u l t e d i n a 82.1 and 85.7 percentage of agreement f o r the two r a t e r s . Again the g r e a t e s t d i f f i c u l t y was i n d i f f e r e n t i a t i n g whether the item of data was d e s c r i b i n g a thought or a f e e l i n g . C o n s i d e r i n g the high l e v e l o f agreement, however, i t appeared t h a t the c a t e g o r i e s guided the r a t e r s i n coding the m a j o r i t y of the data c o r r e c t l y . 44 CHAPTER 4 FINDINGS OF THE STUDY Based on the methodology d e s c r i b e d i n Chapter I I I data were obtained from subjects who were spouses o f myocardial i n f a r c t i o n p a t i e n t s . Using an i n t e r v i e w guide with open-ended questions the researcher asked spouses what t h e i r thoughts, f e e l i n g s and a c t i o n s were i n response to t h e i r p a r t n e r s ' heart a t t a c k . In a d d i t i o n to the verbal data obtained, the spouses' behaviours were observed during each i n t e r v i e w . Common verbal and observed spousal behaviours were i d e n t i f i e d during the six-week p e r i o d of i n v e s t i g a t i o n . Three d i s t i n c t phases o f behaviour over the time of the study were found. Appendix E shows the r e l a t i o n s h i p o f the f i n d i n g s to the three phases of spousal r e a c t i o n to l o s s . PHASE I The Event and I n i t i a l Spousal Response This phase covered the h o s p i t a l i z a t i o n p e r i o d of the p a t i e n t from the t h i r d to the seventeenth day post-myocardial i n f a r c t i o n . The r e a c t i o n s t h a t the spouses experienced were d e s c r i b e d or observed during the f i r s t and second i n t e r v i e w . The i n t e r v i e w s corresponded with the acute (coronary care u n i t ) and convalescent (postcoronary care u n i t ) h o s p i t a l i z a t i o n o f the p a t i e n t . The f i n d i n g s from both i n t e r v i e w s were subsumed under one phase. 45 PHASE I — T h o u g h t s F o u r c a t e g o r i e s were i d e n t i f i e d t h a t d e s c r i b e d what t h e s u b j e c t s were d o i n g i n a c o g n i t i v e s e n s e . They were t e r m e d r e v i e w i n g , a n t i c i -p a t i n g , c o m p a r i n g and r e d e f i n i n g . The o r d e r o f t h e c a t e g o r i e s as r e p o r t e d does n o t n e c e s s a r i l y i m p l y t h e s u b j e c t s p r o g r e s s e d w i t h a s equence o f t h o u g h t s . However , a d e g r e e o f o r d e r i s e v i d e n c e d w i t h some o f t h e c a t e g o r i e s and i s r e p o r t e d as s u c h . R e v i e w i n g Of t h e t w e l v e s u b j e c t s , t e n i n i t i a t e d t h e f i r s t i n t e r v i e w w i t h a s p o n t a n e o u s b l o w - b y - b l o w d e s c r i p t i o n o f "how i t h a p p e n e d " . They moved f r o m a p o s t t o a p r e s e n t t i m e f r a m e and were a b l e t o r e c a l l v i v i d l y t h e i r p a r t n e r s ' symptoms and r e a c t i o n s and t h e n d e t a i l t h e i r own r e a c t i o n s t o t h e s i t u a t i o n s . In r e c a l l i n g t h e i n c i d e n t , s e ven s u b j e c t s d i s c u s s e d t h e i r s u r p r i s e a t s u c h an u n e x p e c t e d e v e n t . Two e x p r e s s e d g u i l t f e e l i n g s . They f e l t i g n o r a n t i n n o t r e c o g n i z i n g t h e symptoms o f a h e a r t a t t a c k and t h o u g h t t h e i r p a s s i v e r o l e i n t h e i n c i d e n t had i n some way i n h i b i t e d t h e s e e k -i n g o f m e d i c a l a t t e n t i o n . A n t i c i p a t i n g Many o f t h e s u b j e c t s ' t h o u g h t s f o c u s e d on t h e a n t i c i p a t e d l o s s o f t h e i r p a r t n e r s . They q u e s t i o n e d many t h i n g s , t h e r e a s o n o r c a u s e o f t h e i l l n e s s - "why t h i s h a p p e n e d " and i s s u e s r e l a t e d t o c o m p l i c a t i o n s , r e c u r r e n c e o f t h e h e a r t a t t a c k and t h e q u a l i t y o f a d j u s t m e n t . D u r i n g 46 the f i r s t i n t e r v i e w the s u b j e c t s ' g r e a t e s t f e a r was t h a t o f another heart a t t a c k , because they p e r c e i v e d the i n t e n s i v e care p e r i o d to be a c r i t i c a l and u n c e r t a i n time. One woman summed up her f e a r s : Well my thoughts are p r e t t y well e v e r y t h i n g how bad i s i t , how well w i l l h i s recovery b e — I mean anything can happen y e t . Fears of recurrence were commonly r e p o r t e d : I am f r i g h t e n e d of another occurrence, t h a t p a r t , t h a t ' s one of the major concerns ... so I worry about when he gets home, and i f he gets home even ... I would always be s o r t o f f r i g h t e n e d a f t e r you have him home, th a t i t would occur again. As the p a t i e n t s progressed i n an uneventful recovery and were t r a n s f e r r e d to the convalescent ward, the s u b j e c t s began to focus l e s s on the f e a r o f r e c u r r e n c e . The questions a t t h i s time centered more on how well t h e i r partners would a d j u s t , both i n the h o s p i t a l and at home. Many s u b j e c t s a n t i c i p a t e d t h e i r partners would not cooperate: So I worry about how I am going to hold him back. Oh I can do i t you know, but I don't want to get i n t o any arguments. A l o t goes through your mind and you t h i n k , w e l l , w i l l he be a l r i g h t when he gets home? I'm worried about (my husband). He's so stubborn. He s a i d he was j u s t w a i t i n g t i l l the nurses weren't watching him so c l o s e l y and then he was going to sneak a walk i n the h a l l s . As the p a t i e n t moved c l o s e r to discharge the m a j o r i t y of s u b j e c t s began to d i s c u s s i n d e t a i l the changes they a n t i c i p a t e d i n r o l e s and r e s p o n s i b i l i t i e s . These changes were perc e i v e d as a f f e c t i n g themselves and t h e i r r e l a t i o n s h i p . The s u b j e c t s a n t i c i p a t e d t h a t the i l l n e s s would a f f e c t t h e i r own l i v e s even more so than i t d i d t h e i r p a r t n e r s . A comment by one woman summed up t h i s a n t i c i p a t i o n : 47 I t has q u i t e a b i t of e f f e c t on me. I t h i n k more so than my husband. For me there are more important ways of doing t h i n g s , than r e a l l y f o r him. Because with him, i f he takes i t easy and doesn't do anything, well with me, I have to plan our s o c i a l l i f e d i f f e r e n t l y and I have to l e a r n to cook d i f f e r e n t l y , and I have to compromise more to h i s way now. Many s u b j e c t s spoke about f i n a n c e s . Only two s u b j e c t s expressed f i n a n c i a l concerns. The m a j o r i t y f e l t f i n a n c i a l matters would not pose a problem i n t h e i r l i v e s . Retirement seemed to play a s i g n i f i c a n t f a c t o r i n f i v e of the s u b j e c t s ' responses. One woman s t a t e d : I don't t h i n k our l i f e s t y l e w i l l change t h a t much. We are r e t i r e d so we can come and go and do as we want. Maybe we don't have as much as some, but we have enough. In the f i r s t i n t e r v i e w one h a l f of the sample asked general questions r e l a t e d to t h e i r i n f o r m a t i o n needs: "What I want to know i s how do we approach t h i s t h i n g ? " "How do I handle him?" As the p a t i e n t moved c l o s e r to discharge ten s u b j e c t s i d e n t i f i e d s p e c i f i c i n f o r m a t i o n needs. A l l s u b j e c t s wanted to know the medical plans "I want to know the do's and don'ts, otherwise he could be doing something and I don't know i f i t ' s r i g h t or wrong." "I want to know a l l about h i s heart so I can do the r i g h t t h i n g f o r him and me." In the second i n t e r v i e w , ten s u b j e c t s organized t h e i r plans f o r approaching the convalescent p e r i o d . T h e i r thoughts d e a l t with the p h y s i c a l and p s y c h o l o g i c a l plans f o r t h e i r p a r t n e r s . In a n t i c i p a t i o n of what was to come, the s u b j e c t s r e d e f i n e d t h e i r r o l e s to i n c l u d e the new r e s p o n s i b i l i t i e s of c o n t r o l l e r and p r o t e c t o r . One young s u b j e c t saw the n e c e s s i t y of changing r o l e s and r e s p o n s i b i l i t i e s , y e t r e a l i z e d the d i f f i c u l t y i n c a r r y i n g these tasks f o r e v e r : I t ' s s trange to me to see him l i k e t h i s (dependent). I t makes me f e e l , well I don't mind. I was always t r e a t e d l i k e the weak one, but I can handle i t p e r f e c t l y w e l l , but I wouldn't want i t to go on f o r -e ver. I t would be too much. Comparing In the f i r s t i n t e r v i e w eleven s u b j e c t s sought a frame o f r e f e r e n c e . They compared t h i s l o s s with o t h e r l o s s e s they had experienced o r t h a t o t h e r people had e x p e r i e n c e d . In t h i s way they seemed to make some sense o f t h e i r l o s s , d e a l i n g with i t i n some f a m i l i a r c o n c r e t e r e f e r e n c e . I had q u i t e an experience with t h i s bad a c c i d e n t so t h i s time I wasn't as confused about i t a l l . He broke h i s femur'in s e v e r a l p l a c e s i n a c a r a c c i d e n t f o u r y e a r s ago. He was i n the General about f o u r months t h i n g s don't seem as bad as they d i d back then. L i k e I say I've been through so much, t h r e e s u f f e r i n g s deaths r e c e n t l y , so i f he's going t o go l e t him go quick. I don't know whether I've hardened because o f t h i s , but I'm prepared. I can cope, I can cope. One woman seemed t o search a c t i v e l y f o r a r e f e r e n c e p o i n t : I saw the s p e c i a l i s t , and he s a i d i t was a s l i g h t a t t a c k , but there are people who have had even s l i g h t e r ones than my husband, but then t h e r e are the people l i k e the r e s t o f h i s f a m i l y who are very bad. The need t o d i s c u s s a frame o f r e f e r e n c e was l e s s i n the second i n t e r v i e w i n which only two o f the s u b j e c t s repeated t h e i r comments. .49 R e d e f i n i n g During t h i s phase the su b j e c t s ' thoughts r e f l e c t e d a time f o r r e d e f i n i t i o n o f s e l f , p a r t n e r , marriage and philosophy o f l i f e . The t o p i c s were d i s c u s s e d b r i e f l y i n the f i r s t meeting, and then d e s c r i b e d i n more d e t a i l by the m a j o r i t y o f su b j e c t s i n the second i n t e r v i e w . The threatened l o s s o f a partner p r e c i p i t a t e d many thoughts of marriage and r e l a t i o n s h i p s . Of the twelve s u b j e c t s e i g h t took stock o f t h e i r marriage, r e f l e c t i n g on the strengths and l i m i t a t i o n s o f t h e i r p a r t n e r s h i p : Our l i f e has been one t h a t you know, there has been no need to f e e l g u i l t y over any lac k t h a t e i t h e r one of us may have done, or may not have done. (My wife) and I have been p r e t t y c l o s e , w e l l , s i n c e we have been about nine years o l d , i t ' s l i k e a p a r t o f y o u r s e l f , — p r e t t y much what she f e e l s I f e e l . It was a r e v a l u a t i o n time a l s o to almost l o s e aloved one makes t h a t person even more c h e r i s h e d . One man, vo i c e choked with emotion e x p l a i n e d i t t h i s way: Li k e I guess everyone probably f e e l s the same way about t h e i r spouse, l i k e she i s the only one. You know you don't r e a l i z e how much one means to the o t h e r , u n t i l a c r i s i s comes. Another woman expressed s i m i l a r thoughts: It ' s a funny t h i n g you know, while he's healthy you do get annoyed with each other and you think you might be able to do without each o t h e r , but you can't do without one another. I can't wait f o r him to come home! 50 Many of the s u b j e c t s r e f l e c t e d on what they b e l i e v e d , and how they were approaching the s i t u a t i o n . They were aware of the u n c e r t a i n t i e s but t r i e d to accept and make the best o f i t : I t ' s kind o f hard to t e l l r i g h t now what to do. I'm j u s t t a k i n g i t as i t comes, and I ' l l judge i t ... No I don't think you can ever f e e l c o n f i d e n t nothing could happen, you j u s t hope f o r the best i f you know there i s no s o l u t i o n you have to wait and see what happens. A f a t a l i s t i c approach to l i f e was voic e d by f i v e o f the s u b j e c t s . One woman simply s t a t e d : "I'm not a c o l d person, but when your time i s up, i t ' s up". Another s u b j e c t quoted an o l d saying: "You know there i s an o l d S c o t t i s h s a y i n g , what's 'fore you won't go past you". This f a t a l i s m seemed to comfort the s u b j e c t s i n some way, as i f t h i s s i t u a -t i o n was no longer i n t h e i r l o c u s o f c o n t r o l and so there was no p o i n t i n worrying. One s u b j e c t s a i d : "Both (my husband) and I are f a t a -l i s t s , what's going to be i s going to be, and there's sweet boo we can do about i t . " The heart attack p r e c i p i t a t e d a l o t o f t h i n k i n g about l i f e and death i s s u e s f o r one spouse: "(My wife) i s n ' t worried now, nor am I, I think you r e a l i z e now, well and t r u l y , you are mortal." The r e d e f i n i t i o n o f s e l f and pa r t n e r was d i s c u s s e d by a l l twelve s u b j e c t s . They de s c r i b e d t h e i r partners' p e r s o n a l i t y c h a r a c t e r i s t i c s , and how they viewed t h e i r p a r t n e r s ' r e a c t i o n s to the i l l n e s s a t t h i s time. Many of the sub j e c t s saw t h e i r partners as very independent and e n e r g e t i c , and a n t i c i p a t e d they would have d i f f i c u l t y a c c e p t i n g the r e s t r i c t e d a c t i v i t y : He's very a c t i v e , he can't s i t down and r e l a x , he's got to be doing something, t h a t ' s what bothers me, because i t ' s going 51 to be very hard f o r him to slow down. He'll have to slow down, but w i l l he be able to? The m a j o r i t y o f the s u b j e c t s d e s c r i b e d t h e i r p a r t n e r s ' e a r l y r e a c t i o n s as non-accepting, "I don't think i t has r e a l l y r e g i s t e r e d y e t , what has happened, not y e t " . By the second i n t e r v i e w the s u b j e c t s f e l t t h e i r p a r t n e r s were more ac c e p t i n g and c o o p e r a t i v e with the medical regime: I t h i n k he's r e a l i z i n g t h a t h e ' l l have to take i t easy, and there are l o t s o f th i n g s h e ' l l have to f o r g e t about. I think I r e a l i z e d more from the beginning than he d i d , he thought once he's out o f the h o s p i t a l he'd be r i g h t back to where he l e f t o f f . Now he's beginning to r e a l i z e t h a t i t j u s t won't be t h a t way anyhow. Accompanying t h i s i n c r e a s e d r e a l i z a t i o n , s u b j e c t s r e p o r t e d partner r e a c t i o n s o f c o n f u s i o n , d e p r e s s i o n , worry, f r i g h t and dependence. The subje c t s ' thoughts turned inward as they r e f l e c t e d on t h e i r p e r s o n a l -i t i e s and how they p e r c e i v e d themselves i n t h i s s i t u a t i o n as a r e s u l t of t h i s l o s s . Some of the p e r s o n a l i t y c h a r a c t e r i s t i c s d e s c r i b e d were: "I'm not a rel a x e d person -- I am a l o n e r " , "I'm an o p t i m i s t , I'm not a whining woman, I'm a p o s i t i v e t h i n k e r " , "I can't take a l o t , I'm weaker than my husband". G e n e r a l l y , the working s u b j e c t s saw themselves as more independ-ent, while the women who d i d not work or were c a r i n g f o r c h i l d r e n a t home viewed themselves as f i n a n c i a l l y or emotionally more dependent on t h e i r p a r t n e r s . Several subjects worried about t h e i r v u l n e r a b i l i t y and r e a l i z e d how tenuous t h e i r emotional and f i n a n c i a l p o s i t i o n s were. One spouse 52 s t a t e d "I f i n d I'm preoccupied with myself" and another r e p o r t e d f e e l i n g s o r r y f o r h e r s e l f , but not showing i t . The m a j o r i t y of spouses viewed t h i s time as a g a t h e r i n g o f s t r e n g t h and doing the best they c o u l d , f o r they recognized the need to be strong and independent. One s u b j e c t d e s c r i b e d how i t f e l t to be strong a t a time l i k e t h i s : Well sometimes i t ' s harder on the person at home. I'm sure i n a l o t o f cases i t c o u l d be very bad. You have to be a w f u l l y strong y o u r s e l f even though you are the person t h a t i s w e l l . PHASE I — F e e l i n g s During the i n t e r v i e w s s u b j e c t s were asked to d e s c r i b e t h e i r f e e l i n g s i n response to t h e i r p artners' heart a t t a c k . Subjects d e s c r i b e d mood s t a t e s and p h y s i c a l or h e a l t h d i s t u r b a n c e s as f e e l i n g s . Mood Statements of shock and d i s b e l i e f were reported by e i g h t of the s u b j e c t s during the i n i t i a l i n t e r v i e w . No matter how much you think you are prepared f o r t h i n g s you are r e a l l y not. I never thought about a heart a t t a c k . It ' s taken me by s u r p r i s e , when someone has never been s i c k before i t h i t s you p r e t t y hard, i t j u s t seems to happen, and i t ' s t h e r e , i t ' s hard. Many of these comments were di s c u s s e d i n r e t r o s p e c t , f o r by the f o u r t h or f i f t h day the s u r p r i s e element had receded, and the heart attack had become more o f a r e a l i t y . However, one s u b j e c t s t i l l f e l t shocked over the s i t u a t i o n : I t doesn't seem l i k e i t i s r e a l l y happen-i n g , once I r e l a x t h i s w i l l h i t me, I haven't had time y e t . I t f i n a l l y " h i t " one woman the day o f the f i r s t i n t e r v i e w : I t was a shock. I t d i d n ' t h i t me u n t i l t h i s morning. I t ' s the f u n n i e s t t h i n g , i t d i d a l l o w me to get r i d o f t e n s i o n and t e a r s , I've had no t e a r s up t i l l now. Another woman d e s c r i b e d the f e e l i n g o f a delayed r e a c t i o n : People do tend to underestimate the s e r i o u s n e s s o f the problem ( h e a r t a t t a c k ) . I t r e a l l y was a r e v e l a t i o n t o me to r e a l i z e how s e r i o u s i t was. I t seems to come more with time. I d i d n ' t grab how s e r i o u s i t was a t the be g i n n i n g . I t ' s j u s t an osmosis t h i n g . The m a j o r i t y o f s u b j e c t s r e p o r t e d f e e l i n g upset, and found the time i n the i n t e n s i v e care u n i t the most d i f f i c u l t . Although i t was a s t r e s s f u l time, the s u b j e c t s were a b l e t o d e s c r i b e t h e i r f e e l i n g s c l e a r l y . Often they c o u l d not f i n d the r i g h t word to d e s c r i b e t h e i r f e e l i n g s t a t e , y e t t h e i r comments and nonverbal behaviours c l e a r l y pointed to the sorrow they f e l t . One woman, s t r u g g l i n g to remain composed, expressed these f e e l i n g s : You do get upset, o f yeah s u r e , ah, I don't t h i n k angry or depressed but you j u s t ah, I don't know, i t ' s r e a l l y hard to say what you r e a l l y f e e l , you know. You j u s t f e e l s o r r y t h a t t h i n g s have to happen t h i s way you k n o w — i t ' s a hard t i me. Subjects a l s o r e p o r t e d f e e l i n g s o f d e s p a i r , d e p r e s s i o n , g u i l t , c o n f u s i o n , and anger. Three f e e l i n g s were i d e n t i f i e d by one woman: 54 Despair more than anything. Anger t h a t I hadn't been ther e when i t happened, and g r a t i t u d e t h a t i t had not happened on the way to work, during rush hour t r a f f i c . The s u b j e c t s , r e g a r d l e s s o f t h e i r sex, d e s c r i b e d the i n t e n s i t y o f t h e i r f e e l i n g s . One man commented: I d i d n ' t think I c o u l d get emotional, but the f i r s t day I r e a l l y broke down. You know i t s o r t of gets automatic, the I l o v e you, and honey, and a l l of t h a t s t u f f , but then t h i s was something e l s e , walking out, a f t e r v i s i t i n g hours, and I'd look back, and my God i t ' s a hard t h i n g to do, to walk away. As the p a t i e n t s progressed i n an uneventful recovery the m a j o r i t y of s u b j e c t s r e p o r t e d f e e l i n g more p o s i t i v e and o p t i m i s t i c : W e l l , I'd say I was 75 percent b e t t e r than l a s t week. Everything p o i n t s to her recovery, so I've changed my mood too as f a r as t h a t goes. Well I f e e l calmer, the t h i n g s you have to c o n s i d e r are more under your c o n t r o l , or a t l e a s t I think so, and I suppose t h a t ' s the important t h i n g , but i t ' s c e r e t a i n l y a shaker at f i r s t . The optimism, however, was guarded as they r e a l i z e d the s i t u a t i o n was. s t i l l p r e c a r i o u s : "Well anything can happen y e t . " "I'm okay as long as i t doesn't happen again." "As long as he watches i t , e v e r y t h i n g w i l l be a l r i g h t . " P h y s i c a l Disturbances Every s u b j e c t reported h e a l t h concerns. I n t e r f e r e n c e s with sleep and a p p e t i t e were most common. Subjects reported f e e l i n g general f a t i g u e and i r r i t a b i l i t y . I have t r o u b l e s l e e p i n g at n i g h t . It gets hard then, e v e r y t h i n g seems to go through your mind and you know you c a n ' t s l e e p . I've gone o f f my food, i f i t weren't f o r (my son) I wouldn't even bother cooking, I have to cook f o r him. Most of the s u b j e c t s spent several hours, day and n i g h t at t h e i r p a r t n e r s ' bedside. One woman maintained a f i v e - d a y v i g i l i n the i n t e n s i v e care u n i t . She d e s c r i b e d her f e e l i n g s : I d i d n ' t l e a v e h i s s i d e . I was a f r a i d he was going to d i e . I t ' s h o r r i b l e watching the monitor through the n i g h t , I t was h o r r i b l e ! I c o u l d ' t e a t , I c o u l d n ' t swallow anything, I c o u l d n ' t s l e e p . One young s u b j e c t d e s c r i b e d her f a t i g u e : I t ' s been a heavy, t h i n k i n g week. I've been ver y , very t i r e d . Short p e r i o d s o f t i r e d , where I haven't been hard l y able to keep my eyes open ... I'm e a t i n g one meal at nigh t t h a t ' s a l l . By the second i n t e r v i e w sleep and a p p e t i t e d i s t u r b a n c e s had decreased but r e p o r t s of i n c r e a s e d f a t i g u e and i r r i t a b i l i t y were more common. Several s u b j e c t s r e p o r t e d being "on edge" with f r i e n d s or f a m i l y . Subjects with c h i l d r e n l i v i n g a t home seemed to experience more t e n s i o n and i r r i t a b i l i t y : I get upset q u i t e e a s i l y . Things have to be j u s t so, or e l s e I get upset. I'm more i r r i t a b l e , e s p e c i a l l y with the young one ... I c a n ' t be bothered with s o c i a l c o n t a c t s , they ask too many questions and get on my nerves. Related to p h y s i c a l d i s t u r b a n c e s were comments of heightened concern f o r ones' own h e a l t h . Four s u b j e c t s ' r e f l e c t i o n s on t h e i r own 56 h e a l t h , and the n e c e s s i t y o f keeping healthy f o r t h e i r p a r t n e r s ' sake were voic e d by fo u r o f the samples: I o f t e n think now, when I get a pain i t probably wouldn't be something s e r i o u s , but i t c o u l d happen ... I'm making sure nothing i s happening to me because I should be keeping myself i n good c o n d i t i o n so I ' l l be able to look a f t e r her. Yes, you have to look a f t e r your own h e a l t h . You can't look a f t e r him then. He c o u l d lean on me a b i t , he's not as f i t as I am. PHASE I — A c t i o n s During the i n t e r v i e w s s u b j e c t s d e s c r i b e d t h e i r behaviour patterns s i n c e t h e i r p a r t n e r s ' heart a t t a c k . The rese a r c h e r a l s o observed the su b j e c t s ' a c t i o n s a t t h i s time. V e r b a l i z e d Behaviours Ten s u b j e c t s reported d i f f e r e n t p a tterns of behaviours during the f i r s t week of h o s p i t a l i z a t i o n . T h e i r a c t i v i t i e s were very p a t i e n t focused, c e n t e r i n g around h o s p i t a l v i s i t s and communicating the c r i t i c a l s i t u a t i o n to f r i e n d s and f a m i l y . The spouses coped as best they c o u l d , o f t e n by keeping busy and r e f u s i n g to thi n k o f themselves or beyond the immediate s i t u a t i o n . One woman exp l a i n e d her behaviours during t h i s c r i t i c a l p e r i o d : You don't have time to break down i n the e a r l y stage, you're too concerned, you're very i n t e n s e and a l l your thoughts are t r a i n e d to hoping h e ' l l get b e t t e r and behave h i m s e l f and not be naughty. And 57 r e a l l y , you don't th i n k o f anything e l s e , and even i f you've got the time, which I d i d n ' t , even i n the c a r , I made sure I had the r a d i o on, so I d i d n ' t t h i n k and a t home you do the washing o r c l e a n the house, change the t u r t l e bowl, feed the c a t , t a l k t o the k i d s and then you are so exhausted you go to bed and sleep and wake up i n the morning and s t a r t again. Another woman saw her behaviours as q u i t e d i f f e r e n t now t h a t her husband was i l l . She re p o r t e d : I've been c l e a n i n g my house thoroughly. I have to keep busy. Normally when he i s home I watch T.V. or read, but I work, I come to the h o s p i t a l , and then there are a few phone c a l l s a t n i g h t and then I go to bed. I go to bed much e a r l i e r . In the second week o f h o s p i t a l i z a t i o n a l l twelve s u b j e c t s r e p o r t e d t h e i r r o u t i n e s as becoming more h e c t i c . Three-quarters o f the s u b j e c t s d i d not d r i v e , so the c o n t i n u a l commuting and t r a v e l arrangements, plu s the added r e s p o n s i b i l i t i e s , d e c i s i o n making and concerns seemed to r e s u l t i n g r e a t e r f a t i g u e with l i t t l e time to s e l f . One woman with three teenage daughters d e s c r i b e d her day: I'm up a t 5:30, the twins have been a b i g help, so I l i k e to make them a good break-f a s t , then I stay up to t i d y the house, and we have a b i g garden so t h a t ' s a l o t of work ... I le a v e home at ten f o r the h o s p i t a l ( f o r t y m i l e s away) I t r y and eat a t the h o s p i t a l and I'm t i r e d when I get home a t night--I'm i n bed a t midnight but I don't sleep w e l l . The actual changes i n d a i l y r o u t i n e s , r e g a r d l e s s o f the q u a n t i t y or q u a l i t y were perc e i v e d s t r e s s f u l by the s u b j e c t s . One man expressed h i s s i t u a t i o n : There's an i n a b i l i t y to s t a r t anything you j u s t do what you can to get by. You keep 58 the place c l e a n , eat pr o p e r l y and get down to the h o s p i t a l and t h a t ' s a f u l l - t i m e job and you don't sleep t h a t w e l l . Although r o u t i n e s were considered h e c t i c , one h a l f o f the group repor t e d l o n e l i n e s s : "I've become a l i t t l e l o n e l y a t home i n the evenings, i t ' s p r e t t y l o n e l y and the evenings are the worst." " I t ' s d i f f e r e n t now by m y s e l f — I never go anywhere, i t ' s no fun going anywhere by y o u r s e l f . " Despite the f a c t t h a t the sub j e c t s g r i e v e d f o r t h e i r p a r t n e r s ' presence, they were not i n t e r e s t e d i n s o c i a l i z i n g with o t h e r s . They seemed too f a t i g u e d and preoccupied with t h e i r own thoughts to i n i t i a t e c o n t a c t s , or l i s t e n to other people's c o n v e r s a t i o n s . The emotional and ph y s i c a l f a t i g u e the spouses f e l t r e s u l t e d i n an a p a t h e t i c approach to t h e i r normal r o u t i n e s . One man who d e s c r i b e d h i m s e l f as a hockey a d d i c t r e p o r t e d : Well, t h i n g s went on the b l i n k . I wasn't i n t e r e s t e d i n the T.V. or the e l e c t i o n s t h a t were on. I could have cared l e s s what was going on. I have no f e e l i n g to play c r i b or bridge or p o o l , which I l i k e doing. Nothing i n t e r e s t s me, I j u s t want to be l e f t alone. I come home at ni g h t and j u s t s i t down and s t a r e i n t o space. The t o p i c o f h e l p f u l others was d i s c u s s e d by eleven s u b j e c t s and f i v e f e l t f r i e n d s and fami l y were not h e l p f u l during t h i s time. "I would j u s t as soon have q u i e t now, because you do have t h i n g s to think about." "I can't be bothered with s o c i a l c o n t a c t s , they ask so many questions." Often " h e l p f u l others" were misguided i n t h e i r attempts to comfort: 59 My s i s t e r t r i e s to minimize e v e r y t h i n g and t h i s i s not r e a l l y a-- well she says i t ' s going to be okay I know t h i s person had t h i s and t h a t , and they are a l l okay, but well t h i s i s d i f f e r e n t i f i t h i t s y o u r s e l f . People are phoning. I f i n d i t t i r i n g i f they t a l k very l o n g . I'm not a telephone person. I t ' s mostly the men who phone and they go on and on. They know every Tom, Dick and Harry t h a t ever had a heart a t t a c k and the r e s u l t s o f i t and I'm not i n t e r e s t e d i n i t ! G e n e r a l l y speaking, f r i e n d s and f a m i l y were sought f o r s o l a c e , and the d o c t o r s and nurses were seen as h e l p f u l f o r i n f o r m a t i o n by s i x o f the sample. Nurses met both o f these needs f o r some s u b j e c t s . One 45 ye a r o l d woman expressed her views towards the nurses. The nurses were wonderful. They were so calm, so you were calm. They were t r u t h f u l and t o l d you e v e r y t h i n g . You c o u l d ask them anything. They brought me c o f f e e a l l the time, I have not gone home y e t ; I've s l e p t i n the c h a i r s i n c e Monday ( f i v e days ago). They (nurses) t r i e d t o get me to go, but they never f o r c e d me. For some spouses the i n v e s t i g a t o r was the only suppport person they had. At the t e r m i n a t i o n o f the f i r s t i n t e r v i e w a 56 ye a r o l d man spoke a p p r e c i a t i v e l y : Thank you f o r l e t t i n g me speak. I t gave me a chance t o l e t my f e e l i n g s out and a i r my concerns, because you know, you can't do i t i n f r o n t o f your p a r t n e r , you t r y and keep p o s i t i v e and keep the homefront going. Another s u b j e c t confirmed the i n a b i l i t y t o c o n f i d e i n her l o v e d one: I t ' s n i c e to t a l k to you, i t gets i t out and i t ' s n i c e and informal here. You know even with my husband and c h i l d r e n I s t i l l keep up a f r o n t and everyone i s han d l i n g i t ( i l l n e s s ) i n t h e i r own way. 60 Keeping up a f r o n t , no matter what the personal c o s t , was a behaviour seven s u b j e c t s d e s c r i b e d . There seemed to be a l t e r e d communications between husbands and wives, almost akin to a co n s p i r a c y of s i l e n c e . For whatever the reason, sharing of f e e l i n g s and concerns was not pe r c e i v e d as a p p r o p r i a t e . One 34 yea r o l d woman de s c r i b e d her communication p a t t e r n s with her husband: We w i l l both be very c a r e f u l r i g h t now of what we'll l e t the other person know. Like he asked me i f I had eaten, and I say of course I've eaten because I don't want him to worry about me because i t ' s not a p r i o r i t y r i g h t now. Observed Behaviours The i n v e s t i g a t o r recorded her observations o f the su b j e c t s ' behaviours during the in t e r v i e w s and compared these observations with the behaviours v e r b a l i z e d by the s u b j e c t s . As i n d i c a t e d e a r l i e r i n the f i n d i n g s , the su b j e c t s viewed the f i r s t week as s t r e s s f u l and t h i s p e r c e p t i o n was evidenced i n t h e i r observed behaviours. Of the 12 s u b j e c t s , f i v e spouses acted as i f they were under great s t r e s s . Two women openly wept during the f i r s t i n t e r -view and the three others v i s i b l y fought f o r emotional c o n t r o l . These f i v e s u b j e c t s were a l l adequately groomed. T h e i r h a i r , make-up and c l o t h i n g were neat and t i d y i n appearance but t h e i r faces looked very drawn and pale with dark c i r c l e s under t h e i r eyes. They t a l k e d with long pauses and s i g h s . T h e i r v o i c e s lacked i n f l e c t i o n and were s o f t o r trembling at times. These spouses r a r e l y smiled or used body gestures f o r emphasis. They gave the i n v e s t i g a t o r o c c a s i o n a l eye c o n t a c t and were noted to glance f r e q u e n t l y down at t h e i r hands or l a p s . 61 Another f i v e spouses saw t h i s time as s t r e s s f u l but they r e p o r t e d being upset more i n r e t r o s p e c t f o r they f e l t the worst was over. Although these s u b j e c t s looked f a t i g u e d and concerned they were able to d i s c u s s t h e i r r e a c t i o n s with l e s s emotional d i f f i c u l t y than the former f i v e . Sighs and long pauses were l e s s f r equent i n t h e i r c o n v e r s a t i o n s . They smiled o c c a s i o n a l l y and gestured with t h e i r hands. Of the 12 s u b j e c t s , the remaining two spouses d i d not present the same behaviours. The behaviours reported and observed by these two women i n d i c a t e d calm and optimism. These s u b j e c t s were responsive and eager to t a l k . They smiled o f t e n , used frequent eye c o n t a c t and gestured a p p r o p r i a t e l y with nods and a c t i v e f a c i a l e x p r e s s i o n s . These su b j e c t s seemed very much i n c o n t r o l of t h e i r emotions. The observable behaviours demonstrated by these two women were congruent with t h e i r r eported behaviours but not congruent with the remaining ten s u b j e c t s . There are several f a c t o r s t h a t c o u l d c o n t r i b u t e to the d i f f e r e n c e s i n the spouses' behaviours and t h i s w i l l be d i s c u s s e d i n the next chapter but an i n t e r e s t i n g c o r r e l a t i o n was found between the time of the f i r s t i n t e r v i e w and the type, frequency and i n t e n s i t y of behaviours. The s u b j e c t s i n t e r v i e w e d from day two to day f o u r of the partners' i l l n e s s p e r c e i v e d t h i s time as very s t r e s s f u l and t h e i r behaviour r e f l e c t e d t h i s p e r c e p t i o n . The time of the f i r s t i n t e r v i e w f o r the remaining s u b j e c t s v a r i e d from day three to day s i x and t h e i r r eported s t r e s s was more i n r e t r o s p e c t which concurred with the behaviours observed by the i n v e s t i g a t o r . 62 At the time of the second i n t e r v i e w a l l p a t i e n t s were c o n v a l e s c i n g i n the post coronary u n i t and the subjects seemed to be l e s s upset and more o p t i m i s t i c about the i l l n e s s . T h e i r r e p o r t e d h e c t i c r o u t i n e s were r e f l e c t e d i n i n c r e a s e d symptoms of f a t i g u e observed by the i n v e s t i -g a t o r. They smiled more f r e q u e n t l y and t h e i r speech showed more i n f l e c t i o n . Eye c o n t a c t was frequent and d i r e c t e d at the i n v e s t i g a t o r . Nods, hand gestures and l e a n i n g forward were common behaviours noted. PHASE II Reaction to the Event The second phase has been termed r e a c t i o n to the event. This phase corresponded to the t h i r d i n t e r v i e w with the s u b j e c t s and covered the i n i t i a l post discharge p e r i o d o f the p a t i e n t . The time frame o f t h i s phase v a r i e d f o r each s u b j e c t the range was from day s i x to day f f o u r t e e n , the average being nine days post d i s c h a r g e . PHASE I I — Thoughts Three thought c a t e g o r i e s have been i d e n t i f i e d i n t h i s phase and l a b e l l e d a s s e s s i n g , implementing and r e d e f i n i n g . Assessi ng At the time of the t h i r d i n t e r v i e w , the study sample c o n s i s t e d of ten s u b j e c t s . A l l ten assessed t h e i r p artners' p h y s i c a l and emotional h e a l t h i n some d e t a i l . During the f i r s t week many of the spouses des c r i b e d t h i s time as d i f f i c u l t or scary. It was termed by one spouse as " l i k e walking on eggs f o r the f i r s t w h i l e " . The 6 3 assessment, e s p e c i a l l y during the f i r s t few days a t home, tended to occupy many of the su b j e c t s ' thoughts: I watch him too much, I watch h i s breath-i n g , I ask 1000 times a day, are you a l r i g h t ? Well l a s t week was the hardest, I was up a l o t , I was up t h r e e , f o u r o r f i v e times a n i g h t , going i n and l o o k i n g at him, I wasn't g e t t i n g any s l e e p . By the end of the f i r s t week and the beginning o f the second week "things were s t a r t i n g to get back to normal". The s u b j e c t s continued to assess t h e i r partners' p h y s i c a l and emotional s t a t e , y e t i n a more r e l a x e d manner. During the h o s p i t a l i z a t i o n phase, the s u b j e c t s were very concerned t h a t t h e i r partners would not cooperate and would exceed t h e i r l i m i t a t i o n s . They a n t i c i p a t e d the worst i n terms o f the adjustment. At the time of t h i r d i n t e r v i e w however, the p a t i e n t s were i n f a c t cooperating s a t i s f a c t o r i l y and the s u b j e c t s f e l t encouraged. The m a j o r i t y spoke p o s i t i v e l y about t h e i r partners' recovery. In d i s c u s s i n g t h e i r p a r t n e r s ' adjustments several areas were examined: Well, t h i n g s are f i n e , they are g e t t i n g back to normal (my husband) i s a d j u s t i n g well to h i s d i e t , he doesn't mind i t - - h e i s well on h i s way to normal a c t i v i t y ... He goes shopping every day, he walks around and does t h i n g s around the house-- there has been an improvement. Not a l l the subjects viewed t h e i r p a r t n e r s ' recovery as p o s i t i v e . A husband's r e a c t i o n was de s c r i b e d by one woman i n t h i s manner: Well i t was so bad and you c o u l d see t h a t i t was a mental t h i n g . To suggest anything wouldn't do any good; he never spoke, he was r e a l q u i e t . I t was a l l up here ( p o i n t s to her head). I suggested t h i n g s but he wasn't keen on doing anything! 64 In an e a r l i e r i n t e r v i e w , one young su b j e c t feared t h a t her en e r g e t i c "hyper" husband would soon become bored and i r r i t a b l e a t home. Her f e a r s were soon r e a l i z e d : Well he's bored, not scared, j u s t bored. I can see he's dying to d r i v e . I enjoy having him here except he's cranky. I thin k he's g e t t i n g stronger and as he gets s t r o n g e r , he gets worse to handle. In terms o f a s s e s s i n g the changes i n t h e i r l i v e s one h a l f o f the su b j e c t s f e l t a l l those changes t h a t were a n t i c i p a t e d e i t h e r d i d not occur or were not as bad as they had f e a r e d . One woman who had a n t i c i p a t e d a l o t o f o f e x t r a work with cooking and shopping was pleased t o f i n d out her concerns were not a c t u a l i z e d : I t h i n k t h i n g s are going to work out f i n e . Things a r e n ' t t h a t much d i f f e r e n t so there i s n ' t t h a t much of an upset. We have a few l i t t l e changes from our r o u t i n e but i t ' s nothing d r a s t i c l i k e I thought i t would be. One woman who c a l l e d h e r s e l f a "worrier" had f e a r e d many changes would occur as a r e s u l t o f her husband's i l l n e s s . In d i s c u s s i n g her thoughts one week a f t e r her pa r t n e r ' s d i s c h a r g e , she no longer held these concerns and she e x p l a i n e d her new t h i n k i n g i n t h i s way: Well you know when i t happens you don't know what r e a l l y to expect and o f course you always th i n k of the worst, but i t ' s good to f i n d out t h a t i t ' s not as bad--so there are not too many changes; not r i g h t now, not r e a l l y — s u r e our s o c i a l l i f e w i l l have to change to a c e r t a i n extent but i t doesn't r e a l l y bother me t h a t much. In t h i s e a r l y post discharge p e r i o d , one h a l f o f the sample reported s i g n i f i c a n t changes i n t h e i r l i v e s . Many of the changes 65 r e v o l v e d around a s h i f t i n r o l e s and r e s p o n s i b i l i t i e s . With two teenagers a t home one woman found her l i f e had many changes: Yeah, i t ' s q u i t e d i f f e r e n t because I can ' t do the th i n g s I use to do. I can't get the vacuum out or have an empty house, to dust f u r n i t u r e . I have to plan around every-t h i n g . My lunches are d i f f e r e n t , my dinner and b r e a k f a s t s are d i f f e r e n t . I have someone asking f o r c o f f e e or tea every hour. Implementing The mental planning and o r g a n i z i n g done by the s u b j e c t s during the h o s p i t a l i z a t i o n time expanded i n t h i s , post discharge p e r i o d to implementation. The approaches or r o l e s the s u b j e c t s had a n t i c i p a t e d they would f u l f i l l were now s p e c i f i c a l l y d e f i n e d and acted out. A l l su b j e c t s d e f i n e d t h e i r r o l e s i n d e t a i l . T h e i r comments r e v e a l e d t h e i r p erceptions o f how they attempted to c o n t r o l the s i t u a t i o n . In a l l areas the spouses acted very much l i k e "watchdogs" they l i m i t e d v i s i t o r s , monitored t h e i r p a r t n e r ' s p h y s i c a l a c t i v i t y , prepared the c o r r e c t d i e t and r e f r a i n e d from engaging i n any emotional i s s u e s . One man commented on h i s new r o l e . Well you wonder i f a disagreement, minor or major, i s something you have to watch and how c a r e f u l am I going to have to be--yeah I watch i n p r a c t i c a l t h i n g s , l i k e you know, f o r people to come and v i s i t , t h a t ' s a l l r i g h t ... And I say to her don't f o r g e t your p i l l s and you don't want to leave the house f o r too lo n g , you scoot over to the sto r e knowing t h a t r e a l l y nothing i s going to happen, but you s t i l l p a r c e l out your time. 66 Several s u b j e c t s hovered around t h e i r p a r t n e r s d u r i n g the f i r s t week, f e a r f u l of l e t t i n g them out of t h e i r s i g h t . As t h e i r partners recuperated, t h e i r own a n x i e t i e s lessened and they slackened t h e i r p r o t e c t o r r o l e somewhat. Fear of not f u l f i l l i n g her new r o l e and thus somehow harming her husband caused a good deal o f g u i l t i n one s u b j e c t . Anxiously she expressed her concerns: I w i l l d e f i n i t e l y do my p a r t . I've got to organize v i s i t o r s b e t t e r so they don't come a l l a t once. I t ' s my f a u l t completely i f he has another one, I have to organize b e t t e r ... I don't want to do anything to rouse him. I am concerned he c o u l d have another heart a t t a c k . We don't sleep together now, I am r e s t l e s s and I don't want to d i s t u r b him r i g h t now ... Well, i f he gains weight i t ' s my f a u l t , i f I don't give him the r i g h t foods low i n c h o l e s -t e r o l t h a t w i l l be my f a u l t . Although the s u b j e c t s were concerned and wanted to do the r i g h t t h i n g s , changes i n r o l e s and r e s p o n s i b i l i t i e s were not p r i o r i t i e s with a l l the group. Three of the sample were working women and t h e i r comments r e f l e c t e d the value placed on t h e i r r o l e a l s o : "At work I am very busy and I don't have much time to worry about him." One woman who took her h o l i d a y s to be with her husband was d e l i g h t e d to r e t u r n to work: "I'm not f u s s i n g and worrying as much now t h a t I'm back a t work." Another s u b j e c t who had spent long hours i n meal p r e p a r a t i o n f o r her husband's r e t u r n home f e l t she would do anything f o r her husband, but she was not going to be a s l a v e , and she was "paying the b i l l s too!" She commented: 67 I think t h a t ' s where the d i f f e r e n c e l i e s between one woman's r e a c t i o n and another. If you are working a l l day you have to cope with e v e r y t h i n g , but i f you're not working you s i t home and fuss and mope and do a l l the l i t t l e t h i n g s f o r him you want to do. Redefining At t h i s time the m a j o r i t y o f the sub j e c t s continued to r e d e f i n e t h e i r p h i l o s o p h i c a l b e l i e f s i n l i g h t o f t h e i r l o s s e s . They seemed to att a c h meaning to more concrete signs t h a t l i f e was r e t u r n i n g to normal. T h e i r comments r e f l e c t e d a more p o s i t i v e and a c c e p t i n g a t t i t u d e . In drawing an analogy from one's r e a c t i o n s to death a s u b j e c t summed up these i d e a s : Well you know t h i s t h i n g (heart attack) i s l i k e what happens when someone d i e s , there i s so much confusion and change and you wonder, w e l l , should I do t h i s or w i l l I now have to do t h a t , and everything i s kind of up i n the a i r , but a f t e r a few weeks or months, t h i n g s s e t t l e down and l i f e goes on. It has t o , whatever i s going to happen w i l l happen, there i s no p o i n t worrying about a l l those t h i n g s . Only a couple o f s u b j e c t s spoke about the f u t u r e i n terms of a n t i c i p a t i n g what to expect or how to pla n . The m a j o r i t y o f the group thought from day to day and t r i e d to be as p o s i t i v e as they c o u l d : W e l l , I thi n k there's no sense i n planning the f u t u r e because you never know. You don't know the score from one day to the next r e a l l y . At f i r s t t h a t upset me, but i t doesn't now because I know you can't change i t , so you j u s t make the best o f the day. 68 The s u b j e c t s ' thoughts r e v e a l e d a more e g o c e n t r i c focus during t h i s time. Many su b j e c t s continued to look a t themselves i n t h i s s i t u a t i o n and comment on how they were a f f e c t e d by the l o s s . The spouses saw themselves as "holding down the f o r t " and t h i s r e s p o n s i -b i l i t y r e s u l t e d i n some negative f e e l i n g s . Some g r i e v e d f o r t h e i r own time and independence. A few f e l t t h a t 24 hour r e s p o n s i b i l i t y f o r t h e i r husbands was too much and they wanted t h e i r own space. In an animated c o n v e r s a t i o n one of the subjects d e s c r i b e d how " s t i r c r azy" she f e l t : The f i r s t week was t e r r i b l e . I co u l d n ' t get out a t a l l . My neighbour was my p s y c h o l o g i s t . I ran up there one day and s a i d , have you got anything to do, j i g s a w s , anything. I'm going out of my mind! In c o n j u n c t i o n with a d e s i r e f o r more f r e e time, f o u r s u b j e c t s reported f e e l i n g overwhelmed. The a l t e r e d r o l e s and e x t r a r e s p o n s i b i l i t i e s kept them very busy. These four worked hard without any s i g n i f i c a n t r e c o g n i t i o n o f t h e i r e f f o r t s . The resentment was now s t a r t i n g to s u r f a c e : Well having him around there's nothing worse than having him s i t t i n g around a l l day. Your r o u t i n e i s o f f - - y o u r ' r e going back and forwards running errands. Men are not good p a t i e n t s . He won't do anything. I s c u r r y around and do the housework; he watches T.V. A r e a l concern f o r o n e s u b j e c t was the l o s s o f a w e l l - e s t a b l i s h e d r o u t i n e a t home whereby her husband would prepare the evening t e a . The i l l n e s s d i s r u p t e d t h i s s p e c i a l r e l a x i n g time f o r her. She repo r t e d : 69 Well of course when he was s i c k I s t a r t e d doing i t (pr e p a r i n g evening t e a ) . Well God I was nuts to s t a r t doing t h a t again. He's a l o t stronger now and he can do i t but he's got t h a t he'd j u s t l i k e to s i t t h e r e and l e t me do i t and t h i s has got to me. Maybe i t ' s cause I'm t i r e d , i t wouldn't r e a l l y i r r i t a t e t h a t much but I haven't even had my shower y e t ! PHASE I I — F e e l i n g s Mood T h i s time was c h a r a c t e r i z e d by a general mood o f g r a t e f u l n e s s . Of the ten s u b j e c t s , seven reported f e e l i n g b e t t e r . This o p t i m i s t i c mood apparently evolved from the d e f i n i t e signs o f t h e i r partners' recovery. Because t h e i r p a r t n e r s had "made it"--were so c o o p e r a t i v e and ac c e p t i n g of t h e i r r e s t r i c t i o n s — t h e s u b j e c t s f e l t they indeed had something to be thankful f o r . One s u b j e c t was d e l i g h t e d to f i n d many of her f e a r s were unfounded and her mood r e f l e c t e d the p o s i t i v e turn i n events: Well t h i n g s are going b e t t e r than I expected--I'm f e e l i n g p r e t t y p o s i t i v e cause he's doing p r e t t y good—I'm f e e l i n g more re l a x e d and th i n g s are s t a r t i n g to get back to normal ... So I can sleep now, and i t helps t h a t he's home, and he's t a k i n g i t (hea r t attack) the way he i s . In commenting on t h e i r mood s t a t e , four women d i s c u s s e d t h e i r f e e l i n g s of ambivalence. Three of the sub j e c t s reported t h i s ambivalence had a f f e c t e d t h e i r mood i n t h a t they f e l t "lower or more i r r i t a b l e . " The women were pleased and g r a t e f u l f o r t h e i r husbands' recovery, y e t at the same time they d e s i r e d r e c o g n i t i o n and thanks f o r t h e i r e f f o r t s and more f r e e time to themselves. The sub j e c t s f e l t 70 g u i l t y about t h i s need and they f r e q u e n t l y berated or admonished themselves f o r being so s e l f i s h . These f e e l i n g s are i l l u s t r a t e d by t h i s s u b j e c t s ' comments: Well I f e e l exhausted, cranky and i r r i t a b l e at times. I'm up e a r l y I do a l l t h i s and t h a t and he doesn't seem to a p p r e c i a t e i t . I get down sometimes. You know he seems so well you sometimes f o r g e t he i s s i c k — i t ' s j u s t t h a t somedays I t h i n k t h a t I get l e f t behind. Sometimes I wonder about my f e e l i n g s I t h i n k , you are s e l f i s h , and I f e e l bad, but i t ' s j u s t t h a t you have f e e l i n g s and you have your own l i f e too, but i t ' s j u s t t h a t what I f e e l you can't take out on you husband so. P h y s i c a l Disturbances A c o r r e l a t i o n was found between mood s t a t e and p h y s i c a l or h e a l t h s t a t u s . In the sample, s i x subjects reported f e e l i n g calmer and more p o s i t i v e as a p p e t i t e and sleep patterns returned to normal. Four su b j e c t s reported f e e l i n g s t r e s s e d , with complaints of s l e e p , a p p e t i t e and stomach d i s t u r b a n c e s . One woman, who p r e v i o u s l y had appeared very p o s i t i v e and calm without any h e a l t h d i s t u r b a n c e s , now experienced a "delayed r e a c t i o n " . She d e s c r i b e d how her f e e l i n g s had a f f e c t e d her h e a l t h : I was r e a l l y s i c k t h a t f i r s t week when he came home. I had t e r r i b l e headaches. I t h i n k the h e a r t attack h i t me stronger than I r e a l i z e d . My head was so bad I c o u l d h a r d l y see and my neck, apparently the veins were a l l swollen up and i t was r e a l l y r o t t e n . It s t a r t e d the day before he came home and I went to see the doctor and he put me on some medication. The doctor thought i t was a l l the s t r e s s . 71 Increased f a t i g u e was r e p o r t e d by the m a j o r i t y during t h i s time. Though t h e i r mood and sleep p a t t e r n s may have improved the changes i n r o l e s and r e s p o n s i b i l i t i e s along with the ever present worries o f r e l a p s e c o n t r i b u t e d to the growing f a t i g u e . PHASE 11--Actions V e r b a l i z e d Behaviours During the f i r s t week of t h e i r partner's discharge the m a j o r i t y o f s u b j e c t s r e p o r t e d behaviours which seemed to be assessment-oriented. They watched t h e i r partners c o n s t a n t l y , checking to see i f they were i n any d i s t r e s s . T h e i r new p r o t e c t o r r o l e , i n c o n j u n c t i o n with the e x t r a domestic, s o c i a l and f i n a n c i a l r e s p o n s i b i l i t i e s meant a very busy schedule. The freedom from h o s p i t a l v i s i t s , however, allowed more time f o r some of the new r o u t i n e s at home. As the week progressed and recovery seemed more assured, many s u b j e c t s reported t h i n g s were now s t a r t i n g to get to normal. As one woman s t a t e d , " I t ' s b e t t e r to have him home than when he was i n the h o s p i t a l ; before I had no time f o r anything e l s e and now I can watch him b e t t e r . " Four of the s u b j e c t s f e l t t h e i r r o l e s and r e s p o n s i b i l i t i e s were g r e a t l y a l t e r e d , and they d i d not see t h e i r l i v e s as r e t u r n i n g to normal. These women g r i e v e d f o r t h e i r own time and independence, they f e l t t h e i r "24 hour duty" allowed f o r l i t t l e p r i v a t e time. Concerns regarding d i e t and a c t i v i t y and medication were voic e d by the m a j o r i t y . The i n f o r m a t i o n g u i d e l i n e s provided by the h o s p i t a l were perceived as h e l p f u l . Yet questions regarding these t o p i c s i n d i c a t e d a need f o r v a l i d a t i o n and reassurance r a t h e r than f o r 72 i n f o r m a t i o n . Two s u b j e c t s d i d focus a good deal on d i e t as evidenced by t h e i r lengthy d i s c u s s i o n s . These women had researched low c h o l e s t e r o l d i e t s i n d e t a i l and had spent hours i n meal planning and pr e p a r a t i o n . The t o p i c o f h e l p f u l others was int r o d u c e d again i n t h i s phase by seven s u b j e c t s . Friends and fa m i l y were u s u a l l y seen as h e l p f u l : they o f f e r e d encouragement and s p e l l e d o f f the boredom f o r the c o n v a l e s c i n g p a r t n e r s . One h a l f o f the group who had f a m i l y c o n t a c t spoke p o s i -t i v e l y of the a s s i s t a n c e they r e c e i v e d . Family and c l o s e f r i e n d s i n p a r t i c u l a r were seen as h e l p f u l "as long as they don't overdue i t " i n terms of t i r i n g the p a r t n e r s . Two subjects mentioned t h e i r f r u s t r a t i o n with t h e i r well-meaning f r i e n d s who i n s i s t e d on imparting a l l t h e i r knowledge about heart a t t a c k s . One woman coped by l e a v i n g her phone o f f the hook. A few su b j e c t s had c o n t a c t with t h e i r general p r a c t i t i o n e r s during t h e i r p artners' check-up v i s i t s . These subjects s t a t e d the v i s i t s were h e l p f u l i n terms of inf o r m a t i o n o f f e r e d and v a l i d a t i o n o f t h e i r partner's progress i n recovery. However, only one su b j e c t approached her doctor to d i s c u s s f e e l i n g s o r concerns. The f i n d i n g s r e f l e c t e d a decrease i n communication between seven of the couples. The t o p i c o f the heart attack was r a r e l y d i s c u s s e d between the cou p l e s , e s p e c i a l l y a f t e r the f i r s t week a t home. Often the impetus f o r d i s c u s s i o n arose when f r i e n d s and f a m i l y v i s i t e d . As one spouse s t a t e d , " I t ' s only when v i s i t o r s come t h a t we t a l k about i t , otherwise we never mention i t . " 73 Four o f the s u b j e c t s expressed concerns t h a t t h e i r p a r t n e r s d i d not know or app r e c i a t e how t i r e d and s t r e s s e d they f e l t . These women f e l t i n a quandary because they wanted a p p r e c i a t i o n and sympathy, y e t they d i d not wish to draw a t t e n t i o n to t h e i r needs and f e e l i n g s f o r f e a r o f causing another heart a t t a c k . One woman expressed her c o n f l i c t : Well (my husband) i s not a t a l k e r , he keeps ev e r y t h i n g to h i m s e l f - - I get down sometimes and he doesn't seem to r e a l i z e ! I don't know why. I'm j u s t keeping my f e e l i n g s i n s i d e . I ' l l never say anything to him. I j u s t go and lo c k myself i n the bathroom ... I f i n d I'm ea t i n g too much. I ' l l have to stop, maybe i t ' s a p a r t o f t h i s s t r e s s , I don't know. The communication patterns o f the remaining three couples c o u l d be de s c r i b e d as open i n t h a t they shared t h e i r f e e l i n g s and concerns and seemed to be aware of each other's needs. Two o f the su b j e c t s s e t down some "ground r u l e s " with t h e i r husbands without f e a r o f r e p r i s a l s . Both women took a f i r m stance on r e f u s i n g to buy c i g a r e t t e s f o r t h e i r house-bound husbands. This was an area with p o t e n t i a l c o n f l i c t but they were able to r e s o l v e the i s s u e by d i s c u s s i n g i t with t h e i r p a r t n e r s . Observed Behaviours The behaviours of the sub j e c t s as observed by the i n v e s t i g a t o r during the t h i r d i n t e r v i e w were found to be congruent with the re p o r t e d behaviours. The o v e r a l l mood o f g r a t e f u l n e s s and a i r o f optimism were r e f l e c t e d i n most of the subj e c t s ' a c t i o n s . T h e i r speech and hand gestures were animated, t h e i r faces were b r i g h t and they smiled 74 f r e q u e n t l y . The s u b j e c t s were well groomed while t h e i r posture was more r e l a x e d . ' There was an absence o f nervous tapping, f i d g e t i n g or tremors seen i n the e a r l i e r i n t e r v i e w s . Good eye c o n t a c t was main-t a i n e d throughout the i n t e r v i e w . During the t h i r d i n t e r v i e w p e r i o d , three of the s u b j e c t s behaved s i m i l a r l y to the r e s t of the group although t h e i r a c t i o n s were somewhat more subdued. These women were f r i e n d l y and t a l k a t i v e , however, the tone of t h e i r speech was s o f t e r and lower with more frequent s i g h s . They looked f a t i g u e d , with l i n e d and drawn faces while t h e i r body posture was slouched. Good eye c o n t a c t was u s u a l l y e v i d e n t and occa-s i o n a l smiles were noted. One change i n behaviour from the previous i n t e r v i e w s was the i n c r e a s e i n the number o f s o c i a l overtures shown towards the i n v e s t i -gator. These s o c i a l gestures v a r i e d from o f f e r s o f tea and c o f f e e to t o u r s o f t h e i r homes and i n v i t a t i o n s extended to d i n n e r o r other s o c i a l events. This s o c i a l theme was a l s o r e f l e c t e d i n the i n c r e a s e in " s o c i a l c h a t t e r " i n the s u b j e c t s ' c o n v e r s a t i o n s . In comparison with previous v i s i t s , a g r e a t e r p r o p o r t i o n of the t h i r d i n t e r v i e w s was comprised o f d i s c u s s i o n s of f a m i l y t o p i c s , s o c i a l a c t i v i t i e s , hobbies and i n t e r e s t s . For the f i r s t time, several of the s u b j e c t s i n d i c a t e d i n t e r e s t i n the i n v e s t i g a t o r ' s s i t u a t i o n beyond the i n t e r v i e w s e t t i n g by q u e s t i o n i n g her hobbies, c a r e e r goals and f a m i l y l i f e . 75 PHASE III Impact o f the Event The l a s t i n t e r v i e w covered the e a r l y c o n v a l e s c e n t p e r i o d of the p a t i e n t , v a r y i n g from day 20 to day 38 post d i s c h a r g e , with an average of approximately 28 days. The f i n d i n g s of the f o u r t h i n t e r v i e w r e v e a l e d two more d i s t i n c t p a t t e r n s i n the thoughts, f e e l i n g s and a c t i o n s of the ten s u b j e c t s . Up to t h i s p o i n t the s u b j e c t s had shared many of the same f e e l i n g s and concerns as r e f l e c t e d i n t h e i r r e p o r t e d and observed r e c t i o n s . The f i n d i n g s were separated i n t o Group A and Group B to i l l u s t r a t e the d i f f e r e n c e s i n the s u b j e c t s ' responses. Group A comprised seven women, the m a j o r i t y o f the sample. Group B were the remaining three s u b j e c t s , one man and two women. PHASE I I I — T h o u g h t s (Group A Findings) The thought c a t e g o r i e s i d e n t i f i e d i n phase three were a s s e s s i n g and r e d e f i n i n g . Assessing The s u b j e c t s continued to assess t h e i r p a r t n e r s ' p h y s i c a l and emotional h e a l t h . G e n e r a l l y the subjects d i d not view the recovery as p o s i t i v e l y as i n phase two. As the convalescence lengthened, many o f the husbands were g e t t i n g bored and f r u s t r a t e d with t h e i r i n a c t i v i t y . Some p a t i e n t s tended to overdo i t and experienced subsequent p a i n . One s u b j e c t was so f r u s t r a t e d with her partner because he never d i s c l o s e d 76 how he was f e e l i n g . She feared he was o v e r a c t i v e : I think about him a l o t ; i f he was honest with you and he'd t e l l you j u s t how he f e e l s then i t would make i t e a s i e r , and when they don't t e l l you, you have to guess and then i t makes i t harder, and sometimes he can hide i t (pain) p r e t t y good too. The s u b j e c t d i s c u s s e d concerns t h a t loomed i n the near f u t u r e : f e a r s of t h e i r partners' d r i v i n g and r e t u r n i n g to work. This d i s c u s -s i o n o f t e n l e d i n t o the o v e r a l l f e a r o f r e c u r r e n c e , a worry t h a t had not been s t r o n g l y v o i c e d s i n c e the e a r l y h o s p i t a l i z a t i o n p e r i o d : Well I don't think he should go back to work, i t ' s too h e a v y — w e l l not f o r a few months—but then i f i t means h e ' l l be cut o f f h i s pension, then h e ' l l have t o . A pension i s important, but he should take l i g h t j o b s — b u t I wonder i f h e ' l l have another one, of course he's been c a r e f u l and he hasn't had any more p a i n s , he has been good a l l along. I worry about another heart a t t a c k , e s p e c i a l l y when he goes back to work. I'm not r e a l l y a w o r r i e r , but when he goes back to work with t h a t company he always does more than h i s j o b — i t ' s so h e c t i c , a l o t of deadlines and (my husband) f l a r e s up so e a s i l y i n work s i t u a t i o n s . Even i f the p a t i e n t ' s recovery was u n e v e n t f u l , the women d i d not view t h i s time as p o s i t i v e f o r the s t r e s s of having t h e i r husbands "around a l l the time" as well as the e x t r a demands placed on them added a l o t of pressure. A l l seven s u b j e c t s assessed the changes i n t h e i r l i v e s . The changes d e s c r i b e d a few weeks e a r l i e r had grown to occupy many of the s u b j e c t s ' thoughts. 77 R e d e f i n i n g Many o f the s u b j e c t s thoughts were e g o c e n t r i c i n f o c u s . The women viewed the l o s s from t h e i r p e r s p e c t i v e . They d i s c u s s e d how they saw themselves i n t h i s s i t u a t i o n as a r e s u l t o f the l o s s . They continued to speak o f t h e i r p r o t e c t o r r o l e s and e x t r a r e s p o n s i b i l i t i e s , but a l s o began to v e r b a l i z e how many o f t h e i r thoughts were focused on them-s e l v e s . The time had come f o r them to take a hard look a t t h e i r l i v e s and t h e i r f u t u r e . One woman expressed these thoughts w e l l : W e l l , t h i s l a s t week I've become very very s e i f - c e n t e r e d - - I r e a l l y became greedy--no not greedy, j u s t over concerned, over compensating f o r myself--I was a b s o l u t e l y at the end o f my rope, I c o u l d n ' t take i t . I've been t h i n k i n g , I'm young and I've got a long f u t u r e ahead o f me and i t ' s r e a l l y something t o thi n k about. I f I thought (my husband) would be i n c a p a c i t a t e d or unable t o g e t back i n t o the main stream i t would r e a l l y i n v o l v e a l o t , and the k i d s — a n d we have a l o t o f f i n a n c i a l problems. The d i s r u p t i o n o f a normal l i f e meant e x t r a worry and • r e s p o n s i b i l i t y f o r many o f the s u b j e c t s : I t takes a l o t more e f f o r t , you have to thin k more about every thing--you r e a l l y have more to worry about, l i k e b efore you d i d n ' t worry, you j u s t knew e v e r y t h i n g would go by p l a n , and not i t ' s a l l — w e l l i t ' s a l l stopped. I t ' s l i k e grand c e n t r a l s t a t i o n h e r e — I ' m b u r i e d with r e s p o n s i -b i l i t i e s , i t ' s hard 'cause I've never had a l l these b e f o r e . I don't mind because I know I can do i t , but i t gets t o y o u — i t adds up, a l l the r e s p o n s i b i l i t i e s . Several s u b j e c t s mentioned t h a t the changes i n t h e i r r o u t i n e s were patterned a f t e r t h e i r husbands' wishes. They conceded to t h e i r 78 partners f o r f e a r o f i n i t i a t i n g an argument and p o s s i b l y another heart a t t a c k : He wants to do the things he can't do but then he doesn't want to do some of my work, even simple t h i n g s , y e t you don't want to have a row so. My house today i s so d i r t y , i t looks l i k e a hu r r i c a n e h i t i t , y e t I can't touch i t . (My husband) wants to do the p a i n t i n g outside--and i t ' s j u s t not worth the argu-ment to say, look I want to do the housework, but i t ' s very important t o me because I am a very fussy housekeeper. PHASE I I I - - F e e l i n g s Mood The upward swing i n mood found i n the e a r l y post discharge p e r i o d was no longer apparent i n t h i s group. A general slump i n mood l e v e l was re p o r t e d . The impact o f the i l l n e s s r e a l l y seemed to have " h i t home". F e e l i n g s o f dep r e s s i o n , resentment and g u i l t were most commonly re p o r t e d . Several o f the s u b j e c t s d i s c u s s e d t h e i r depression openly. One woman spoke q u i e t l y : Well he i s okay, no problems there but I th i n k my mood i s lower compared to how i t used to be. I am q u i t e normal, but I am nervous person though. Although the a l t e r a t i o n i n mood was n o t i c e a b l e with a l l the group s u b j e c t s the i n t e n s i t y o f depression was most remarkable i n the two youngest women. Both of them had adolescent c h i l d r e n at home f i n a n c i a l concerns and other r e s p o n s i b i l i t i e s . One 34 o l d woman d e s c r i b e d her mood since our l a s t v i s i t : Well the l a s t couple of weeks r e a l l y turned around. I became very deeply depressed. Small t h i n g s kept bothering me, I got stuck with a l l the work, the house, the garden, e v e r y t h i n g . I have been r e a l l y very t e a r y - - I become p h y s i c a l l y very i l l . The doctor gave me some a n t i d e p r e s s a n t s , they are j u s t s t a r t i n g to work ... Things are, p i c k i n g up a b i t , they c o u l d n ' t have got any worse. T h i s same woman had spent a g r e a t deal o f time r e f l e c t i n g on her thoughts and f e e l i n g s . She expressed her home and f a m i l y r e s p o n s i b i l i t i e s and her r o l e i n t h i s s i t u a t i o n : I don't have time to be s i c k , you have no time to break down--you have to be the p i v o t p o i n t f o r everyone, so the more people i n v o l v e d the more d i f f i c u l t i t becomes. The younger the f a m i l y i s , then i t becomes even more important. Many woman g r i e v e d f o r t h e i r own time and space. So many demands had been p l a c e d on them t h a t they f e l t " b u r i e d " . The e x t r a demands combined with the l a c k o f r e c o g n i t i o n f o r t h e i r e f f o r t s were reported as major concerns. One s u b j e c t reported f e e l i n g " l e f t behind", c o n t i n u i n g she s t a t e d : Well I don't begrudge doing anything f o r anyone, but I don't have any time. Anyway, maybe i t ' s j u s t the way I'm t h i n k i n g , but I f e e l nobody cares t h a t I don't have any time, and nobody knows how I f e e l . The m a j o r i t y of the group spoke o f t h e i r d e s i r e f o r time to themselves. This time was d i f f i c u l t to come by. Even i f they "freed-up" t h e i r time and r e s p o n i b i l i t i e s they had t h e i r p a r t n e r s to contend with: I am one of these people who l i k e s time to myself, I don't know what I do with i t , but I can't r e a l l y get along without having 80 t h a t time. R i g h t now I c a n ' t go i n t o town by m y s e l f - - h e ' l 1 say, oh I ' l l go with you, and I don't want him to!--and he won't understand t h a t I don't want him to come. The resentment r e p o r t e d i n the e a r l y d i s c h a r g e . p e r i o d was pronounced a few weeks l a t e r . Four s u b j e c t s v e r b a l i z e d resentment over the lack of f r e e time. The e x t r a r e s p o n s i b i l i t i e s : cooking, c l e a n i n g , c a r i n g f o r husband, c h i l d r e n , e n t e r t a i n i n g v i s i t o r s , a l l compounded t h i s f e e l i n g . One s u b j e c t e x p l a i n e d e m o t i o n a l l y why she f e l t so angered and r e s e n t f u l : I have had dozens and dozens o f v i s i t o r s i n my home these l a s t few weeks. I t o l d them (the l a t e s t v i s i t o r s ) I can't take any more of t h i s , no more people v i s i t i n g . (My husband) i s very s u r p r i s e d t o hear me say t h i s . Men c a n ' t r e a l l y understand a l l o f t h i s because they r e a l l y have no r e a l i t y on the s u b j e c t a t a l l ! They don't know what's i n v o l v e d i n the cooking, c l e a n i n g , laundry, t o w e l s , bathrooms. R e a l l y ! They think the magic f a i r y does i t a l l , and when a l l y our v i s i t o r s are here you s t i l l have to do a l l the cooking, c l e a n i n g and keep doing t h i n g s , keep people f e d , keep them e n t e r t a i n e d . Along with a i r i n g t h e i r resentment the s u b j e c t s i n the same breath, admonished themselves f o r being so s e l f i s h and unkind. They wanted to express t h e i r need f o r more f r e e time and r e c o g n i t i o n and a t the same time to acknowledge t h e i r g r a t i t u d e f o r t h e i r husbands' h e a l t h and t h e i r good marriage. T h i s ambivalence s u r f a c e d with several e x p r e s s i o n s of g u i l t : No r e a l l y , I'm so g r a t e f u l he's home and he d i d n ' t have a worse he a r t a t t a c k . I t h i n k how s e l f i s h I am that I t h i n k of these t h i n g s when I should be so g r a t e f u l he's here. 81 You f e e l t h a t you are wanting a l l the a t t e n t i o n , and there's nothing wrong with you r e a l l y — i t ' s j u s t t h a t I'm f e e l i n g s h o r t changed, and then I f e e l g u i l t y , I cou l d o f l o s t him, which I never wanted to d o — a n d he's the best o f husbands and he provides and he's so good and he has s p o i l e d me t e r r i b l y - ^ b u t j u s t a n i c e k i n d word would be n i c e , and then you get to f e e l i n g bad because they ( f a m i l y ) are not unkind. The impact o f the i l l n e s s f i n a l l y h i t one s u b j e c t , a woman who had p r e v i o u s l y denied any concerns and had c o n s i s t e n t l y maintained a very l i g h t , cheery manner. She spoke of her experience: I had a delayed r e a c t i o n , i t dawned on me e x a c t l y j u s t what had h a p p e n e d — i t dawned . on me t h a t i t was J u l y , my mind was a blank and t h i n g s h i t me a l l a t once. I was r e a l l y scared. I t was h o r r i f y i n g , w e l l , the thought t h a t God he co u l d have g o n e — and I thought o f f i n a n c e s and what c o u l d I d o ? — a n apartment--I c o u l d never look a f t e r t h i s house, I mowed the lawn f o r the f i r s t time i n my l i f e t h i s week because (my husband) used to do i t — a n d a l l those t h i n g s h i t me j u s t 1 ike t h a t ! P h y s i c a l Disturbances The general emotional slump f e l t by the sub j e c t s c o i n c i d e d with r e p o r t s o f in c r e a s e d f a t i g u e and i r r i t a b i l i t y . This f a t i g u e ranged from "being t i r e d " to f e e l i n g i n c a p a c i t a t e d . In r e t r o s p e c t one s u b j e c t d e s c r i b e d her f a t i g u e , "Gee i t ' s r e a l l y f r i g h t e n i n g , I j u s t d i d n ' t r e a l i z e how t i r e d I was, I was so sleepy a l l the time!" Three women were the most s e r i o u s l y d i s t r a u g h t and repor t e d the g r e a t e s t number of p h y s i c a l symptoms: I became p h y s i c a l l y very i l l , i t was j u s t e v e r y t h i n g . It manifested i t s e l f i n my 82 back and kidneys and stomach--At f i r s t I thought I had a kidney i n f e c t i o n . These headaches keep bothering me, they are r i g h t a t the back o f my neck. I don't r e a l l y f e e l l i k e e a t i n g . I'm not s l e e p i n g much, I'm up every hour or so. PHASE 111--Actions V e r b a l i z e d Behaviours As the weeks progressed the subjects continued to f u l f i l l the p r o t e c t o r - c o n t r o l l e r r o l e as they had done i n the e a r l y phase. This r o l e d i d not occupy as much of t h e i r time f o r t h e i r husbands were c o n v a l e s c i n g w e l l . Along with t h i s r e c u p e r a t i o n came boredom and f r u s t r a t i o n f o r the p a t i e n t s , and so they looked to t h e i r spouses and f r i e n d s f o r entertainment. The changes i n r o l e s and added r e s p o n s i b i l i t i e s continued to keep many of the women very a c t i v e . As the weeks passed by the c o n t i n u a l energy r e q u i r e d to cook, c l e a n , organize f a m i l y and watch over husband began to show i t s f u l l impact. Organization o f the p a r t n e r s ' d i e t s t i l l occupied a l o t of time f o r two s u b j e c t s . The t o p i c o f h e l p f u l others was d i s c u s s e d again during t h i s p e r i o d . Due to t h e i r general f a t i g u e and slump i n mood several s u b j e c t s d i d not welcome v i s i t o r s a t t h i s time. A few c l o s e f r i e n d s and r e l a t i v e s were h e l p f u l i n r e l i e v i n g the p a t i e n t ' s boredom. Too many v i s i t o r s , however, were p e r c e i v e d by the s u b j e c t s as t i r i n g f o r both- p a t i e n t and subject and t h e r e f o r e not welcomed. Although the s u b j e c t s c o n f i d e d f r e e l y with the i n v e s t i g a t o r , they spoke of a general r e l u c t a n c e to d i s c u s s t h e i r f e e l i n g s with t h e i r 83 p a r t n e r s , f r i e n d s , f a m i l y or p h y s i c i a n s . Two women, both t e a r y and depressed d e s c r i b e d t h i s r e l u c t a n c e : I need someone to t a l k t o . I hate to go to my d o c t o r , i t makes me f e e l s t u p i d , 'cause t h e r e ' s nothing r e a l l y wrong, well (my husband) i s b e t t e r so--I hate t a l k i n g to a strange d o c t o r — I ' d j u s t end up i n t e a r s , and I'd f e e l worse. I'm sure i t wouldn't upset the doctor but i t would upset me. W e l l , you c a n ' t t a l k t o your f r i e n d s or r e l a t i v e s about t h i s , even with your doctor you c a n ' t t a l k because he doesn't r e a l l y understand. There's nothing t h a t the d o c t o r can say t o the wives, n a t u r a l l y the d o c t o r i s more i n t e r e s t e d i n the p a t i e n t , but the e f f e c t i t has on the f a m i l y and the spouse i s tremendous, and the younger the f a m i l y the more traumatic because t h a t means more people i n v o l v e d and more f u t u r e t o t h i n k about. Many s u b j e c t s d e s c r i b e d a h e s i t a n c y to d i s c l o s e t h e i r thoughts and f e e l i n g s with t h e i r p a r t n e r s . Several f e l t t h e i r husbands c o u l d not o r would not understand. Some men are l i k e t h a t — h e has n o t i c e d I'm g e t t i n g t i r e d but he j u s t doesn't do anything t o h e l p — h e j u s t doesn't t h i n k . (My husband) can't r e l a t e to how I f e e l , he j u s t doesn't see i t . I don't know why. I c r i e d , he i s very s e n s i t i v e t o t h a t , but he s t i l l doesn't understand. Observed Behaviours The changes i n the group's mood were well r e f l e c t e d i n the s u b j e c t s non-verbal behaviours. The s u b j e c t s appeared q u i e t e r than i n the previous i n t e r v i e w . The o v e r a l l r e p o r t s o f f a t i g u e and d e p r e s s i o n were ev i d e n t i n t h e i r tone o f v o i c e and slouched body posture. These 84 s u b j e c t s sighed a l o t and r a r e l y smiled. A c t i v e hand movements, ta p p i n g , c l a s p i n g and unclasping of hands were noted with two s u b j e c t s . These movements were absent i n the previous i n t e r v i e w s . Three subjects who had looked f a t i g u e d two weeks e a r l i e r appeared more so a t t h i s time. T h e i r f a c e s were drawn with dark c i r c l e s under t h e i r eyes. A s u b j e c t , who reported being deeply depressed, spoke i n a s o f t monotone v o i c e and her posture was slouched. She looked drawn and wore no make-up. Her obvious depression was i n s t a r k c o n t r a s t to her previous appearances as a well groomed, e n e r g e t i c , a r t i c u l a t e woman. The s o c i a l theme e v i d e n t i n phase two was found to be subdued at t h i s time. Many s u b j e c t s made some type o f s o c i a l overture to the i n v e s t i g a t o r but the gestures were not as e f f u s i v e . PHASE III (Group B F i n d i n g s ) The thoughts, f e e l i n g s and a c t i o n s of the remaining three subjects v a r i e d s i g n i f i c a n t l y from Group A. Group B s u b j e c t s seemed b e t t e r a d j u s t e d . These subjects discussed t h e i r present s i t u a t i o n at length but a l s o moved beyond the present to a f u t u r e - o r i e n t a t i o n and spoke o p t i m i s t i c a l l y of the months and year to come. This group comprised three s u b j e c t s , two women and one man. The two women had f u l l - t i m e employment o u t s i d e t h e i r homes. The man, although r e t i r e d , supplemented h i s income through h i s a r t work. A l l three subjects had c h i l d r e n but none of them had f a m i l y members l i v i n g a t home. 85 PHASE 111--Thought The main thought c h a r a c t e r i s t i c s found i n t h i s group were a s s e s s i n g and p l a n n i n g . Assessing The assessment i n c l u d e d the checking of t h e i r partner's p h y s i c a l and mental he a l t h and as the weeks progressed these thoughts occupied l e s s o f the s u b j e c t s ' time. The assessment v a r i e d from the Group A s u b j e c t s i n t h a t i t expanded to i n c l u d e more of an "us" or p a r t n e r s h i p o r i e n t a t i o n . The s u b j e c t s examined, as a couple, the changes t h a t had occurred and were s t i l l to come. They planned r e a l i s t i c a l l y , y e t o p t i m i s t i c a l l y f o r the f u t u r e . One s u b j e c t d i s c u s s e d h i s thoughts about h i s wife's heart a t t a c k : Well I suppose i t ' s a veneer on almost e v e r y t h i n g . You t h i n k o f e v e r y t h i n g i n terms of i s i t too much, or are there too many v i s i t o r s and so o n — b u t I f i n d as each day goes by (my wife's) s i t u a t i o n takes a l i t t l e l e s s o f my thoughts, so now I can think more i n terms of what I am going to f i n d over a t the s t o r e , r a t h e r than I must be away only twenty minutes. The time has sped by and she i s j u s t so much b e t t e r . Time dimmed the memory o f the heart a t t a c k , and l i f e began to r e t u r n to normal f o r these s u b j e c t s . The determination to l i v e a normal l i f e and "push" the heart a t t a c k from t h e i r l i v e s was f e l t by a l l s u b j e c t s . One woman explained t h i s f e e l i n g : I think l i f e i s g e t t i n g back to normal. The longer i t g e t s — l i k e today i t ' s been s i x weeks s i n c e the heart attack and every week i t gets a l i t t l e b i t b e t t e r and we are pushing i t away. Because, f o r one t h i n g , you don't see anything, i f somebody would r e a l l y look down o r bad then you would have t h a t i n f r o n t o f y o u r eyes a l l the time, but t h i s way i s d i f f e r e n t . So we j u s t do t h i n g s and l i f e goes on. The heart a t t a c k brought many changes to the l i v e s o f these s u b j e c t s . Whatever the new l i m i t a t i o n s , the group seemed a b l e t o cope w e l l ; the changes were accepted m a t t e r - o f - f a c t l y . These s u b j e c t s looked on the b r i g h t s i d e o f the changes i n t h e i r l i v e s : Well I don't know, but I t h i n k t h a t e v e r y t h i n g goes f o r the b e t t e r ! He has changed completely he has been more t a l k a t i v e . Now he says i f something h u r t s or whatever, and he does t h i n g s around the house. Well sometimes a change can b r i n g a good r e a c t i o n t o o . I go f o r walks a l o t more than I used t o . He chases me out f o r walks. I t ' s good f o r both o f us.—I'm happy, I t h i n k we both d i d p r e t t y good! Planning Subjects planned r e a l i s t i c a l l y y e t o p t i m i s t i c a l l y f o r the f u t u r e . A heart attack can a c t as a c a t a l y s t i n a couple's l i v e s , b r i n g i n g welcomed change. One couple f i n a l l y decided to s e l l t h e i r home--something they had been " s i t t i n g on" f o r y e a r s . T h i s same spouse was d e l i g h t e d with the changes i n v o l v e d with the hea r t a t t a c k such as f r e s h a i r , e x e r c i s e and e x t r a time spent with h i s w i f e . He e x p l a i n e d h i s new s i t u a t i o n : Gosh I don't know how to say t h i s — b u t a h — a h e a r t a t t a c k can have a l o t o f b e n e f i t s too! ( l a u g h t e r ) - - i t f o r c e s you to go out and do the t h i n g s you've always wanted to do! A l l three s u b j e c t s took stock o f t h e i r s i t u a t i o n s . They r e f l e c t e d but d i d not dwell on t h e i r l o s s e s ; they viewed t h e i r l i f e and t h e i r 87 r e l a t i o n s h i p o p t i m i s t i c a l l y . R e a l i z i n g t h a t t h e i r time together was tenuous they seemed to look forward to the f u t u r e , determined to make the best o f i t . One woman portrayed t h i s frame o f mind with these words: Some people think about i t (he a r t attack) a l l the time, and well you can c r e a t e more t r o u b l e f o r y o u r s e l f . Sure e v e r y t h i n g looked so grey and dreary a t f i r s t but now i t ' s s t a r t i n g to look b e t t e r — y o u have to say well i t ' s happened, now l e t ' s t r y and make the best o f i t . Well I know i t ' s hard to plan f o r the f u t u r e , but we are going with a good frame of mind f o r our vaca-t i o n — a n d our daughter i s coming t o v i s i t i n October so ... . For one man, the heart attack p r e c i p i t a t e d a r e f l e c t i o n on h i s own m o r t a l i t y : Well I think i t (heart attack) c e r t a i n l y makes you r e a l i z e t h a t you are m o r t a l . You know, you don't go on t h i n k i n g you never reach the end. So (my wife's) heart attack has caused me to think a l o t — b u t ah, maybe t h a t ' s a normal way to go and th a t ' s how acceptance b u i l d s . Acceptance i s d e s c r i b e d i n another s u b j e c t ' s thoughts. She seemed to s i z e up the past, present and f u t u r e r e a l i s t i c a l l y , y e t with an a i r of optimi sm: Well we are both i n t e l l i g e n t enough to r e a l i z e t h a t we are very l u c k y , and we have a l o t going f o r us. We have nothing to complain about; a f t e r a l l I'm f i f t y - s e v e n and (my husband) i s s i x t y and we've had l o t s o f good times i n our l i v e s . I t ' s not l i k e we are t h i r t y . And y e t we have a l o t of good times ahead, as long as we do the thi n g s t h a t we should, and maybe do a few d i f f e r e n t l y . And (my husband) l o v e s to p a i n t , and r e a l l y wants to get back p a i n t i n g so I t o l d him to get h i s easel up and get busy! 88 One s u b j e c t compared h i s s i t u a t i o n to other heart a t t a c k v i c t i m s . His comments spoke to a frame of r e f e r e n c e : Well we were walking t h i s morning, and you can see the f a s t walkers, and you can spot them and can say well he's one o f the c l u b ! (Heart a t t a c k v i c t i m . ) You know what I mean, very muscular men i n t h e i r f i f t i e s and walking to beat h e l l , and you t h i n k well they've been there too. And you see them h u s t l i n g around, and t h a t makes you f e e l more comfortable with the f u t u r e . PHASE I I I — F e e l i n g s Mood In c o n t r a s t to the o f t e n depressed mood of Group A s u b j e c t s t h i s group rep o r t e d f e e l i n g calm, thankful and i n good s p i r i t s . These f e e l i n g s were r e f l e c t e d i n t h e i r c o n v e r s a t i o n s : Well I'm about 99 percent back to normal, I'm f e e l i n g good. Sure e v e r y t h i n g looked so grey and dreary at f i r s t , but now i t ' s s t a r t i n g to look b e t t e r . Well I'm f e e l i n g e a s i e r , every day i s another mark on the wall--I'm f e e l i n g p r e t t y well myself now. There's no concern a t l e a v i n g the house where as a t f i r s t you get scared r e a l l y to go out and then you kind o f run back every f i v e minutes to see i f she i s s t i l l a l i v e ; not now, now I'm more at ease. One woman, i n e a r l i e r i n t e r v i e w s , had expressed a l o t o f r e s e n t -ment and anger towards her husband. She f e l t he had p r e c i p i t a t e d h i s own heart a t t a c k . He had ignored her pleas to change h i s behaviour and subsequently had a heart a t t a c k . Her comments i n t h i s l a s t i n t e r v i e w seemed more i n s i g h t f u l . In examining her behaviour she had worked hard at a new approach, one she f e l t y i e l d e d a healthy compromise: 89 I guess maybe I s t i l l have t h a t b i t o f resentment, i f I allow i t t o be, but i f i t get busy and do something to occupy my time then I'm f i n e . You know i t can well up i n s i d e of you and i t does. I c o u l d n ' t p o s s i b l y s u r v i v e i f I d i d n ' t say something. I'm not going to be a mickey mouse with him j u s t cause he had a heart a t t a c k but at the same time I'm f a r b e t t e r than I used to be, simply because I don't want him to have another heart a t t a c k . And i f t h a t means t h a t f o r me, not saying a l o t w i l l h elp, then okay, and i t seems to be working out f i n e . Physical Disturbances The reported improved mood and general f e e l i n g of calm and optimism were a l s o r e f l e c t e d i n a improved s t a t e of p h y s i c a l h e a l t h . A l l three subjects reported f e e l i n g w e l l , t h e i r sleep and a p p e t i t e patterns were "back to normal." The f a t i g u e and i r r i t a b i l i t y d e s c r i b e d by Group B were not reported by these s u b j e c t s . PHASE I I I - - A c t i o n s V e r b a l i z e d Behaviours The changes i n r o l e s and r e s p o n s i b i l i t i e s i n t h i s group were shared by both p a r t n e r s . Two s u b j e c t s , both working women, found t h e i r husbands assumed more of the domestic r o l e s during t h e i r convalescence. This had a dual b e n e f i t : i t a l l e v i a t e d the husbands' boredom and lessened the subjects' r e s p o n s i b i l i t i e s a f t e r work hours. One s u b j e c t spoke of the changes i n her husband's a t t i t u d e towards the housework: Well when I get home from work I'm t i r e d and I f a l l a s leep f o r awhile. Well he has 90 changed completely, he does t h i n g s around the house. So he i s a c t i v e , and he says why d i d you do t h a t , j u s t leave i t f o r me, so he keeps busy--I don't mind him doing the d i s h e s , i t ' s not l i k e b e f o r e , t h e r e was j u s t one person, and t h a t was me, you know. One e n e r g e t i c spouse had been moving f u r n i t u r e and c l e a n i n g c a r p e t s the day p r i o r to the i n t e r v i e w . She spoke s y m p a t h e t i c a l l y of her husband's f e e l i n g s : Well (my husband) f e e l s so badly t h a t he can't do anything f o r me. I s a i d don't f e e l bad about the c a r p e t s , there are other t h i n g s you can do. So he's been c l e a n i n g the s i l v e r and f i x i n g the meals and i t r e a l l y h e l p s . Switching r o l e s came e a s i l y to one o f the s u b j e c t s . He e x p l a i n e d how the couple's experiences had helped them cope with t h e i r present changes: Well i t ' s been p r e t t y easy. We don't r e a l l y have a l o t o f d e f i n e d r o l e s — a n d we have been through t h i s i n a k i n d o f m i n i - s e r i e s before you know. Like i f (my wife) was l a i d up with anything, or i f I was l a i d up with anything i t was the same as i t i s now. We'd j u s t switch r o l e s , so there hasn't had to be any accommodation to another r o l e . No concerns were v o i c e d by t h i s group i n regards t o d i e t , medica-t i o n or a c t i v i t y . The s u b j e c t s were pleased with the convalescence and they d i d not f e e l t h e i r partners were "overdoing i t " . One p a t i e n t had alr e a d y returned to work part-time. This a c t i v i t y was welcomed by both p a t i e n t and s u b j e c t with no d i f f i c u l t i e s r e p o r t e d . Returning to work was a concern f o r one 53 year o l d s u b j e c t . She f e l t her husband, a l a b o u r e r , would no longer be able to handle the s h i f t work and p h y s i c a l r e s p o n s i b i l i t i e s . Her a t t i t u d e , however, was p o s i t i v e : 91 Well i t might not be so easy f o r (my husband) but we'll j u s t have to see how i t works out. I t ' s not the end of the world anyhow—I'm working so i t helps some. A l l three s u b j e c t s r e p o r t e d a f a i r l y q u i e t s o c i a l l i f e . An occa-s i o n a l v i s i t from f r i e n d or r e l a t i v e was welcomed but there was a general tendency not to reach out and i n i t i a t e a l o t o f s o c i a l c o n t a c t . Both p a r t i e s seemed to agree on the amount o f s o c i a l i z i n g to be done and were able to arrange an a p p r o p r i a t e schedule. Two s u b j e c t s expressed p o s i t i v e f e e l i n g s about t h e i r f a m i l y doc-t o r s . They found them h e l p f u l , p a r t i c u l a r l y i n o f f e r i n g i n f o r m a t i o n and v a l i d a t i n g t h e i r partners' p o s i t i v e recovery. One s u b j e c t mentioned how he found other h e a r t attack p a t i e n t s h e l p f u l and comforting. Yeah, there's an amazing number of people t h a t have been through i t (heart a t t a c k ) and you meet them and you r e a l i z e i t ' s not a l l t h a t bad, i t ' s s c a r y , but see, they are s t i l l going strong, so ... . The communication between the s u b j e c t s and t h e i r partners was reported to be "good" and i n some cases had improved s i n c e the h e a r t a t t a c k . The i l l n e s s had drawn these couples together; they seemed able to share t h e i r thoughts and concerns f r e e l y . This time was used to r e f l e c t on t h e i r r e l a t i o n s h i p and t h e i r c u r r e n t s i t u a t i o n . Many of t h e i r thoughts, f e e l i n g s and a c t i o n s had a team o r i e n t a t i o n : Well the heart attack i s i n our conversa-t i o n s , but we don't dwell on i t . This has been a s e r i o u s s i t u a t i o n and i t b r i n g s you c l o s e r together. I suppose c l o s e r i n the way t h a t there i s a complete dependence on one another. Well (my wife's) a t t i t u d e has been g r e a t . She knows e x a c t l y how much she can take, so i t ' s been p r e t t y well a 50/50. 92 d e c i s i o n . We haven't c o n s c i o u s l y s a i d well what do you t h i n k , i t j u s t happens. One s u b j e c t complained t h a t her husband used to work midnight s h i f t and t h i s had s t r a i n e d t h e i r r e l a t i o n s h i p . Since the heart attack she had n o t i c e d changes i n t h e i r r e l a t i o n s h i p and she spoke p o s i t i v e l y of t h i s time: Well he has changed completely. He has been more t a l k a t i v e . Before he would hardl y say anything, and now he t a l k s about h i s heart a t t a c k and what he has been doing. Now i t ' s b e t t e r , because when I come home he's awake, and we t a l k . Before the heart a t t a c k , I only saw him s l e e p i n g from the s h i f t work, so now i t ' s b e t t e r . Observed Behaviours The behaviours of the s u b j e c t s during t h i s l a s t i n t e r v i e w were congruent with t h e i r reported r e a c t i o n s . They seemed to enjoy the i n t e r v i e w . They were a l e r t and responsive, devoid of many o f the a n x i e t i e s and t e n s i o n noted i n the e a r l i e r group. The faces and body posture of the spouses appeared calm and r e l a x e d . T h i s contentment was a l s o r e f l e c t e d i n t h e i r eye c o n t a c t and v o i c e i n f l e c t i o n . The s u b j e c t s used t h e i r hands to gesture a p p r o p r i a t e l y or e l s e they held them i n t h e i r l a p s . One man, s i t t i n g n e s t l e d i n h i s f a v o u r i t e c h a i r , leaned back o c c a s i o n a l l y with h i s hands behind h i s head. He seemed d e l i g h t e d to have the opportunity to t a l k . In f a c t none of the subjects were in a hurry to terminate the c o n v e r s a t i o n . The f r i e n d l i n e s s and comfortable atmosphere were al s o r e f l e c t e d i n the number of s o c i a l overtures made 93 to the i n v e s t i g a t o r . This group was very s o c i a l and i n i t i a t e d o f f e r s o f t e a , lunch and d i s c u s s i o n s o f f a m i l y and other i n t e r e s t s . Summary The f i n d i n g s from these three phases r e v e a l e d a common pa t t e r n o f behaviours which spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . The p a t t e r n of behaviours comprised the thoughts, f e e l i n g s and a c t i o n s o f the s u b j e c t s from the i n i t i a l impact o f i l l n e s s to s i x weeks post myocardial i n f a r c t i o n . The data d e s c r i b e d the process spouses experienced from the i n i t i a l p e r c e p t i o n of the l o s s to the subsequent impact of the event. 94 CHAPTER 5 DISCUSSION Th i s study focused on the r e a c t i o n s t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . The s u b j e c t s ' thoughts, f e e l i n g s and a c t i o n s were d e s c r i b e d i n Chapter IV. The * f i n d i n g s i n d i c a t e d t h a t the spouses experienced behaviours i n response to l o s s t h a t were common and formed a pa t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : the event and i n i t i a l spousal response, r e a c t i o n to the event, and impact of the event. In order to understand the ongoing process o f l o s s experienced by the spouses, the f i n d i n g s were i n t e r p r e t e d i n l i g h t o f the three c o n s t r u c t s e l u c i d a t e d i n the l i t e r a t u r e review: the r e a c t i o n s to l o s s , the elements of l o s s , and the meaning of l o s s . The purpose of t h i s chapter was to i n t e g r a t e the f i n d i n g s with the l o s s l i t e r a t u r e and thus to develop an understanding of the phenomenon of l o s s f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . An overview of the i n t e r p r e t a t i o n of the f i n d i n g s i s presented i n Appendix F. Phase I The Event and I n i t i a l Spousal Response Reactions to l o s s The thoughts, f e e l i n g s and a c t i o n s o f the s u b j e c t s i n t h i s study had a c l o s e resemblance to the c h a r a c t e r i s t i c s of a n t i c i p a t o r y g r i e f as i d e n t i f i e d by Lindemann (1944). Lindemann d e s c r i b e d acute g r i e f as a d e f i n i t e syndrome with p s y c h o l o g i c a l and somatic symptoms. He suggested t h a t i n d i v i d u a l s who experienced a n t i c i p a t o r y g r i e f moved 95 through the same process o f g r i e f work as those who had experienced g r i e f a f t e r an actual l o s s . Lindemann d e s c r i b e d g r i e f work as a heightened preoccupation with the departed, a review o f a l l forms o f death which might b e f a l l one, and an a n t i c i p a t i o n o f the modes o f readjustment which might be n e c e s s i t a t e d . The p e r i o d of "heightened preoccupation" was a "very heavy t h i n k -ing time" f o r the s u b j e c t s and several thoughts occupied t h e i r minds. They o f t e n questioned why the l o s s had occurred and attempted to appor-t i o n blame somewhere. Not only d i d they search f o r a cause, or reason, but they a l s o looked f o r some frame of r e f e r e n c e , a concrete comparison to help them understand and accept t h e i r l o s s . The s u b j e c t s ' c o g n i t i o n extended to i n c l u d e thoughts of t h e i r marriage and t h e i r l i v e s t ogether. In t a k i n g stock o f t h e i r l i v e s they o f t e n r e f l e c t e d on how much they loved and needed t h e i r p a r t n e r . This "heightened preoccupa-t i o n with the departed" was a l s o d e s c r i b e d by Parkes (1971) i n h i s London widow study where he termed the behaviour " s e a r c h i n g " . Lindemann a l s o noted t h a t the wives of s o l d i e r s who had departed f o r war reviewed the forms of death t h a t might b e f a l l t h e i r l o v e d ones. Bereaved persons o f t e n have a need to review the events l e a d i n g up to and surrounding the death of a loved one. F u l t o n and F u l t o n (1972) concluded t h a t f a m i l i e s faced with the terminal i l l n e s s o f one o f t h e i r members w i l l rehearse the death before i t o c c u r s . This rehearsal may i n c l u d e thoughts about when, as well as how, the p a t i e n t may d i e . Rehearsal of death i s an ominous phrase, y e t one t h a t a p t l y de s c r i b e d the s u b j e c t s ' thought processes o f reviewing and a n t i c i p a t i n g during t h i s c r i t i c a l time. A common behaviour noted i n t h i s study was 96 the "blow-by-blow d e s c r i p t i o n " or "how i t happened". This behaviour termed reviewing, seemed to allow the s u b j e c t s time to r e f l e c t and contemplate the extent o f t h e i r experiences and i n t e g r a t e the past events and f e e l i n g s , with the present. Working through the past memories may have a s s i s t e d the s u b j e c t s i n accepting the r e a l i t y o f the present and the t h r e a t of f u t u r e l o s s . The m a j o r i t y o f s u b j e c t s viewed death of the spouse as c l o s e . T h e i r g r e a t e s t f e a r s during the f i r s t week were of c o m p l i c a t i o n s and of recurrence of another h e a r t attack f o r t h e i r p a r t n e r . They p e r c e i v e d t h i s time as c r i t i c a l and u n c e r t a i n and thus would l i e awake at n i g h t , r e h e a r s i n g or a n t i c i p a t i n g the worst t h a t might b e f a l l t h e i r p a r t n e r s . The s u b j e c t s ' behaviours of a n t i c i p a t i n g can be i n t e r p r e t e d i n l i g h t of Lindemann's t h i r d c h a r a c t e r i s t i c termed " a n t i c i p a t i n g the modes of readjustment". I n i t i a l l y , the subjects questioned whether t h e i r l i v e s would change i n the f u t u r e , and they acknowledged the changes t h a t had occurred i n t h e i r d a i l y r o u t i n e s w i t h i n the l a s t few days. As the p a t i e n t moved c l o s e r to d i s c h a r g e , the s u b j e c t s a n t i c i -pated the changes t h a t would occur i n t h e i r l i v e s and the readjustment t h a t these changes n e c e s s i t a t e d . A l l o f the s u b j e c t s agreed t h a t t h e i r partners would have to change t h e i r l i v e s with regard to work, s o c i a l a c t i v i t y and d i e t . Three quarters o f the s u b j e c t s feared and prepared themselves f o r the worst i n terms of t h e i r p a r t n e r s ' p h y s i c a l and p s y c h o l o g i c a l adjustment. Of the twelve s u b j e c t s , nine spoke s p e c i f i -c a l l y about the a n t i c i p a t e d changes t h a t would a f f e c t them. Over one h a l f of these s u b j e c t s feared the worst. The thoughts of the modes o f readjustment r e l a t e d to the i l l n e s s , not to the death of t h e i r 97 p a r t n e r s . The spouses feared the worst i n terms o f changes and upset i n t h e i r normal r o u t i n e s but they d i d not d i s c u s s readjustment t h a t might be n e c e s s i t a t e d by the partner's death. Although f e a r o f death was c e r t a i n l y on t h e i r minds i t may have been too p a i n f u l to e n t e r t a i n f o r any l e n g t h o f time. When the thought o f death was d i s c u s s e d i t was in r e l a t i o n to f e e l i n g s of h e l p l e s s n e s s , l o n e l i n e s s and dep r e s s i o n . The r e p o r t e d mood s t a t e s and somatic d i s t u r b a n c e s d e s c r i b e d i n t h i s acute phase approximated several of the a n t i c i p a t o r y g r i e f a c t i o n s d e s c r i b e d by Lindemann. In a d d i t i o n to c o r r o b o r a t i n g Lindemann's J f i n d i n g s , the r e a c t i o n s o f the su b j e c t s during t h i s c r i t i c a l p e r i o d o f the partner's i l l n e s s are s i m i l a r to the r e a c t i o n s d e s c r i b e d by other w r i t e r s who have focused s p e c i f i c a l l y on the stages or phases t h a t f o l l o w a major a n t i c i p a t e d or actual l o s s (Bowlby, 1961; Engel, 1962; Fink, 1967; Kubler-Ross, 1969; Parkes, 1972; Shontz, 1975). The sub-j e c t s ' i n i t i a l responses to l o s s i n t h i s study m i r r o r e d the r e a c t i o n s d e s c r i b e d during the i n i t i a l phase o r stage o f a major l o s s . G r i e f r e a c t i o n s were well d e s c r i b e d by many authors (Parkes, 1971; Royle, 1973; Skelton and Dominian, 1973; L a r t e r , 1976; Mayou, Foster and Williamson, 1978). T h e i r d e s c r i p t i o n o f l o s s resembled the i n i t i a l r e a c t i o n s d e s c r i b e d by the subjects o f t h i s study. The f i n d i n g s r e p o r t e d by Skelton and Dominian (1973) and Mayou, Fos t e r and Williamson (1978) were of p a r t i c u l a r r e l e v a n c e . These w r i t e r s s t u d i e d a r e p r e s e n t a t i v e sample of wives o f myocardial i n f a r c -t i o n p a t i e n t s during the acute " h o s p i t a l i z a t i o n p e r i o d . Common r e a c t i o n s noted by both r e s e a r c h e r s were sleep and a p p e t i t e d i s t u r b -ances, anxiety and t e n s i o n . Skelton and Dominian (1973) reported 98 f e e l i n g s of l o s s and depression as well as other psychosomatic i l l n e s s r e l a t e d to the p a t i e n t ' s heart a t t a c k . The study r e p o r t e d spouses having many d i f f e r e n t f e e l i n g s , how-ever, depression was not commonly de s c r i b e d by the s u b j e c t s i n Phase I. This f i n d i n g was i n t e r e s t i n g , f o r i t d i f f e r e d from Skelton and Dominian's study, where reported and observable behaviours of depression were noted. Mayou, Foster and Williamsons' (1978) f i n d i n g s , on the other hand, noted depression as a l a t e r r e a c t i o n e v i d e n t i n the i n t e r v i e w s two months a f t e r h o s p i t a l d i s c h a r g e . The f i n d i n g s o f t h i s study concurred with t h i s view. In terms o f a c t i o n s v e r b a l i z e d by the s u b j e c t s , a noteworthy d i f f e r e n c e was found between the i n v e s t i g a t o r ' s data and the f i n d i n g s of Mayou, e t a l . These researchers noted the s u b j e c t s had a tendency to c l i n g to other people. None o f the s u b j e c t s i n the present study d e s c r i b e d what could be reported as c l i n g i n g behaviour. Six subjects f e l t f a m i l y and f r i e n d s were h e l p f u l w i t h o u t apparent dependency on t h i s a s s i s t a n c e . F i v e o f the sample p r e f e r r e d to be alone and d i d not a p p r e c i a t e c o n t a c t at t h i s time as i t was a busy t h i n k i n g time and they d e s i r e d s o l i t u d e . There seemed to be a v a r i a t i o n i n the degree to which f r i e n d s , f a m i l y , doctors and nurses were repor t e d as h e l p f u l by the spouses. F u r t h e r , the spouses r a r e l y sought i n f o r m a t i o n from the i n v e s t i g a t o r . Although the m a j o r i t y o f s u b j e c t s i n d i c a t e d a need f o r i n f o r m a t i o n , i t appeared that the s t r u c t u r e d c a r d i a c teaching program met t h e i r needs during t h i s e a r l y phase. The p e r i o d . o f r e a c t i n g to the event was d e s c r i b e d as a l o n e l y time. The s u b j e c t s only wanted to be with t h e i r p a r t n e r s and o f t e n no 99 one e l s e c o u l d s u b s t i t u t e . As one spouse s t a t e d , " I f I c a n ' t be with (my wife) then I'd j u s t r a t h e r be by myself." This behaviour i s s i m i l a r to t h a t d e s c r i b e d by Marris (1968) i n h i s study o f the e f f e c t o f bereavement on London widows. He found the bereaved o f t e n tend to devalue a l l r e l a t i o n s h i p s except the one which has been l o s t , so t h a t i n s t e a d of t u r n i n g to c h i l d r e n , f a m i l y or f r i e n d s the widow may become almost i n d i f f e r e n t to them. Although the myocardial i n f a r c t i o n spouses i n t h i s study seemed u n i n t e r e s t e d i n s o c i a l c o n t a c t they d i d , i n f a c t , yearn f o r a t t e n t i o n and support as evidenced by t h e i r eager w i l l i n g n e s s to t a l k to the i n v e s t i g a t o r . One woman de s c r i b e d the r e s e a r c h e r as a " c a r i n g o u t s i d e r " . Although the researcher was concerned about being i n t r u s i v e a t a time o f g r i e f , these i n d i v i d u a l s r e p o r t e d t h a t the research was very h e l p f u l . The subjects had a great need f o r v e n t i l a . t i o n . This need i s well documented i n the l i t e r a t u r e (Lindemann, 1944; Glaser and S t r a u s s , 1965; Parkes, 1971; Hampe, 1975). Dracup and Breu found a s i m i l a r r e a c t i o n i n i n t e r v i e w i n g spouses of c r i t i c a l l y i l l c a r d i o v a s c u l a r p a t i e n t s . They found the spouses expressed g r a t i t u d e f o r having the o p p o r t u n i t y to share t h e i r f e e l i n g s with an o b j e c t i v e , empathic person--a person o u t s i d e the f a m i l y u n i t — i n which a l l of the members were sharing t h e i r anguish. The researchers b e l i e v e d the b e n e f i t s of a d d i t i o n a l support and an oppor-t u n i t y to v e n t i l a t e t h e i r r e a c t i o n s outweighed the r i s k of psycho-l o g i c a l trauma. Parkes (1971) found a s i m i l a r r e a c t i o n when he undertook a l o n g i t u d i n a l study of the r e a c t i o n s of London widows. Although the widows of t e n withdrew from s o c i a l c o n t a c t , they welcomed 100 the i n v e s t i g a t o r ' s study. I n i t i a l l y Parkes had some m i s g i v i n g s about the study, f o r he d i d not wish to i n t r u d e upon the widow's g r i e f and cause her unnecessary p a i n . He found, however, the o p p o s i t e : On the c o n t r a c t , the m a j o r i t y seemed g r a t e f u l f o r the o p p o r t u n i t y to t a l k f r e e l y about the d i s t u r b i n g problems and f e e l i n g s t h a t preoccupied them ... she seemed to f i n d the i n t e r v i e w t h e r a p e u t i c ... I had no sense o f i n t r u s i o n a f t e r the f i r s t few minutes o f the i n i t i a l c o n t a c t . (Parkes, 1971, p. 35.) The Elements of Loss Both the l i t e r a t u r e and t h i s study found t h a t an a n a l y s i s o f the l o s s process produced some common elements or c h a r a c t e r i s t i c s . From the comments and observed behaviours of the spouses i t was ev i d e n t t h a t the elements of l o s s were r e l a t e d to the per c e p t i o n o f the event i n time. The l o s s was a sudden, traumatic event s i n c e the heart attack was unexpected. The h e a r t a t t a c k had oc c u r r e d but was d e s c r i b e d by the spouses i n three separate time frames. They reviewed what had happened, d i s c u s s e d the l o s s i n terms o f the present consequences and a n t i c i p a t e d l o s s f o r the f u t u r e . In p a r t i c u l a r , the event had a strong f u t u r e and a n t i c i p a t o r y q u a l i t y . The su b j e c t s focused more on the threatened or a n t i c i p a t e d l o s s o f t h e i r p a r t n e r . I t was a c r i t i c a l time f o r the s u b j e c t s with the f e a r o f t h e i r partner's death looming as a formidable l o s s i n an un c e r t a i n f u t u r e . The heart attack a l s o p r e c i p i t a t e d the r e c a l l o f oth e r l o s s experienced i n the past which seemed to o f f e r a frame of reference f o r the spouses. 101 Loss was a l s o conceived as two events o c c u r r i n g simultaneously. From the o b j e c t i v e eye of the i n v e s t i g a t o r the heart a t t a c k was viewed as an observable concrete event: an actual l o s s t h a t had c l e a r l y a l t e r e d the b i o l o g i c a l f u n c t i o n i n g of the he a r t . For the spouse e x p e r i e n c i n g the same event the l o s s was a very s u b j e c t i v e one. The Meaning of Loss The f u l l r e a l i t y o f what had happened d i d not penetrate the consciousness o f the s u b j e c t s a t f i r s t . The r e a l i t y o f any c a t a -s t r o p h i c l o s s producing g r i e f i s g e n e r a l l y too overwhelming to pe r c e i v e a c c u r a t e l y and to i n t e g r a t e f u l l y . That which had occurred was incon-gruent with the r e a l i t y p r e v i o u s l y known to the su b j e c t s ( C a r l s o n , 1978). Most o f the s u b j e c t s d e s c r i b e d t h e i r f e e l i n g s o f shock and d i s b e l i e f while t h e i r r e a c t i o n s r e v e a l e d a gradual development of awareness as they began to understand and a t t a c h some meaning to the 1 oss. Although persons commonly go through the same stages or phases f o l l o w i n g a major l o s s , there are several d i f f e r e n c e s t h a t can occur i n t h i s passage. For example, an i n d i v i d u a l ' s "timing" may be d i f f e r e n t : one may move slowly o r r a p i d l y through phases, bypass a phase, or perhaps v a c i l l a t e between phases ( C a r l s o n , 1978; Roberts, 1978). Carlson developed t h i s p o i n t by saying t h a t g e n e r a l i z a t i o n s about personal experience and behaviour are useful only when one maintains a commitment to the understanding and acceptance o f i n d i v i d u a l v a r i a t i o n s ( C a r l s o n , 1978, p. 88). 102 Most of the spouses r e p o r t e d s i m i l a r behaviours during the i n i t i a l impact o f the i l l n e s s , however, two s u b j e c t s d i d not " f i t " the de s c r i b e d behaviours o f the group. Two women denied f e e l i n g any shock or numbness and r e p o r t e d f e e l i n g " p r e t t y good and w e l l " . T h e i r behaviours, as observed by the i n v e s t i g a t o r , were congruent with t h e i r r e p o r t e d f e e l i n g s t a t e s : they smiled f r e q u e n t l y , demonstrated good eye co n t a c t , and gestured a p p r o p r i a t e l y with nods and a c t i v e f a c i a l g e s t u r e s . They seemed res p o n s i v e and eager t o t a l k and d i s p l a y e d a mood of calm and optimism. One i n t e r p r e t a t i o n o f these r e a c t i o n s i s t h a t the spouses were a c t i v e l y denying t h e i r l o s s . For whatever reason, the l o s s was too p a i n f u l to encounter so the su b j e c t s used d e n i a l mechanisms to remove themselves e m o t i o n a l l y from the l o s s . This i n t e r p r e t a t i o n bears some v a l i d i t y , because i n the t h i r d and f o u r t h i n t e r v i e w , the su b j e c t s d i d r e p o r t the impact o f the he a r t a t t a c k as " h i t t i n g them l a t e r " and "harder" than they thought. The v i v i d d e s c r i p t i o n s o f t h e i r r e a c t i o n s a t t h i s time resembled the re p o r t e d r e a c t i o n s o f the other s u b j e c t s during phase one. The reasons f o r the d e n i a l , then r e s t e d on many f a c t o r s . These two women had s u f f e r e d r e c e n t major l o s s e s t h a t c o u l d have a f f e c t e d t h e i r r e a c t i o n s , a t t h i s time, to t h e i r p a r t n e r ' s h e a r t a t t a c k . One woman had almost " l o s t " her husband i n a s e r i o u s c a r ac c i d e n t . Although i t had been three y e a r s s i n c e the event, the woman co n s t a n t l y r e c a l l e d the i n c i d e n t i n d e t a i l and reassured h e r s e l f t h a t " t h i s " (heart a t t a c k ) was not as bad, and t h a t she was prepared t h i s time. S i m i l a r reassurance was echoed by the second woman, who had "been through a number o f f a m i l y deaths r e c e n t l y " . This experience 103 caused her to minimize the present event. She s t a t e d , "I can cope, I can cope." Although the s u b j e c t s looked i n t o the past and to the f u t u r e , many of t h e i r thoughts focused on the present. T h e i r p h i l o s o p h i c a l b e l i e f s r e f l e c t e d a here-and-now stance. I t may have been too uncomfortable f o r the s u b j e c t s to p r o j e c t i n t o the f u t u r e when i t was such an uncer-t a i n and u n p r e d i c t a b l e time. Many o f the s u b j e c t s spoke about hope. Hope has been i d e n t i f i e d as a need r e l a t e d to the process o f a n t i c i p a -t o r y g r i e f . T h is need has been s t u d i e d i n r e l a t i o n to the threatened l o s s experienced by s i g n i f i c a n t o thers o f c r i t i c a l or t e r m i n a l l y i l l p a t i e n t s (Friedman, Choi d o f f and Hamburg, 1963; Futterman, Hoffman and Sabshin, 1972; Hampe, 1975; Dracup and Breu, 1978). To f e e l there i s hope was found to be the most s i g n i f i c a n t need i d e n t i f i e d by r e l a t i v e s o f c r i t i c a l l y i l l p a t i e n t s during the i n t e n s i v e care phase o f h o s p i t a l -i z a t i o n (Moulter and Captain, 1979). Korner (1970) d i s c u s s e s the coping value o f hope. She says the more u n c e r t a i n man i s , the more he needs a cushion of defense a g a i n s t h i s f e a r s and a n x i e t i e s . Not a l l the s u b j e c t s were ho p e f u l . Some of them took what c o u l d be d e s c r i b e d as a f a t a l i s t i c approach during t h i s c r i t i c a l time. T h i s approach i s d i f f i c u l t to i n t e r p r e t . Are the s u b j e c t s preparing f o r the worst? Are they a b s o l v i n g themselves? Does f a t a l i s m have coping value? A f a t a l i s t i c approach does tend to take the r e s p o n s i b i l i t y and perhaps f e a r out of the event. The l o s s i s e s s e n t i a l l y out of one's l o c u s o f c o n t r o l . Two s u b j e c t s i n d i c a t e d these b e l i e f s were o f long standing and t h i s was how they approached l i f e i n g e n e r a l . An i n t e r -e s t i n g f i n d i n g was t h a t three s u b j e c t s who held f a t a l i s t i c values could 104 not f i n d a reason f o r t h e i r p a r t n e r ' s heart a t t a c k . They c o u l d not a f f i x blame, so to speak, on the p a t i e n t , on r i s k f a c t o r s , or on themselves. A c o n j e c t u r e , a t t h i s p o i n t , i s t h a t perhaps the s u b j e c t s a c t i v e l y searched f o r some ex p l a n a t i o n and "found" a metaphysical or superordinate s t r u c t u r e as r e s p o n s i b l e . Somehow i t was j u s t meant to be. Not only were the spouses' p e r c e p t i o n s important i n regards to t h e i r thoughts and f e e l i n g s but a l s o s i g n i f i c a n t with t h e i r a c t i o n s The need to seek out support, or i n f o r m a t i o n was c o n t i n g e n t on a " c r i t -i c a l t iming f a c t o r " . If the timing was not r i g h t f o r the s u b j e c t s , he or she would not seek support or information and d i d not p e r c e i v e i t as h e l p f u l . One s u b j e c t f e l t h i s f a m i l y was h e l p f u l i n the f i r s t few days, but once the i n i t i a l impact had h i t , he p r e f e r r e d to be by him-s e l f , as he had "a l o t to t h i n k about". Im summary, the f i n d i n g s i n d i c a t e d the s u b j e c t s responded to t h e i r own perceptions o f the l o s s , not the o v e r t r e a l i t y as observed by an " o u t s i d e r " . T h e i r thoughts, f e e l i n g s and a c t i o n s d e s c r i b e d a process they experienced as they attempted to understand and a t t a c h meaning to the l o s s . Phase II Reaction to the Event Reactions to l o s s The f i n d i n g s i n t h i s phase d e s c r i b e d a s h i f t i n the s u b j e c t s ' d e s c r i p t i o n s of t h e i r r e a c t i o n s to the l o s s event. In b r i e f , the heightened thought processes decreased while the s u b j e c t s ' a c t i o n s i n c r e a s e d . This was a busy time f o r the s u b j e c t s , y e t i t was a l s o c h a r a c t e r i z e d as a more c e r t a i n p e r i o d , one i n which the s u b j e c t s had more c o n t r o l o v e r t h e i r p a r t n e r s ' l i v e s . T h i s c o n t r o l i s well i l l u s t r a t e d i n Vachon's (1978) study o f widows of men with c h r o n i c c a r d i o v a s c u l a r d i s e a s e . Vachon found t h a t the wives f e l t they played an a c t i v e r o l e i n h e l p i n g t h e i r husbands during the time o f i l l n e s s , she s t a t e d : These women f e l t t h a t i f they f e d t h e i r husbands r i g h t , helped them a l l e v i a t e t h e i r s t r e s s , made them c u t down a c t i v i t i e s , t h a t they wouldn't d i e (Vachon, 1978, p. 56). In c o n t r a s t t o the e a r l i e r phase, the m a j o r i t y o f s u b j e c t s appeared b r i g h t , r e s p o n s i v e and vo i c e d g r a t e f u l n e s s and optimism f o r the f u t u r e . Although f o u r s u b j e c t s complained of sle e p and a p p e t i t e d i s t u r b a n c e s with i n c r e a s e d f a t i g u e , t h e i r a f f e c t remained p o s i t i v e and they r e p o r t e d a calmer, more p o s i t i v e mood s t a t e . The u p l i f t i n mood can be i n t e r p r e t e d i n l i g h t o f the f a c t t h a t many s u b j e c t s a n t i c i p a t e d the worst w h i l e t o t h e i r d e l i g h t many o f the changes d i d not occur o r were not as tr a u m a t i c as a n t i c i p a t e d . The s u b j e c t s ' mood s h i f t may a l s o have r e f l e c t e d the mood of t h e i r p a r t n e r s . They had "made i t " through the f i r s t week at home. Although t h i s time was d e s c r i b e d as very s t r e s s f u l t h i n g s were s t a r t i n g to improve. T h i s upswing i n mood i s not well r e p o r t e d i n the l o s s l i t e r a t u r e . However, the eu p h o r i c "we have made i t " f e e l i n g i s s i m i l a r t o the euphoric response observed by Kimball (1969). In a study o f the post o p e r a t i v e behaviour o f c a r d i a c surgery p a t i e n t s a euphoric response was noted during the l a t e r convalescent p e r i o d o f h o s p i t a l i z a t i o n when the 106 c r i t i c a l stages o f t h e i r surgery had passed. Kimball i d e n t i f i e d the behaviours as c o n f i d e n t , b r i g h t , responsive and "glad to be a l i v e " . The r e s e a r c h e r has a l s o n o t i c e d a s i m i l a r behaviour i n her nursing experience while c a r i n g f o r c r i t i c a l l y i l l p a t i e n t s . Many i n d i v i d u a l s who have recovered from a l i f e t h r e a t e n i n g event do r e f l e c t on how lucky they are to be a l i v e . An i n f e r e n c e was drawn t h a t i n d i v i d u a l s who are threatened with the l o s s o f t h e i r l i v e s , or t h e i r loved ones, experience a response s i m i l a r to t h a t d e s c r i b e d by the s u b j e c t s i n t h i s study. The subjects reported t h i s time to be very busy. T h e i r "watchdog or p r o t e c t o r " behaviours i n v o l v e d h e c t i c schedules o f o r g a n i z i n g the household, f a m i l y and v i s i t o r s as well as monitoring t h e i r partners' d i e t , medications and a c t i v i t i e s . Many o f the s u b j e c t s had gained i n f o r m a t i o n about t h e i r partners' p r e s c r i b e d d i e t , medications and l e v e l o f a c t i v i t y from the s t r u c t u r e d i n - h o s p i t a l c a r d i a c teaching program. Two su b j e c t s however, seemed rather anxious about the d i e t planning. Cooking the r i g h t meals was perc e i v e d as very important and these women spent hours i n reading about and preparing low c h o l e s t e r o l d i e t s . One i n t e r p r e t a t i o n o f t h i s behaviour was t h a t the spouses viewed d i e t p r e p a r a t i o n as a f a m i l i a r role--one they had enacted f o r many y e a r s — t h e y c o u l d perform i t w e l l . I t enabled them to p r o t e c t t h e i r partners i n a concrete f a s h i o n . However, the two sub j e c t s r e c e i v e d the same d i e t information as the r e s t o f the group, and t h e i r husbands' d i e t s were not d i f f e r e n t from those o f the other p a t i e n t s . What c o u l d e x p l a i n t h e i r preoccupation and anxiety over d i e t ? In re-examining the data, the rese a r c h e r found these subjects v e r b a l i z e d a 107 l o t o f g u i l t . They p e r c e i v e d themselves, i n p a r t , as r e s p o n s i b l e f o r the partner's h e a r t a t t a c k . They had cooked " a l l the wrong t h i n g s " . Thus, these f e e l i n g s o f g u i l t might have played a s i g n i f i c a n t r o l e i n c o n t r i b u t i n g to t h e i r behaviour. The Elements o f Loss In phase one the l o s s event was viewed by the su b j e c t s with a f u t u r e and a n t i c i p a t o r y p e r s p e c t i v e . The time frame changed i n the e a r l y discharge p e r i o d to focus more on the present. The event now had a l i f e o f three weeks. It was no longer seen as sudden or u n p r e d i c t -a b l e . As one s u b j e c t r e p o r t e d : "Well, i t ' s (the heart attack) now three weeks o l d you know". The s u b j e c t s found t h a t t h e i r a n t i c i p a t e d f e a r s of. recurrence and poor partner adjustment had not m a t e r i a l i z e d . T h e i r p a r t n e r s were c o n v a l e s c i n g well and the present and f u t u r e looked o p t i m i s t i c . The heart attack now seemed f a i r l y p r e d i c t a b l e and w i t h i n c o n t r o l . I n i t i a l l y the i l l n e s s or threatened l o s s o f t h e i r partners had a concrete observable q u a l i t y . The s u b j e c t s began to view the l o s s w i t h i n a wider context; the i n i t i a l l o s s expanded to i n c l u d e secondary l o s s e s , many of which were a b s t r a c t i n nature. Subjects i d e n t i f i e d l o s s they had experienced i n terms of t h e i r r o l e s , r e l a t i o n s h i p s and self-esteem. The i n i t i a l threatened l o s s o f t h e i r p a r t n e r s ' l i v e s had not occurred, now other l o s s was being r e a l i z e d by the s u b j e c t s . 108 The Meaning of Loss The s u b j e c t s ' perceptions of l o s s broadened i n t h i s phase and now encompassed three areas; the p a t i e n t , the couple and the spouse. Through the s u b j e c t s ' eyes, t h i s phase can best be d e s c r i b e d as the c l o s u r e o f the c r i t i c a l time o f t h e i r p a r t n e r s ' i l l n e s s . The s u b j e c t s c o u l d now allow themselves time to "take a deep breath" and say "we have made i t " . In the same b r e a t h , the s u b j e c t s began to focus more i n t r o s p e c t i v e l y on t h e i r l o s s . Some women g r i e v e d f o r t h e i r own time and independence. The added r o l e s and r e s p o n s i b i l i t i e s , i n c l u d i n g a l a c k of r e c o g n i t i o n f o r t h e i r e f f o r t s , caused them great concern. T h e i r own l o s s was only beginning to be f e l t . The euphoric s p i r i t tended to counter or de-emphasize t h e i r concerns and they admonished themselves f o r being so s e l f i s h when they f e l t they should have been g r a t e f u l f o r t h e i r partners' h e a l t h . It was a d i f f i c u l t time f o r the s u b j e c t s , a time o f t r a n s i t i o n . The meaning o f l o s s as experienced by the s u b j e c t s i n t h i s e a r l y post discharge p e r i o d i s i l l u s t r a t e d i n Figure 1. The meaning of l o s s cannot be comprehended by t a k i n g a narrow p e r s p e c t i v e and f o c u s i n g on o n l y one aspect o r l e v e l o f a l o s s . The meaning of l o s s as experienced by the s u b j e c t s now encompassed three d i f f e r e n t l e v e l s . There i s an e v i d e n t need to view l o s s i n t h i s t o t a l i t y i n order to c o n c e p t u a l i z e the phenomenon of l o s s . Phase III Impact of the Event (Group A) Reactions to Loss Many of the s u b j e c t s ' thoughts were e g o c e n t r i c i n f o c u s . These 109 1. P a t i e n t Focus C l o s u r e of a n t i c i p a t e d l o s s ... "He i s a l i v e and welI and hasn't had another heart a t t a c k " . ... "I'm watching him and l o o k i n g a f t e r him". 2. Couple Focus Loss as i t a f f e c t s us ... "We have made i t ... we're working t o g e t h e r " . ... "Yeah l o t s of changes f o r us". 3. P e r s o n a l - s e l f Focus Beginning of actual l o s s "I miss my own time" ... "I do a l l the work and get no thanks". ... "I have my own l i f e t oo!". Figure 1. The Meaning o f Loss 110 women viewed the l o s s from t h e i r own p e r s p e c t i v e . They continued to speak of t h e i r p r o t e c t o r r o l e s and e x t r a r e s p o n s i b i l i t i e s but a l s o began to v e r b a l i z e how many o f t h e i r thoughts were focused on themselves. The time had come f o r them to take a hard look at t h e i r l i v e s and t h e i r f u t u r e . The s u b j e c t s ' f e e l i n g s were heightened i n t h i s phase, s i m i l a r to the i n t e n s i t y d e s c r i b e d i n Phase I. In c o n t r a s t to the shock, numb-ness, a n x i e t y and t e n s i o n r e p o r t e d i n i t i a l l y the s u b j e c t s d e s c r i b e d a range of emotions: anger, b i t t e r n e s s , resentment, g u i l t and s e l f -reproach with depression the most commonly reported f e e l i n g . The m u l t i p l i c i t y of f e e l i n g s r e p o r t e d by the s u b j e c t s i n t h i s study i s well corroborated i n the research f i n d i n g s (Adsett and Bruhn, 1968; Skelton and Dominian, 1973; Harding and M o r e f i e l d , 1976; L a r t e r , 1976; Mayou, Foster and Williamson, 1978). In t h i s phase ambivalence surfaced again but i t was now more in t e n s e . The s u b j e c t s were angry and r e s e n t f u l y e t they admonished themselves f o r being so s e l f i s h and unkind. They could not come to terms with what they f e l t and what "others" expected them to f e e l . Anger and resentment were turned inward with r e s u l t a n t g u i l t and depression. The ambivalence experienced by the s u b j e c t s was s i m i l a r to the secondary emotional r e a c t i o n s i d e n t i f i e d by Peretz (1970). He d e s c r i b e d these ambivalent r e a c t i o n s as c o n f l i c t between f e e l i n g s t h a t an i n d i v i d u a l a n t i c i p a t e d and accepted with those he d i d not expect and c o u l d not accept. The subjects had d i f f i c u l t y d e a l i n g with t h e i r resentment and anger. They resented the e x t r a workload and demands placed on t h e i r I l l time y e t they f e l t g u i l t y i f they expressed these f e e l i n g s . Even i f they f e l t abused they would not speak out f o r f e a r o f u p s e t t i n g t h e i r partners and perhaps p r e c i p i t a t i n g another heart a t t a c k . Many wives f e l t i t wasn't " r i g h t " to complain, a f t e r a l l , weren't they the healthy ones? As one woman s t a t e d : " I t ' s catch-22, you are damned i f you do, and damned i f you don't." Poor communication, and l i t t l e evidence of sharing on a f e e l i n g l e v e l seemed to e x i s t between the p a t i e n t s and t h e i r spouses. This f i n d i n g was a l s o reported in recent s t u d i e s (Adsett and Bruhn, 1968; Harding and M o r e f i e l d , 1976; L a r t e r , 1976). The s u b j e c t s had an obvious need to v e n t i l a t e t h e i r f e e l i n g s . Although t h i s need was reported i n the r e c e n t r e s e a r c h (Hampe, 1975; Dracup and Breu, 1978; Moulter and Captain, 1979), i t was not always met by h e a l t h p r o f e s -s i o n a l s . At a time when the s u b j e c t s were most d i s t r a u g h t , they f e l t they had no one to turn to other than a few c l o s e f a m i l y or f r i e n d s . The s u b j e c t s p e r c e i v e d t h a t "no one r e a l l y understood". Due to the l i m i t a t i o n s of the study i t was d i f f i c u l t to c o n j e c t u r e why the s u b j e c t s i n such obvious need d i d not speak or reveal t h e i r f e e l i n g s . There could be many reasons why the spouses grew apart from t h e i r p a r t n e r s . Several r e p o r t e d not speaking out f o r f e a r of p r e c i p i -t a t i n g a heart a t t a c k ; others d e s i r e d to " p r o t e c t " t h e i r p a r t n e r s . Some sub j e c t s f e l t t h e i r f e e l i n g s were s o c i a l l y unacceptable and i t j u s t wasn't r i g h t to d i s c u s s them. Another i n t e r p r e t a t i o n was t h a t the p r i o r communication p a t t e r n s o f the couples were non.-sharing i n nature. The Elements o f Loss The nature of the l o s s experienced by the spouses continued to broaden i n t h i s phase as the i n i t i a l l o s s p r e c i p i t a t e d many secondary l o s s e s (e.g. l o s s of own time, independence, r o u t i n e s ) and threatened f u t u r e a d d i t i o n a l l o s s e s ( f e a r of p a r t n e r s ' d r i v i n g and r e t u r n i n g to work). Many of the s u b j e c t s r e a c t i o n s up to t h i s p o i n t were i n response to the threatened l o s s o f t h e i r p a r t n e r . This l o s s can be c h a r a c t e r -i z e d as o v e r t . It was concrete and e a s i l y r e c o g n i z a b l e , and as such, was more r e a d i l y understood and accepted by the s u b j e c t s e x p e r i e n c i n g the l o s s or to those o u t s i d e viewing the l o s s . The l o s s d e s c r i b e d by the s u b j e c t s i n phase two and more i n t h r e e , was a d i f f e r e n t c h a r a c t e r . I t spoke more to the l o s s of p e r s o n a l l y s i g n i f i c a n t needs and v a l u e s . This l o s s was more c o v e r t i n nature and was, t h e r e f o r e , not as e a s i l y i d e n t i f i e d or understood. Regardless of the c o v e r t nature of the l o s s , the g r i e f r e a c t i o n s experienced by the spouses a t t h i s time were very heightened, s i m i l a r to the i n t e n s i t y of f e e l i n g s d e s c r i b e d i n phase one. The Meaning of Loss T h i s phase was s i m i l a r to the acknowledgement stage d e s c r i b e d i n the l i t e r a t u r e (Bowlby, 1961; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972). G l i c k , Weiss and Parkes (1974) described t h i s time as the g r i e v i n g phase. The i n d i v i d u a l was confronted with the d a i l y r e a l i t i e s of l o s s and the f u l l impact of the l o s s was now t r u l y f e l t . At t h i s time the i n i t i a l l o s s expanded to i n c l u d e numerous secondary l o s s e s . 113 While profound sadness and depression are dominant during t h i s phase, the i n d i v i d u a l may experience numerous f e e l i n g s and v a c i l l a t e between these s t a t e s . There are many v a r i a b l e s t h a t c o u l d have i n f l u e n c e d the spouses' perceptions a t t h i s time. Robinson (1974) s t a t e d t h a t past e x p e r i e n c e s , successes, f a i l u r e s , r e l a t i o n s h i p s and standards can mold a person's p e r c e p t i o n s and r e a c t i o n s t o t h e i r l o s s . In t h i s group a l l but one of the s u b j e c t s were non-working women. The meaning of the l o s s v a r i e d s i g n i f i c a n t l y f o r these women compared to the working women. The non-working women seemed p s y c h o l o g i c a l l y more dependent on t h e i r p a r t n e r s . Many o f t h e i r v a l u e s , b e l i e f s , and sense o f worth were apparently bound i n e x t r i c a b l y to t h e i r husbands. One co u l d i n f e r from these f i n d i n g s t h a t the degree t o which one's s e l f concept was t i e d o r mi r r o r e d to a loved one would have an a f f e c t on the l o s s experienced. An i n t e r e s t i n g p o i n t i s t h a t the one working woman i n the group had been coping well with her husband's i l l n e s s u n t i l the l a s t i n t e r -view. She d e s c r i b e d h e r s e l f a t t h a t time, as having a "setback", because of a very r e c e n t l o s s o f a c l o s e f a m i l y member. A f a c t o r t h a t can i n f l u e n c e an i n d i v i d u a l ' s c a p a c i t y t o adapt to a l o s s i s a concur-r e n t l o s s ( P e r e t z , 1970; Schoenberg, 1970). T h i s f a c t o r , then, could have i n f l u e n c e d t h i s s u b j e c t ' s r e a c t i o n s a t t h i s time. The s u b j e c t s g r i e v e d f o r t h e i r sense o f s e l f , t h e i r i n t e g r i t y , worth and the normalcy o f t h e i r l i v e s . Depression was most commonly repor t e d . Depression was f e l t most i n t e n s e l y by the two youngest s u b j e c t s . Both women had ad o l e s c e n t c h i l d r e n a t home. T h e i r r e s p o n s i -b i l i t i e s were e n d l e s s : home, garden, p e t s , a d o l e s c e n t s , v i s i t o r s and 114 s i c k husbands. As one woman e x p l a i n e d , "you have to be the p i v o t p o i n t f o r everyone, so the more people i n v o l v e d , the more d i f f i c u l t i t becomes". When one c o n s i d e r s the q u a l i t y and q u a n t i t y o f change t h a t the younger su b j e c t s experienced, i t i s not d i f f i c u l t to understand the s e v e r i t y o f t h e i r g r i e f r e a c t i o n s . Goldston (1962) confirmed t h i s view, and st a t e d t h a t the gre a t e r the changes and s h i f t s a f a m i l y was fo r c e d to make as a r e s u l t o f a heart a t t a c k , the g r e a t e r becomes the s t r e s s s i t u a t i o n w i t h i n the f a m i l y . The r e l a t i o n s h i p between age and s e v e r i t y o f g r i e f r e a c t i o n s found i n t h i s study was c o r r o b o r a t e d by Skelton e t a l . (1973). These re s e a r c h e r s found t h a t the severe g r i e f r e a c t i o n s were more common among younger w i v e s — l e s s than 45 ye a r s of age--than among o l d e r wives. One cannot examine the spouse i n i s o l a t i o n . The r e a c t i o n s o f the p a t i e n t and the other f a m i l y members are s i g n i f i c a n t to c o n s i d e r . How the p a t i e n t p e r c e i v e d the l o s s would indeed a f f e c t the s u b j e c t . Because o f the commonalities i n the l o s s experience one c o u l d expect t h a t the p a t i e n t experienced s i m i l a r thoughts and f e e l i n g s . If the phenomenon of l o s s i s viewed as a process, however, the couples may have been at d i f f e r e n t phases at d i f f e r e n t times. The meaning of l o s s f o r each person guided t h e i r own l o s s journey. It was p o s s i b l e t h a t the l o s s experienced by both p a t i e n t and spouse was so intense and eg o c e n t r i c t h a t they were unable t o look o r f e e l beyond themselves. The data i n t h i s study corroborated the increased d i s t a n c e between the couples i n terms o f communication t h a t may have l i m i t e d s h a r i n g o f t h e i r thoughts and f e e l i n g s . 115 PHASE III Impact o f the Event (Group B) Reactions to Loss The r e a c t i o n s to l o s s of the remaining s u b j e c t s , two women and one man, were d i f f e r e n t and have been d e s c r i b e d s e p a r a t e l y as Group B. These s u b j e c t s i n c o n t r a s t to Group A were i n good s p i r i t s , content with t h e i r p a r t n e r s and themselves. T h i s contentment touched on a l l p a r t s of t h e i r l i v e s . They were pleased with t h e i r p a r t n e r s ' a d j u s t -ment and seemed g r a t e f u l f o r what they had accomplished and how they managed together as a team. The s u b j e c t s looked forward to the f u t u r e with optimism. Many of the r e a c t i o n s d e s c r i b e d by the s u b j e c t s i n t h i s phase are s i m i l a r to the acceptance and adaptation phase d e s c r i b e d i n the l i t e r a -t u r e when an i n d i v i d u a l copes s u c c e s s f u l l y with l o s s (Bowlby, 1961; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972; Shontz, 1975). This phase i s c h a r a c t e r i z e d by a gradual move forward to organize one's l i f e and i n t e g r a t e the r e a l i t i e s o f l o s s . Often the i n d i v i d u a l experiences a decrease i n anxiety as hope takes the place of hopelessness. Instead of f o c u s i n g on what has been l o s t , a t t e n t i o n i s r e d i r e c t e d to the present and f u t u r e . The s u b j e c t s i n t h i s group seemed more accepting o f t h e i r l o s s . They viewed the b r i g h t e r more p o s i t i v e s i d e o f the changes t h a t had d i s r u p t e d t h e i r l i v e s . T h e i r comments were honest and r e a l i s t i c . L i f e had been very d i f f i c u l t f o r them and they were aware of some hard and u n c e r t a i n times ahead. Yet the o v e r a l l f e e l i n g was one o f "we have made i t , as a couple", and i t seemed these p o s i t i v e gains r e i n f o r c e d t h e i r adaptive behaviour. The l i f e - t h r e a t e n i n g nature o f the i l l n e s s 116 a l s o prompted a r e v a l u a t i o n o f the values and goals i n t h e i r r e l a t i o n s h i p . There was a r e a l i z a t i o n f o r these couples t h a t t h e i r time together was not u n l i m i t e d . Although i t may appear f o r t u i t o u s , t h i s group was aware o f the need f o r hard work. They a l s o knew t h e i r l i v e s would never r e t u r n to what they had before the heart a t t a c k . This p o i n t was emphasized by Carlson (1978). She s t a t e d t h a t acceptance and adaptation do not imply a 100 percent r e t u r n to the p r e - l o s s s t a t e . A person may never completely get over a major l o s s . Healthy adaptive behaviour may be, i n f a c t , p i c k i n g up the pieces and t r y i n g to make the best o f the s i t u a t i o n . The Elements of Loss O v e r t l y the l o s s had s i m i l a r c h a r a c t e r i s t i c s to those d e s c r i b e d by the subjects i n Group A. It was an event t h a t had s t a r t e d as a b i o l o g -i c a l l o s s and grown to i n c l u d e psychosocial l o s s f o r both the p a t i e n t and spouse. In c o n t r a s t with Group A s u b j e c t s , the time frame of l o s s was d i f f e r e n t f o r Group B s u b j e c t s . Group A s u b j e c t s focused very much on the present, overwhelmed with the l o s s of normalcy i n t h e i r l i v e s and they feared f u t u r e a d d i t i o n a l l o s s . For the Group B s u b j e c t s the l o s s at t h i s time was seen more i n r e t r o s p e c t . Time had pushed the l o s s away. It was seen as a past event, an event t h a t had changed t h e i r l i v e s f o r the p o s i t i v e . 117 The Meaning of Loss These s u b j e c t s d i d not appear to turn inward and view the l o s s from an e g o c e n t r i c f o c u s , and they d i d not seem to g r i e v e f o r l o s s o f s e l f . Many o f t h e i r comments r e f l e c t an "us" o r couple f o c u s . There are several f a c t o r s to c o n s i d e r t h a t c o u l d shed some l i g h t on why these i n d i v i d u a l s r e a c t e d so d i f f e r e n t l y to t h e i r l o s s . In c o n t r a s t to the dependence e v i d e n t i n the s u b j e c t s ' r e l a t i o n s h i p s i n Group A, the r e l a t i o n s h i p s o f Group B c o u l d be d e s c r i b e d as interdependent. The l a t t e r leaned on each o t h e r : the balance between the dependence and independence was comfortable. They shared t h e i r f e a r s and concerns and worked out the changes i n r o l e s and r e s p o n s i b i l i t i e s . T h e i r r o u t i n e s were d i s r u p t e d but they d i d not p e r c e i v e the changes as overwhelming. From an o b j e c t i v e viewpoint, t h e i r l i v e s were not d i s r u p t e d as g r e a t l y as those of some o f the Group A s u b j e c t s . Another f a c t o r to c o n s i d e r was t h a t these l a t t e r i n d i v i d u a l s were employed and were not home during the day to worry over t h e i r p a r t n e r s . Apparently they d i d not see themselves as dependent on t h e i r partners because v a l i d a t i o n o f t h e i r v a l u e s , worth and a b i l i t i e s was a l s o gained from t h e i r work. L a r t e r (1976) found that the degree of m a r i t a l accord was an important v a r i a b l e i n examining the impact o f i l l n e s s on wives o f myocardial i n f a r c t i o n p a t i e n t s . Although i t i s d i f f i c u l t to i n f e r from the present data, i t seems Group B couples had open and s h a r i n g communication p a t t e r n s . They f e l t t h a t the heart attack had acted as a c a t a l y s t and had improved t h e i r communication p a t t e r n s g r e a t l y . 118 Previous l i f e experiences can a s s i s t an i n d i v i d u a l i n d e a l i n g with a l o s s , by h e l p i n g to develop a r e p e r t o i r e of coping mechanisms which can be used i n f u t u r e adjustments. The male s u b j e c t i n t h i s group c e r t a i n l y agreed t h i s was the case with h i s l o s s . He f e l t he had coped well with the event because o f a previous "experience". He had been i n j u r e d during the war; h i s long and r e c u r r i n g i l l n e s s had caused him to be bed-bound f o r months a t a time. He f e l t both he and h i s wife had experienced many changes i n t h e i r l i v e s , and had always managed to come through i n the end. He approached t h i s r e c e n t l o s s with a p o s i t i v e a i r and some workable ways of coping. Summary The l o s s experienced by the spouses of myocardial i n f a r c t i o n p a t i e n t s was d e s c r i b e d i n t h i s chapter w i t h i n a phenomenological p e r s p e c t i v e . In each phase the nature of the l o s s experience was unique. The l o s s event, the per c e p t i o n s o f l o s s and the r e a c t i o n s to l o s s d e f i n e d the process i n which the s u b j e c t s d e a l t with l o s s . The i n i t i a l l o s s event expanded i n depth and breadth to impact s i g n i f i -c a n t l y on the spouse. The heart attack could now be viewed w i t h i n the t o t a l i t y of the phenomenon o f l o s s . 119 CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Th i s study was designed to provide i n s i g h t i n t o understanding the event o f a myocardial i n f a r c t i o n w i t h i n the c o n t e x t o f the phenomenon of l o s s . An overview o f the study i s presented i n t h i s chapter followed by the a r t i c u l a t i o n o f a framework, based on the l i t e r a t u r e and the f i n d i n g s , which r e l a t e s the concept o f l o s s to the experience of spouses o f myocardial i n f a r c t i o n p a t i e n t s . In a d d i t i o n , i m p l i c a -t i o n s and recommendations f o r nursing education, nursing p r a c t i c e and f u r t h e r research are d e l i n e a t e d . Overview of the Study T h i s e x p l o r a t o r y study examined the phenomenon of l o s s as expressed by the spouses o f myocardial i n f a r c t i o n p a t i e n t s . The pur-pose of the study was to d e s c r i b e the thoughts, f e e l i n g s , a c t i o n s and observable behaviours o f the spouses from the i n i t i a l impact o f i l l n e s s to s i x weeks post myocardial i n f a r c t i o n and to develop a framework, based on the l i t e r a t u r e , which r e l a t e d the concept o f l o s s to the experience o f spouses o f M.I. p a t i e n t s . The study was conducted with a convenience sample of 12 spouses, ten women and two men, whose partners had experienced t h e i r f i r s t myocardial i n f a r c t i o n . Using a semi-structured i n t e r v i e w guide with open-ended que s t i o n s , the i n v e s t i g a t o r interviewed each s u b j e c t , four times, from day three to day 52 o f the partner's h e a r t a t t a c k . This p e r i o d covered the time o f the i n i t i a l impact o f i l l n e s s to 120 approximately s i x weeks post myocardial i n f a r c t i o n . The f i r s t i n t e r -view was scheduled w i t h i n 96 hours o f the heart a t t a c k and the second i n t e r v i e w f o l l o w e d d u r i n g week two o f the p a t i e n t ' s h o s p i t a l i z a t i o n . The t h i r d and f o u r t h i n t e r v i e w s were scheduled f o r one and three weeks post discharge o f the p a t i e n t . The i n t e r v i e w s ranged from 12 to 75 minutes, with an average time of 35 minutes. Each i n t e r v i e w covered th r e e content areas: the thoughts, f e e l i n g s , a c t i o n s o f the spouses. Broad open-ended questions were used to e l i c i t data on the spouses' thoughts, f e e l i n g s and a c t i o n s . During the i n t e r v i e w the i n v e s t i g a t o r observed the verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus of c o n v e r s a t i o n ) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance) behaviours o f the spouses. An e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. Data coding and a n a l y s i s were approached using the constant comparative method, an i n d u c t i v e method o f d i s c o v e r i n g grounded theory developed by Glaser and Strauss (1967). The f i n d i n g s rev e a l e d t h a t the spouses experienced behaviours i n response to l o s s t h a t were common and formed a p a t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : Phase 1 the event and i n i t i a l spousal response; Phase 2 r e a c t i o n to the event; Phase 3 impact of the event. The phases were d e s c r i b e d f u r t h e r i n l i g h t o f the c o n s t r u c t s formu-l a t e d from the l i t e r a t u r e review: (1) the r e a c t i o n s to l o s s ; (2) the elements o f l o s s ; (3) the meaning o f l o s s . Phase I covered the h o s p i t a l i z a t i o n p e r i o d o f the p a t i e n t . T h i s phase was c h a r a c t e r i z e d by heightened thought processes. Many of the spouses' thoughts were p a t i e n t - o r i e n t e d and focused on the a n t i c i p a t e d 121 l o s s o f t h e i r p a r t n e r through c o m p l i c a t i o n s o r occurrence o f another heart a t t a c k . The s u b j e c t s perceived t h i s time as c r i t i c a l and uncer-t a i n while the r e a l i t y o f the l o s s was beginning to penetrate i n t o t h e i r awareness. T h e i r r e a c t i o n s d e s c r i b e d the process o f understand-ing and a t t a c h i n g meaning to the l o s s . The second phase covered the e a r l y discharge p e r i o d o f the p a t i e n t . This phase was c h a r a c t e r i z e d by decreased t h i n k i n g and i n c r e a s e d a c t i o n s r e l a t e d to p r o t e c t o r or c o n t r o l l e r a c t i v i t i e s . The present and f u t u r e were viewed with more p r e d i c t a b i l i t y and optimism. The s u b j e c t s began to view the l o s s w i t h i n a wider c o n t e x t as t h e i r p e r c e p t i o n s o f l o s s encompassed three areas; the p a t i e n t , the couple and the spouse. Since the threatened l o s s o f t h e i r p a r t n e r ' s l i v e s had not o c c u r r e d , o t h e r l o s s was now being r e a l i z e d by the s u b j e c t s i n terms o f r o l e s , r e l a t i o n s h i p s and self-esteem. Phase I I I d e s c r i b e d the impact o f the event f o r the spouses. Two d i s t i n c t p a t t e r n s o f behaviours were i d e n t i f i e d i n t h i s phase. Group A f i n d i n g s comprised one p a t t e r n o f r e a c t i o n s f o r seven o f the s u b j e c t s . D i f f e r e n t r e a c t i o n s were d e s c r i b e d by the remaining three s u b j e c t s i n the Group B f i n d i n g s . The nature o f the l o s s f o r the Group A s u b j e c t s continued to broaden to i n c l u d e many secondary l o s s e s f o r the spouses (e.g. l o s s o f time, independence, normalcy o f r o u t i n e s ) and the threatened f u t u r e a d d i t i o n a l l o s s e s ( f e a r o f p a r t n e r s d r i v i n g and r e t u r n i n g to work). The spouses viewed the l o s s from an e g o c e n t r i c f o c u s . Ambivalent f e e l i n g s were heightened i n t h i s phase. The s u b j e c t s f e l t angry and r e s e n t f u l over t h e i r personal l o s s experiences y e t expressed g u i l t and depression over t h e i r " s e l f i s h , unkind" 122 thoughts. In c o n t r a s t , the Group B s u b j e c t s d i d not seem to view the l o s s from an e g o c e n t r i c f o c u s . They were i n good s p i r i t s , content with t h e i r p a r t n e r s and themselves. Many of t h e i r r e a c t i o n s r e f l e c t e d an "us" or couple f o c u s . The l o s s was viewed as a past event, an event t h a t had changed t h e i r l i v e s f o r the p o s i t i v e . They looked forward t o the f u t u r e with optimism. A Loss Framework The f i n d i n g s i n t h i s study s t r o n g l y support the use of a l o s s framework f o r a s s e s s i n g the r e a c t i o n s o f spouses who are threatened with the death o f t h e i r p a r t n e r . From the l i t e r a t u r e and the research f i n d i n g s of t h i s study s e v e r a l c o n s t r u c t s were i d e n t i f i e d t h a t r e p r e s e n t e d the major s t r u c -t u r e s of a l o s s framework f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . The process of l o s s f o r the spouses began with the i n i t i a l l o s s e v e n t — t h e h e a r t a t t a c k . The i l l n e s s was a stimulus which p r e c i p -i t a t e d a s e r i e s o f events t h a t became p a r t o f the phenomenon of l o s s . From the i n i t i a l stimulus the spouses moved on to p e r c e i v e and to a t t a c h meaning to the l o s s . The elements o f l o s s d e s c r i b e d i n t h i s study shaped the nature of the l o s s e x p e r i e n c e . In a d d i t i o n , many i n d i v i d u a l v a r i a b l e s can be c o n s i d e r e d as i n f l u e n c i n g the s u b j e c t i v e meaning of l o s s f o r each spouse. Loss was a l s o d e s c r i b e d i n terms of the the behavioural responses t h a t f ollowed the p e r c e p t i o n o f the l o s s event. The thoughts, f e e l i n g s and a c t i o n s d e s c r i b e d by the spouses were the three main c a t e g o r i e s of behaviour corresponding to the p s y c h o l o g i c a l , emotional and 123 p h y s i o l o g i c a l d i s t u r b a n c e s found i n the l i t e r a t u r e . Often the spouses e x h i b i t e d a complex combination of a l l three c a t e g o r i e s o f r e a c t i o n s to l o s s . Another important c o n s t r u c t d e s c r i b e d i n the l i t e r a t u r e and i n t h i s study was the concept o f phases o f l o s s . In t h i s study, the spouses' behaviours were s i m i l a r to one another and formed a p a t t e r n through time. The p a t t e r n o f behaviours comprised t h r e e d i s t i n c t phases. Although the " l a b e l l i n g " of the phases i n t h i s study d i f f e r e d from t h a t o f the l i t e r a t u r e i t was evident t h a t the process or sequence of a d aptation was apparently the same. The three phases d e s c r i b e d the process i n which the spouses d e a l t with l o s s . The l o s s l i t e r a t u r e was h e a v i l y laden with the word "process". Authors have not d e f i n e d o r d e s c r i b e d t h i s process i n i d e n t i c a l terms. For a n a l y t i c a l purposes, w r i t e r s have taken apart the concept o f l o s s and given i t v a r i o u s l a b e l s , stages o r phases but they have neglected to put i t back together again. This "Humpty Dumpty" approach r e s u l t s i n a f r a c t u r e d concept o f l o s s , frozen i n time, and n e g l e c t f u l o f the actual experience of l o s s . Loss i s not a s e r i e s of a r r i v a l s but r a t h e r a journey. It i s a process t h a t i n d i v i d u a l s become p a r t of i n an attempt to r e s t r u c t u r e l i f e a f t e r a major d i s r u p t i o n . Process i m p l i e s c o n t i n u i t y or movement. It i s dynamic, purposeful and has an element of time. Based on the f i n d i n g s from t h i s study a framework of l o s s evolved based on a phenomenological p e r s p e c t i v e . Loss was seen as a process experienced from the i n i t i a l event or stimulus to the s u c c e s s f u l or unsuccessful r e s o l u t i o n of the l o s s . On one l e v e l l o s s was seen as the 124 i n i t i a l event t h a t p r e c i p i t a t e s the i n d i v i d u a l going through the p e r c e i v i n g and a t t a c h i n g o f meaning to l o s s . On another l e v e l , l o s s was the sequence o f g r i e f r e a c t i o n s experienced i n response to the l o s s event. These a c t i v i t i e s were viewed as interwoven or o v e r l a p p i n g , l i k e a matrix. The v e r t i c a l threads d e s c r i b e d the r e a c t i o n s i n response t o l o s s while the h o r i z o n t a l threads represented the meaning of l o s s f o r the spouse. A process o f l o s s paradigm was i n c l u d e d to i n d i c a t e the framework of l o s s f o r spouses o f myocardial i n f a r c t i o n p a t i e n t s (see Figure 2). Imp!ications Nursing P r a c t i c e Nurses are c o n t i n u a l l y i n t e r a c t i n g with p a t i e n t s and spouses who have experienced major l o s s e s . The nurse can perform a c r i t i c a l r o l e i n preventing or l e s s e n i n g the impact of l o s s . The r e s u l t s of t h i s study p o i n t s t r o n g l y to the importance o f a s s e s s i n g the actual and p o t e n t i a l l o s s e s o f the spouses i n understanding the i n d i v i d u a l ' s perception of the l o s s . Armed with t h i s knowledge, nurses are b e t t e r able to provide the necessary guidance and support to the spouses with subsequent b e n e f i c i a l e f f e c t on the p a t i e n t s . Although t h i s study d i d not focus on r e l a t i o n s h i p s between v a r i -a b l e s , many f a c t o r s emerged t h a t must be c o n s i d e r e d i n understanding the variance i n the spouses' r e a c t i o n s to l o s s . Not only must the nurses be knowledgeable about l o s s but an understanding of the f a c t o r s i n f l u e n c i n g the p e r c e p t i o n of l o s s and i t s s e v e r i t y i s imperative i f they are to perform t h e i r r o l e e f f e c t i v e l y . 125 I n d i v i d u a l i n f l u e n c i n g f a c t o r s (e.g. age, f a m i l y , I work s t a t u s , past l o s s experiences) Heart Attack a l o s s event-(stimulus) 7 -£>perception a t t a c h meaning to l o s s A Reactions To Loss Phases ->(1) Thoughts (2) F e e l i n g s (3) Actions elements of l o s s (e.g. p a s t , p r e s e n t , f u t u r e , a c t u a l , a n t i c i p a t e d , c o n c r e t e a b s t r a c t ) r e s o l v e d \ ^ l o s s u n resolved l o s s THE PROCESS OF LOSS < : > Figure 2. A l o s s framework f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . 126 This study suggested t h a t spouses may experience a n t i c i p a t o r y g r i e f soon a f t e r the i n i t i a l l o s s event. The r e a c t i o n s as d e s c r i b e d i n phase one provide i n s i g h t i n t o the v a r i o u s ways i n d i v i d u a l s experienced and d e s c r i b e d t h i s a n t i c i p a t o r y g r i e f r e a c t i o n . The nurse who can recognize a n t i c i p a t o r y g r i e f can b e t t e r assess the spouses' r e a c t i o n s and i n t e r v e n e to help these i n d i v i d u a l s cope with these f e e l i n g s . It has been suggested t h a t t a l k i n g about f e e l i n g s t h a t deal with such a c r i t i c a l area as a l i f e t h r e a t e n i n g i l l n e s s i s d i f f i c u l t and i n t r u s i v e f o r the i n d i v i d u a l e x p e r i e n c i n g the l o s s or t h r e a t o f l o s s . The r e s u l t s o f t h i s study do not support t h i s suggestion. A l l of the s u b j e c t s i n t h i s sample were w i l l i n g respondents, eager to t a l k about t h e i r concerns and touched t h a t someone cared enough to ask. This f i n d i n g had important i m p l i c a t i o n s f o r nurses because i t i n d i c a t e d t h a t spouses were approachable very e a r l y i n t h e i r l o s s experience and they need comfort and support as well as i n f o r m a t i o n . Nurses must be a v a i l a b l e to p a t i e n t s and t h e i r f a m i l i e s and must be able and w i l l i n g to l i s t e n i f the need a r i s e s . Spouses must be encouraged to d i s c u s s t h e i r concerns s i n c e they need v a l i d a t i o n t h a t t h e i r responses are normal r e a c t i o n s to t h e i r l o s s . The phases i d e n t i f i e d i n t h i s study d e s c r i b e d a common p a t t e r n o f r e a c t i o n s t h a t spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . These phases can serve as o r g a n i z i n g c e n t e r s f o r approaching problems and working towards need s a t i s f a c t i o n f o r spouses. The l o s s framework presented i n t h i s study o f f e r e d d i r e c t i o n f o r nursing p r a c t i c e . The r e a c t i o n s experienced by the spouses must be examined over a c o n s i d e r a b l e length of time. It i s not enough to 127 i n t e r v e n e once i n the h o s p i t a l o r make one home v i s i t . Nurses must meet r e g u l a r l y with p a t i e n t s and spouses throughout the course o f recovery. The f a m i l y members should be encouraged to v e n t i l a t e t h e i r thoughts and f e e l i n g s while the nurse must be a v a i l a b l e to l i s t e n . The study r e v e a l e d a p a t t e r n o f divergence i n the s h a r i n g o f thoughts and f e e l i n g s between some p a t i e n t s and t h e i r spouses. The nurse i s i n a p o s i t i o n to f a c i l i t a t e i n t e r a c t i o n between the c o u p l e . A c t i n g as a f a c i l i t a t o r the nurse can a s s i s t both the p a t i e n t ' s and the spouse's adjustment to t h e i r l o s s with r e s u l t a n t improved h e a l t h f o r a l l f a m i l y members. Nursing Education A l l l e v e l s of n u r s i n g education should i n c l u d e the a p p r o p r i a t e knowledge and s k i l l s r e l a t e d to a f a m i l y focus i n h e a l t h c a r e . Nursing education must prepare the nurse to assess the spouses' r e a c t i o n s i n response to l o s s and to help p a t i e n t s and spouses cope with t h e i r r e a c t i o n s . A l l nursing programs should i n c l u d e the concept of l o s s i n t h e i r c ore c u r r i c u l a . Included a l s o should be content r e l a t e d to f a m i l y dynamics, c r i s i s and r o l e t h e o r i e s , a d a p t a t i o n , change theory and i n t e r p e r s o n a l and communication theory. This knowledge and s k i l l w i l l provide the students with a general guide to a s s e s s i n g l o s s i n i n d i v i d u a l s , i n f a m i l i e s and i n t h e i r own experiences. As well as r e c o g n i z i n g the commonalities of l o s s , the nurse must be taught to understand and accept the i n d i v i d u a l i t y of any l o s s experience and plan nursing i n t e r v e n t i o n s a c c o r d i n g l y . 128 Nursing Research T h i s study has provided f u r t h e r knowledge of the common pat t e r n s of r e a c t i o n s t h a t spouses experience i n response to l o s s . To what extent are these phases or common pa t t e r n s of r e a c t i o n s present i n the population of spouses o f myocardial i n f a r c t i o n p a t i e n t s ? It i s necessary f o r these r e a c t i o n s to be examined to a g r e a t e r extent with a random s e l e c t i o n of spouses from a v a r i e t y o f s e t t i n g s . Further study i s a l s o r e q u i r e d to i d e n t i f y the commonalities and d i f f e r e n c e s between the sexes. This study was conducted during a s i x week time p e r i o d , f o l l o w i n g the p a t i e n t ' s d i a g n o s i s . A l o n g i t u d i n a l study examining the r e a c t i o n s experienced by p a t i e n t s and spouses would provide g r e a t e r i n s i g h t i n t o the l o s s experienced. T h i s study d i d not examine the p a t i e n t ' s r e a c t i o n s i n response to l o s s . Many questions are unanswered. Are the p a t i e n t s e x p e r i e n c i n g s i m i l a r r e a c t i o n s to l o s s ? Are t h e i r r e a c t i o n s c o n c u r r e n t with those o f t h e i r spouses? What accounts f o r the convergence and divergence i n the p a t i e n t and spouse's r e l a t i o n s h i p ? How does t h i s r e l a t e to the l o s s experienced? Further research i s needed t o e x p l o r e the l o s s - r e l a t e d v a r i a b l e s . The variance i n i n d i v i d u a l s ' r e a c t i o n s i n t h i s study are e v i d e n t and most remarkable. While t h i s study has added t o the body o f knowledge of l o s s t h a t spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i t has a l s o r a i s e d many questions about the phenomenon. In a d d i t i o n , nurse researchers must begin to study the e f f e c t s o f s e l e c t e d planned 129 n u r s i n g i n t e r v e n t i o n s on p a t i e n t s and spouses e x p e r i e n c i n g l o s s . Such research should e v e n t u a l l y l e a d to more e f f i c i e n t and e f f e c t i v e nursing c a r e . Recommendations On the b a s i s of the f i n d i n g s and i m p l i c a t i o n s of t h i s study i t i s recommended t h a t : 1. Nurse p r a c t i t i o n e r s assess the r e a c t i o n s t h a t spouses experience i n response to l o s s and provide the immediate guidance and support r e q u i r e d to f a c i l i t a t e the spouses' maximum adjustment to t h e i r l o s s . The p a t i e n t with a f a m i l y focus should be an i n t e g r a l p a r t o f nursing care i n a l l s e t t i n g s . 2. Nurse educators provide the nursing student with the appro-p r i a t e knowledge and s k i l l s r e q u i r e d to assess the actual and p o t e n t i a l l o s s e s o f spouses and to understand the i n d i v i d u a l ' s need f o r meaning during the l o s s process. This knowledge should i n c l u d e an under-standing o f the many v a r i a b l e s i n f l u e n c i n g the spouses' pe r c e p t i o n s of l o s s as well as the elements or c h a r a c t e r i s t i c s o f l o s s . 3. Future s t u d i e s with a l a r g e random sample o f spouses from a v a r i e t y o f s e t t i n g s be conducted to i n c r e a s e the g e n e r a l i z a b i l i t y of the r e s u l t s concerning the phenonmenon of l o s s . 4. Research be conducted to examine the d i f f e r e n c e s between the Group A and B f i n d i n g s with p a r t i c u l a r a t t e n t i o n to l o s s r e l a t e d v a r i a b l e s . 5. Spouses' and p a t i e n t s ' r e a c t i o n s to l o s s should be examined simultaneously i n l o n g i t u d i n a l s t u d i e s . BIBLIOGRAPHY 130 A d s e t t , A., & Bruhn, J . Short term group psychotherapy f o r post myocardial i n f a r c t i o n p a t i e n t s and t h e i r wives. Canadian Medical  A s s o c i a t i o n J o u r n a l , 1968, 99 (12), 577-584. A l d r i c h , C. K. Some Dynamics of A n t i c i p a t o r y G r i e f i n A n t i c i p a t o r y  G r i e f . E d i t e d by B. Schoenberg, A.C. C a r r , A.H. Kutscher, D. Peretz and I.K. Golberg. New York: Columbia U n i v e r s i t y Press, 1974. Anthony, S. The C h i l d ' s Discovery of Death. New YorK: Harcourt Brace and World, Inc., 1940. Atwood, J . R. A grounded theory approach to the study o f p e r i m o r t a l i t y c a r e . Communicating Nursing Research, 1976, 17 (9) , 58-65. A v e r i l l , J . G r i e f : I t s nature and s i g n i f i c a n c e . P s y c h o l o g i c a l  B u l l e t i n , 1968, 70 (1), 721-748. Baden, C. Teaching the coronary p a t i e n t and h i s f a m i l y . Nursing  C l i n i c s o f North America, 1972, 7 (3), 101-107. Bowl by, J . Processes o f mourning. Internal Journal P s y c h o a n a l y s i s , 1961,.42, 317-340. Bri n k , P.,, Wood, M. Bas i c Steps i n Planning Nursing Research. Massachusetts: Duxbury Press, 19/8. Burnside, I. M. G r i e f work i n the aged p a t i e n t . Nursing Forum, 1969 (8), 416-427. C a r l s o n , C. G r i e f i n Behavioural Concepts and Nursing I n t e r v e n t i o n . E d i t e d by C. C a r l s o n , 2nd ed. Phi 1adelphi a: L i p p i n c o t t Co., 1978, 87-89. Crawshaw, J . Community r e h a b i l i t a t i o n a f t e r acute myocardial i n f a r c t i o n . Heart and Lung, 1974, (3), 258-259. Croog, S., Levine S. & L u r i e , Z. The heart p a t i e n t and the recovery process. S o c i a l , Science and Medicine, 1968, (2), 111-164. Croog, S., & Le v i n e , S. The Heart Attack P a t i e n t Recovers. New York: Human Sciences Press, 1977. D i e r s , D. Research i n Nursing P r a c t i c e . P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 1979. Dracup, K . , & Breu, C. Using nursing research f i n d i n g s to meet the needs o f g r i e v i n g spouses. Nursing Research, 1978, 27 ( 4 ) , 212-216. : 131 Endress, M. E f f e c t of H o s p i t a l i z a t i o n on the Nuclear Family. T h e s i s , S e a t t l e , Washington: 1971. Engel, G. P s y c h o l o g i c a l Development i n Health and Disease. Phi 1adelpnTai W.B. Saunders Co., 1962. Epperson, M. F a m i l i e s i n sudden c r i s e s : process and i n t e r v e n t i o n i n a c r i t i c a l c are c e n t e r . S o c i a l Work i n Health Care, 1977, 2 ( 4 ) , 265-273. F i l s t e a d , Wm.J. ( E d . ) . Q u a l i t a t i v e Methodology. Chicago: Markham P u b l i s h i n g Co., 1970. Fink, S. C r i s i s and M o t i v a t i o n : a t h e o r e t i c a l model. Archives of  Physical Medicine and R e h a b i l i t a t i o n , 1967, 48 (11), 592-59/. F i s h e r , S.H. P s y c h i a t r i c c o n s i d e r a t i o n s of hand d i s a b i l i t y . A rchives  of P h y s i c a l Medicine and R e h a b i l i t a t i o n , 1960, 41, 60-62. Freud, S. Mourning and Melancholia. C o l l e c t e d Papers, 1946, 4, 152-170. F r i e d , M. G r i e v i n g For a Lost Home i n The Environment of the  Metropol Iis. E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1972. Friedman, S.B., Chodoff, P., Mason, J.W., & Hamburg, D.A. Behavioural observations on parents a n t i c i p a t i n g the death of a c h i l d . P e d i a t r i c s , 1973, 32 ( 4 ) , 610-625. F u l t o n , R., & F u l t o n , J . A n t i c i p a t o r y g r i e f : a Psychosocial aspect o f terminal c a r e . In Psychosocial Aspects of Terminal Care. E d i t e d by Schoenberg e t a l l New York: Columbia U n i v e r s i t y Press, 1972. Futterman, E.H., Hoffman, I., & Sobshin, M. Parental A n t i c i p a t o r y Mourning. In Psychosocial Aspects of Terminal Care. E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1972. G l a s e r , B., Strauss, A. The Discovery of Grounded Theory - S t r a t e g i e s  f o r Q u a l i t a t i v e ResearcTT Chicago: A l d i n e P u b l i s h i n g Co., 196/. - Time For Dying. Chicago: A l d i n e P u b l i s h i n g Company, 1968. G l i c k , 1.0., Weiss, R.S., & Parkes, CM. The F i r s t Year o f  Bereavement. Toronto: John Wiley and Sons, 1974. Goldston, E. Meaning of Heart Disease to the Family. Post Graduate  Course i n Basic Physiology and Psychology of Work, 1962, (6), 18-21. 132 Gul1 edge, D. The P s y c h o l o g i c a l Aftermath o f a Myocardial I n f a r c t i o n , i n P s y c h o l o g i c a l Aspects o f Myocardial I n f a r c t i o n and Coronary Care. E d i t e d by W,. Gentry and R. W i l l i a m s . St. Louis: Mosby Co., 1975, 107-121. Hampe, S. Needs of the g r i e v i n g spouse i n a h o s p i t a l s e t t i n g . Nursing  Research, 1975, 24 ( 2 ) , 113-120. Harding, L., & M o r e f i e l d , M. Group i n t e r v e n t i o n f o r wives o f myocardial i n f a r c t i o n p a t i e n t s . Nursing C l i n i c s of North America, 1976, 11 ( 2 ) , 339-347. H o i s t i , 0. Content A n a l y s i s f o r the S o c i a l Sciences and Humanities. Don M i l l s , O n t a r i o : Addison Wesley, 1969. Kahn, R. & C o n n e l l , C. The Dynamics of Int e r v i e w i n g . New York: John Wiley and Sons, 1965. K e r l i n g e r , F. Foundations of Behavioural Research. 2nd ed. Toronto: Holt, Rinehart, and Winston, 1973. K i m b a l l , C P . P s y c h o l o g i c a l responses to the experience o f open heart surgery. American Journal of P s y c h i a t r y , 1969, 126 (3), 97-107. K l e i n , R. The impact of i l l n e s s upon the spouse. Journal Chronic  D i s a b i l i t y , 1967, 20, 241-247. Korner, J.N. Hope as a method of coping. J . C o n s u l t i n g and C l i n i c a l  Psychology, 1970, 34 (2), 2-3. Kubler-Ross, E. On Death and Dying. New York: The MacMillan Company, 1969. ~~ L a r t e r , M. M. I. Wives need you. R.N., 1976, ( 8 ) , 45-46. Lindemann, E. Symptomatology and management o f acute g r i e f . American  Journal of P s y c h i a t r y , 1944, 101 ( 9 ) , 141-148. , Lipowski, Z.J. P h y s i c a l i l l n e s s , the i n d i v i d u a l , and the coping process. I n t e r n a t i o n a l Journal of P s y c h i a t r y In Medicine 1, 1970, 91-101. M a r r i s , P. Widows and T h e i r F a m i l i e s . London: Routeledge and Kegan Paul, 195"8^ Mayou, R., F o s t e r , A. & Williamson, B. The p s y c h o l o g i c a l and s o c i a l e f f e c t s o f myocardial i n f a r c t i o n on wives. B r i t i s h Medical  J o u r n a l , 1978, 6114 ( 3 ) , 699-701. Moos, R. Coping with P h y s i c a l I l l n e s s , New York: Plenum Medical Book, 1977. 133 Moulter, N. Needs o f r e l a t i v e s o f c r i t i c a l l y i l l p a t i e n t s . Heart and  Lung, 1979, 8 ( 2 ) , 322-339. Nagy, M. The C h i l d ' s View of Death, In the Meaning of Death. E d i t e d by Herman F i e f e e . New York: McGraw Hi I I, Co. 1959. Parkes, CM. Bereavement: Studies o f G r i e f i n A d u l t L i f e . New York: Basic Books, 19/Z. Peretz, D. Development, O b j e c t - R e l a t i o n s h i p s and Loss i n Loss and  G r i e f : P s y c h o l o g i c a l Management i n Medical P r a c t i c e . E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1970, 3-9. P i a g e t , J . The Language and Thoughts of the C h i l d . London: Routledge, 1952. P r a n u l i s , M.F. Loss: a f a c t o r a f f e c t i n g the welfare of the coronary p a t i e n t . . Nursing C l i n i c s of North America, 1972, 7 (3), 445-455. Quint, J . D e l i n e a t i o n of q u a l i t a t i v e aspects of nursing c a r e . Nursing  Research, 1962, 11 ( 4 ) , 205-206. Roberts, S. Behavioural Concepts and Nursing Throughout the L i f e Span. New Jersey"! P r e n t i c e - H a l l Inc., 19/8. Robinson, L. L i a i s o n Nursing, P s y c h o l o g i c a l Approach to P a t i e n t Care. P h i l a d e l p h i a ! l-.A. Davis Co., 19/4. R o c h l i n , G. The l o s s complex. Journal of the American P s y o a n a l y t i c A s s o c i a t i o n , 1959, 7 (4), 299TJT5: Royle, J . Coronary p a t i e n t s and t h e i r f a m i l i e s r e c e i v e incomplete c a r e . Canadian Nurse, 1973, 69 (2), 21-25. Ruskin, H. MMPI comparison between p a t i e n t s with coronary h e a r t d i s e a s e and t h e i r spouses together with o t h e r demographic data. Scandinavian Journal of R e h a b i l i t a t i o n and Medicine, 1970, ( 2 ) , 99-104. Schmidt, L., & Hatton, C. The Concept of Loss i n F i v e Years Co-operation to Improve C u r r i c u l a i n Western Schools of Nursing Western I n t e r s t a t e Commission f o r Higher Education. E d i t e d by J . Smith Boulder: Colorado, 1972, 26-51. Schoenberg, B., Carr, A., P e r e t z , D. & Kutscher, A. Loss and G r i e f :  P s y c h o l o g i c a l Management i n Medical P r a c t i c e . New York: Columbia U n i v e r s i t y Press, 1970. S e l l i t z , C , Cook, S.W., & Wrightsman, L.S. Research Methods i n S o c i a l  R e l a t i o n s . (3rd Ed.) New York: Holt, Rinehart and Winston, 19/6. 134 Shontz, F.C. The Psy c h o l o g i c a l Aspects of Physical I l l n e s s and D i s a b i l i t y . New York: MacMiI Ian Co., 1975. ~~ S i l v a , M. Spouses need nurses too. Canadian Nurse, 1977, 73 (12). 39-41. Sk e l t o n , M., & Dominian, J . Ps y c h o l o g i c a l s t r e s s i n wives o f p a t i e n t s with myocardial i n f a r c t i o n . B r i t i s h Medical J o u r n a l , 1973, 2 ( 4 ) , 101-103. S t r i c k l e r , M., & La Sor, B. The concept o f l o s s i n c r i s i s i n t e r v e n t i o n . Mental Health Hygiene, 1970, 54 (2), 301-305. Toth, A., & Toth, S. Post-coronary p a t i e n t s r e c e i v e group therapy. H o s p i t a l Progress, 1977, (8), 72-75. Vachon, M.L.S. The f i n a l i l l n e s s i n cancer: the widow's p e r s p e c t i v e . CMA J o u r n a l , 1977, 117 (9), 1151-1154. W i l l i a m s , C , & Ri c e , D. The I.C.U. - s o c i a l work i n t e r v e n t i o n with f a m i l i e s o f the c r i t i c a l l y i l l p a t i e n t . S o c i a l Work i n Health Care, 1977, 2 (10), 391-398. Wu, R. Behaviour and I l l n e s s . Englewood C l i f f s , New J e r s e y : P r e n t i c e Hal 1 , 1973. Yokes, J . Family R e h a b i l i t a t i o n : an Adult with Myocardial I n f a r c t i o n , i n Family Health Care. E d i t e d by D. Hymovich. New York: McGraw-Hill, 1973. Appendix A: Consent Form 136 CONSENT FORM Consent to p a r t i c i p a t e i n Research Study conducted by P a t t i Gauchie, R.N. I, , agree to p a r t i c i p a t e i n the research study being conducted by P a t t i Gauchie. I understand that t h i s study deals with examining the f e e l i n g s and r e a c t i o n s that the spouse experiences when the partner has s u f f e r e d a heart a t t a c k . I understand t h a t my p a r t i c i p a t i o n w i l l i n v o l v e four i n t e r v i e w s of approximately one hour each and I have agreed to have these i n t e r v i e w s tape recorded. I understand that I w i l l remain anonymous and that the tapes of the in t e r v i e w w i l l be a v a i l a b l e only t o the i n v e s t i g a t o r and the members o f her t h e s i s committee. I a l s o understand that t h i s tape w i l l be erased when the i n v e s t i g a t o r ' s t h e s i s has been completed. I understand t h a t I am fr e e to withdraw from the study at any time, and that t h i s a c t i o n w i l l not j e o p a r d i z e the treatment of my spouse. Signed: Witnessed: Date: Appendix B: Information Related to Cardiac Research Study I 138 INFORMATION RELATED TO CARDIAC RESEARCH STUDY ' As p a r t o f t h e d a t a c o l l e c t i o n f o r my M a s t e r T h e s i s i n N u r s i n g , I am c o n d u c t i n g i n f o r m a l i n t e r v i e w s w i t h s p o u s e s whose p a r t n e r s a r e h e a r t a t t a c k p a t i e n t s b e i n g t r e a t e d i n t h e c o r o n a r y c a r e u n i t a t S t . P a u l ' s H o s p i t a l . My t h e s i s t o p i c d e a l s w i t h e x a m i n i n g t h e f e e l i n g s and r e a c t i o n s t h a t t h e spouse e x p e r i e n c e s when t h e p a r t n e r has s u f f e r e d a h e a r t a t t a c k . As a n u r s e , I have worked w i t h h e a r t a t t a c k p a t i e n t s and have been c o n c e r n e d w i t h h e l p i n g t h e s p o u s e s cope w i t h t h e s t r e s s o f t h e i l l n e s s . In n u r s i n g ' w e have n o t s t u d i e d t h e s p o u s e v e r y t h o r o u g h l y , so we have l i t t l e i n f o r m a t i o n t o g u i d e us i n p r o v i d i n g t h e a s s i s t a n c e s p o u s e s may r e q u i r e . I b e l i e v e t h a t my r e s e a r c h i s i m p o r t a n t i n g a t h e r i n g t h i s i n f o r m a t i o n . I hope t h a t you w i l l c o n s i d e r p a r t i c i p a t i n g i n t h i s s t u d y . I w o u l d l i k e t o c o n d u c t f o u r i n f o r m a l i n t e r v i e w s w i t h y o u , two d u r i n g t h e h o s p i t a l i z a t i o n p e r i o d o f y o u r p a r t n e r and t h e f i n a l two a t one and t h r e e weeks a f t e r h o s p i t a l d i s c h a r g e . The t i m e and l e n g t h o f t h e i n t e r v i e w s w o u l d be a r r a n g e d a t y o u r c o n v e n i e n c e . A l l i n t e r v i e w s w i l l be c o n f i d e n t i a l , y o u r c o n t r i b u t i o n s w i l l r e m a i n anonymous . You may w i t h d r a w f rom t h e s t u d y a t any t i m e . I w i l l g l a d l y s h a r e t h e r e s u l t s o f t h i s s t u d y upon c o m p l e t i o n o f my r e s e a r c h . I w i l l t e l e p h o n e you w i t h i n the week t o answer any f u r t h e r q u e s t i o n s you may have i n r e g a r d t o t h e s t u d y and t o d i s c u s s t h e p o s s i b i l i t y o f y o u r p a r t i c i p a t i o n . I w i s h t o s t r e s s t h a t r e f u s a l t o p a r t i c i p a t e i n t h i s s t u d y w i l l n o t j e o p a r d i z e c u r r e n t o r f u t u r e t r e a t m e n t o f y o u r p a r t n e r . I l o o k f o r w a r d t o t a l k i n g w i t h y o u . Thank y o u , P a t t i G a u c h i e , R .N . U . B . C . S choo l o f N u r s i n g Appendix C: Data C o l l e c t i o n Tool DATA COLLECTION TOOL Demograph i c D a t a : D a t e : Name o f Spouse ( i n i t i a l s ) Spouse s a g e : P a t i e n t ' s a g e : S p o u s e ' s s e x : I n t e r v i e w G u i d e : Number o f days p o s t M. I The i n t e r v i e w w i l l e x p l o r e t h e d e g r e e , f r e q u e n c y , i n t e n s i t y and d u r a t i o n o f s p e c i f i c p s y c h o l o g i c a l and s o m a t i c r e s p o n s e s . A r e a s t o be examined w i l l b e : 1. v e r b a l ( t y p e , . q u a l i t y c h a r a c t e r i s t i c s o f s p e e c h , f o c u s o f c o n v e r s a t i o n ; 2. n o n - v e r b a l ( a c t i v i t y , eye c o n t a c t , body l a n g u a g e , a p p e a r a n c e ) . Q u e s t i o n s ( b r o a d - o p e n e n d e d ) : 1. Can y o u t e l l me what y o u r t h o u g h t s have been i n r e l a t i o n t o y o u r s p o u s e ' s h e a r t a t t a c k s i n c e I l a s t saw you? 2. When y o u t h i n k a b o u t y o u r s p o u s e ' s h e a r t a t t a c k how do y o u f e e l ? 3. Can y o u d e s c r i b e y o u r b e h a v i o u r s i n c e y o u r s p o u s e ' s h e a r t a t t a c k ? 4. Is t h e r e a n y t h i n g e l s e t h a t y o u f e e l i s i m p o r t a n t t o m e n t i o n ? Appendix D: Sample of Data Coding and A n a l y s i s Procedure 142 SAMPLE OF DATA CODING AND ANALYSIS PROCEDURE DISCRIMINATION • STEP: Data s o r t e d and c o l o u r coded. Category I d e n t i f i e d and c o l o u r coded. Sample of I l l u s t r a t i v e Data (coded with a red dot) He Is not a person who t e l l s you he Is hurt so when t h i s happened • • • • He had pains In h i s arms so I was wondering .... W e l l , how I t happened was s o r t of a s u r p r i s e .... W e l l , we were up at Sechelt in our new motor home .... Spouses g i v e a blow-by-blow d e s c r i p t i o n of the heart a t t a c k . I n v e s t i g a t o r uses i l l u s t r a t i v e data to name the category. HOW IT HAPPENED DEFINITION STEP: Category de f i n e d and d e s c r i b e d . Category reworked u n t i l p r o p e r t i e s and concepts become c l e a r e r . C h a r a c t e r i s t i c s or p r o p e r t i e s : HOW IT HAPPENED| > 1 4. 5. I n i t i a t e d the f i r s t i n t e r -view with a d e s c r i p t i o n of event; moved from past to present time frame; v i v i d l y r e c a l l e d t h e i r p a r t n e r ' s symptoms; d e t a i l e d t h e i r own r e a c t i o n s ; progressed from these thoughts t o question the reason or cause of I l l n e s s i . e . why i t happened. CLASSIFICATION i n t e r p r e t a t i o n in IIght of loss framework category of [REVIEWING| STEP: Category compared and c o n t r a s t e d t o other c a t e g o r i e s , threaded together. Larger a b s t r a c t concepts evolve. Concepts and p r o p e r t i e s are Compared and c o n t r a s t e d REVIEWING with comparing r e d e f i n i n g and a n t i c i p a t i n g Main themes emerge (a) p a t i e n t focus; (b) heightened thoughts (c) a n t i c i p a t e d loss of partner Phase I The Event and I n i t i a l Spousal Response A p p e n d i x E: O v e r v i e w o f t h e F i n d i n g s 144 APPENDIX E PHASES FINDINGS Phase I The Event and I n i t i a l Spousal Response 1. H o s p i t a l i z a t i o n p e r i o d of p a t i e n t . 2. Subjects Interviewed and observed twi c e (week one and two). Thoughts: ( t ) reviewing; (2) a n t i c i -p a t i n g ; (3) comparing; (4) r e d e f i n i n g . FeelInqs: (1) mood-shock/disbelief, upset with gradual c o n t r o l guarded optimism; (2) p h y s i c a l d i s t u r b a n c e s , loss of sleep and a p p e t i t e , increased f a t i g u e and I r r i t a b i l i t y . A c t i o n s : (1) verbal I z e d - h e c t i c schedules, loss of s o c i a l c ontact: (2) observed c r y i n g , long s i g h s , decreased eye co n t a c t , slouched posture, f a t i g u e d faces, few s m i l e s . Phase II - Reaction To The Event 1. E a r l y post discharge p e r i o d of the p a t i e n t . 2. Subjects interviewed and observed once (week t h r e e to f o u r ) . M E Phase I I Impact Of The Event Later post discharge p e r i o d of the p a t i e n t . Subjects Interviewed and observed once (week f i v e t o s i x ) . Two separate p a t t e r n s of r e a c t i o n s - Group A f i n d i n g s Group B f i n d i n g s Thoughts: (1) a s s e s s i n g ; (2) implement-ing; (3) r e d e f i n i n g . FeelInqs: (1) mood-gratefulness, optimism, beginning of g u i l t , r e s e n t -ment and ambivalence; (2) p h y s i c a l disturbances--improved a p p e t i t e and sl e e p . Increased f a t i g u e . A c t i o n s : (1) verbal Ized-watchdog, p r o t e c t o r behaviours, a l t e r e d r o l e s and r e s p o n s i b i l i t i e s ; (2) observed animated speech, Increased s m i l e s Increased eye c o n t a c t , s o c i a l o v e i — \ t u r e s . Group A Thoughts: (1) a s s e s s i n g ; (2) r e d e f i n i n g Feel Ings: (1) mood - depression, g u i l t resentment; (2) p h y s i c a l disturbances increased f a t i g u e , loss of sleep and a p p e t i t e , headaches. A c t i o n s : ( I ) v e r b a l i z e d - loss of own. time, Increased changes i n r o l e s and r e s p o n s i b i l i t i e s , decreased communi-c a t i o n with p a r t n e r ; (2) observed increased s i g h i n g , monotone v o i c e s , slouched posture, no make-up, decreased eye conta c t and s o c i a l o v e r t u r e s . Group B Thoughts: (1) assessing; (2) p l a n n i n g . FeelInqs: (1) mood - calm, t h a n k f u l , p o s i t i v e , a c c e p t i n g ; (2) p h y s i c a l d i s t u r b a n c e s h a l t h back to normal. A c t i o n s : (1) v e r b a l i z e d - shared r o l e s and r e s p o n s i b i l i t i e s , communication with partner; (2) observed - a l e r t , r e sponsive, calm, r e l a x e d voice and body posture, increased eye co n t a c t and s o c i a l o v e r t u r e s . Appendix F: Overview of the I n t e r p r e t a t i of the F i n d i n g s 146. APPENDIX F 1n t e r p r e t a t l o n Major Themes . Phase 1 The Event and I n i t i a l - r e a c t i o n s s i m i l a r t o a n t i c i p a t o r y 1. heightened thought Spousal Response g r i e f r e a c t i o n s described by processes; Lindemann; 2. p a t i e n t focus; - loss i s sudden and traumatic and experienced in 3 time frames, 3. a n t i c i p a t e d loss past, present and f u t u r e ; of p a r t n e r . - f u l l r e a l i t y of loss has not penetrated, s u b j e c t s beginning t o p e r c e i v e and attach meaning t o l o s s . Phase 11 Reaction to the Event - c l o s u r e of a n t i c i p a t e d l o s s , 1. decreased thought p a t i e n t r e c o v e r i n g well and processes; s u b j e c t s p r o t e c t i n g and watching t h e i r p a r t n e r s ; 2. p a t i e n t and spouse focus; - couple focus - loss examined as i t a f f e c t s "us"; 3. euphoric f e e l I n g s . - personal s e l f focus - subjects express actual loss of s e l f (e.g. time, independence, r o u t i n e s ) . Phase 111 Impact to the Event 'Group A: 1. heightened thought - unresolved loss processes; - loss expands to focus on loss of spouses needs, v a l u e s , r o l e s , 2. e g o c e n t r i c focus; more covert a b s t r a c t loss experienced by s u b j e c t s . 3. hei ghtened - acknowledgement phase, the t r u e ambivalence and - Impact of the loss now f e l t with depress i o n . numerous secondary l o s s e s . Group B: 1. acceptance and - r e s o l v e d loss - acceptance and optimIsm; adaptation; - loss viewed from an us or couple 2. couple or us focus not from e g o c e n t r i c focus; p e r s p e c t i v e ; - loss seen as a past event, an event 3. fu t u r e o r i e n t e d . t h a t had changed t h e i r l i v e s f o r the p o s i t i v e ; - view f u t u r e with optimism. 

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